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Second Opinion Diagnosis in Prostate Pathology by Francisco G. La Rosa, MD* *Associate Professor, Department of Pathology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 800045 “29 th International Prostate Cancer Update” January 24 th , 2019 - Beaver Creek, CO Disclosure: Consultant at “Precision Biopsy”

Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

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Page 1: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Second Opinion Diagnosis in Prostate Pathology

by Francisco G. La Rosa, MD*

*Associate Professor, Department of Pathology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 800045

“29th International Prostate Cancer Update”January 24th, 2019 - Beaver Creek, CO

Disclosure: Consultant at “Precision Biopsy”

Page 2: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Prostate cancer:

• Most common male cancer in the USA (other than skin)

• Second leading cause of cancer death

• Gold standard diagnosis: Pathology

• Therapy options are primarily based on pathology

Page 3: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Weekly “2nd. Opinion GU Conference”

University of Colorado, Anschutz Medical Campus

Page 4: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Pitfalls in Pathology Diagnosis of Prostate Cancer:

• Histology Laboratory Factors: Proficiency and experience in the preparation of biopsies and prostatectomy specimens.

• Pathologist Factors: Expertise recognizing and evaluating PCa under the microscope.

Page 5: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Pitfalls in Pathology Diagnosis of Prostate cancer:

HISTOLOGY LABORATORY FACTORS• Poor histopathological preparations

Page 6: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 7: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 8: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 9: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 10: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Pitfalls in Pathology Diagnosis of Prostate cancer:

PATHOLOGIST FACTORS:- Pathologists need to be updated in the constant changes in prostate cancer classification and in the evaluation of other specific tumor features.

- Pathologists need to maintain a permanent and close professional collaboration with their clinical, oncology and surgical colleagues, to construct sound clinical-pathological correlations that can secure the right care for their patients.

Page 11: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Pitfalls in Pathology Diagnosis of Prostate cancer:

PATHOLOGIST FACTORS:1. EVALUATION OF GLEASON SCORE (GS)The diagnosis of lower Gleason grade tumors can significantly change the treatment strategy for patients with prostate cancer: Watchful Waiting, Targeted Focal Therapy, Chemotherapy, Radical Prostatectomy.

Page 12: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 13: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Barqawi AB, Turcanu1 R, Gamito1 EJ, Lucia MS, O’Donnell CI, Crawford ED, La Rosa DD, La Rosa FG. The value of second-opinion pathology diagnoses on prostate biopsies from patients referred for management of prostate cancer. Int J Clin Exp Pathol 2011;4(5):468-475

Page 14: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Int J Clin Exp Pathol 2011;4(5):468-475

Page 15: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 16: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Barqawi AB, Turcanu1 R, Gamito1 EJ, Lucia MS, O’Donnell CI, Crawford ED, La Rosa DD, La Rosa FG. The value of second-opinion pathology diagnoses on prostate biopsies from patients referred for management of prostate cancer. Int J Clin Exp Pathol 2011;4(5):468-475

Page 17: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Pitfalls in Pathology Diagnosis of Prostate cancer:

PATHOLOGIST FACTORS:2. REPORTING EXTRAPROSTATIC EXTENSION (EPE)The presence of EPE on needle core biopsy is associated with extensive, high-grade tumors with very poor prognoses.

Miller JS, Chen Y, Ye H, Brian D. Robinson BD, Fadi Brimo F, Epstein JI. Extraprostatic extension of prostatic adenocarcinoma on needle core biopsy: report of 72 cases with clinical follow-up. BJU Int. 106(3):330-333, 2010.

Page 18: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Int J Clin Exp Pathol 2011;4(5):468-475

Page 19: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Pitfalls in Pathology Diagnosis of Prostate cancer:PATHOLOGIST FACTORS: 3. REPORTING PERINEURAL INVASION (PNI)- Foci of PNI 0.25 mm or larger appear to be associated with substantially higher rates of progression [1]

- Immediate treatment rather than watchful waiting may be more appropriate for patients with localized prostatic cancer and perineural invasion [2].

1.- Maru N, Ohori M, Kattan MW, Scardino PT, Wheeler TM. Prognostic Significance of the Diameter of Perineural Invasion in Radical Prostatectomy Specimens. Human Pathology 32:8, 2001.

2.- Harnden P, Shelley MD, Clements H, Coles B, Tyndale-Biscoe RS, Naylor B, Mason MD. The prognostic significance of perineural invasion in prostatic cancer biopsies: a systematic review. Cancer. 2007 Jan 1;109(1):13-24.

Page 20: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 21: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 22: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 23: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Maru N, Ohori M, Kattan MW, Scardino PT, Wheeler TM. Prognostic Significance of the Diameter of Perineural Invasion in Radical Prostatectomy Specimens. Human Pathology 32:8, 2001.

Page 24: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Lee MC, Moussa AS, Yu C, Kattan MW, Magi-Galluzzi C, Jones JS. Multifocal High Grade Prostatic Intraepithelial Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010

Pitfalls in Pathology Diagnosis of Prostate cancer:

PATHOLOGIST FACTORS: 4. REPORTING HIGH GRADE PIN:a.Multifocal and bilateral presentation of high grade prostatic intraepithelial neoplasia (HG-PIN) are adverse features that significantly increase the risk of prostate cancer despite adjusting for other clinical indicators such as prostate specific antigen and abnormal digital rectal examination.

Page 25: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 26: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Srodon M, Epstein JI. Central Zone Histology of the Prostate: A Mimicker of High-grade Prostatic Intraepithelial Neoplasia. Human Pathology 33:5, 2002, 518-523

Pitfalls in Pathology Diagnosis of Prostate cancer:

PATHOLOGIST FACTORS: 4. REPORTING HIGH GRADE PIN:b.Recognition of the distinctive features of Central Zone histology. (i.e., complex glands with tall columnar cells, eosinophilic cytoplasm, prominent basal cell layer, small nucleoli, and lack of cytologic atypia) can help avoid a misdiagnosis of HG-PIN or “atypia” on needle biopsy.

Page 27: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 28: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 29: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

2nd Opinion Case Review:

65 y.o. Caucasian male with history of elevated PSA = 5.9 ng/ mL and no family history of prostate cancer.

Page 30: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 31: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis
Page 32: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Review outside slides, xxxxxx, xx/xx/xxxx, :

L) Prostate, left lateral base, needle core biopsy:- Prostatic adenocarcinoma Gleason grade 4 + 4 (score = 8; Grade group 4), ductal type (see comment)- No evidence of perineural invasion or extraprostatic extension

A-K, M, N) Prostate, right apex, right mid, right base, right lateral apex, right lateral mid, right lateral base, left apex, left mid, left base, left lateral apex, left lateral mid, anterior, left P2 PI-RADS 4, needle core biopsies:- Prostatic tissue with no evidence of malignancy (0/11 cores)

Comment: We changed the outside pathology report diagnosis of specimen L (left lateral base), since the tumor shows a predominant ductal type differentiation, which should be considered Gleason grade 4. Dr. xxxxx has reviewed this case and concurs.

Page 33: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

SUMMARY

1. Gleason score, perineural invasion, extraprostatic extension, and number of positive cores in the biopsy specimen were preoperative independent predictors of positive surgical margin after laparoscopic radical prostatectomy.

Rong Yang R, Cao K, Han T, Zhang Y, Zhang G, Xu L, Lian H, Li X, Guo H. Perineural invasion status, Gleason score and number of positive cores in biopsy pathology are predictors of positive surgical margin following laparoscopic radical prostatectomy. Asian Journal of Andrology (2017) 19, 468–472

Page 34: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

Barqawi AB, Turcanu1 R, Gamito1 EJ, Lucia MS, O’Donnell CI, Crawford ED, La Rosa DD, La Rosa FG. The value of second-opinion pathology diagnoses on prostate biopsies from patients referred for management of prostate cancer. Int J Clin Exp Pathol 2011;4(5):468-475

SUMMARY

2. The diagnosis of lower Gleason score tumors and the omission of important additional histopathological lesions can significantly change the treatment strategy for patients with prostate cancer.

Page 35: Second Opinion Diagnosis in Prostate Pathology · Neoplasia is a Risk Factor for Subsequent Prostate Cancer. The Journal Of Urology 184, 1958-1962, 2010 Pitfalls in Pathology Diagnosis

SUMMARY

3. We strongly recommend that a re-evaluation by in-house urologic pathologists should be performed on all outside prostate pathology specimens before patients are admitted for treatment in any institution.

Barqawi AB, Turcanu1 R, Gamito1 EJ, Lucia MS, O’Donnell CI, Crawford ED, La Rosa DD, La Rosa FG. The value of second-opinion pathology diagnoses on prostate biopsies from patients referred for management of prostate cancer. Int J Clin Exp Pathol 2011;4(5):468-475