Are Molecular Characteristics Of A Tumor Included On A Surgical Pathology Report
Certain molecular tests, sometimes called biomarker tests, are done as part of the initial pathology analysis for all cases of a given cancer type. For example, a pathology report for a patient with suspected breast cancer will include the results of testing for estrogen and progesterone receptors and the protein HER2/neu. The results of these tests can help identify what treatments are best for an individual patient.
A liquid biopsyin which a sample of blood or other body fluid is tested to look for pieces of DNA that have been released from tumor cellsis another way that the molecular characteristics of a tumor may be analyzed. The findings of these additional tests may be provided in separate reports that are linked to the pathology report.
Pathology examination is increasingly incorporating analyses of the structure and sequence of DNA extracted from fresh and fixed tissue samples to refine the cancer diagnosis through improved subtyping and stratification of tumor types and to better inform treatment.
Grading Of Prostate Cancer
The Gleason grading system is currently the most widely used histologic grading scheme for prostatic adenocarcinoma in the United States and worldwide . The Gleason grading method is based entirely on architectural arrangements of prostatic carcinoma . The grading diagram depicting Gleason patterns has undergone modifications from the original diagram. This most current diagram is based on modifications according to a 2014 consensus meeting of the ISUP published in 2016 and was endorsed by the World Health Organization .
The Gleason grading system allows for two separate grade patterns in an individual tissue sample, but the histomorphological appearance of prostatic carcinoma is more heterogeneous than this. Indeed, in one study, an average of 2.7 Gleason grade patterns was found in carcinomas in whole prostate glands . The number of grades assigned depends on tumor sample size and size of the tumor in the whole gland. In needle biopsy tissue, 4% of cases have more than two grades, whereas tumors > 12 cm3 in size in radical prostatectomy tissue sections tend to have more than two grades .
Other Terms On The Biopsy Report
Atrophy means shrinkage of prostate tissue . When it affects the entire prostate gland it is called diffuse atrophy. This is most often caused by hormones or radiation therapy to the prostate. When atrophy only affects certain areas of the prostate, it is called focal atrophy. Focal atrophy can sometimes look like prostate cancer under the microscope.
Adenocarcinoma is the type of cancer that typically develops in the prostate gland
Atypical adenomatous hyperplasiaor Adenosis is a benign condition that can sometimes be seen on a prostate biopsy.
Seminal vesicles are glands that lie just behind the prostate which are occasionally sampled during a biopsy.
Acute inflammation or chronic inflammation ?
Inflammation of the prostate is called prostatitis. Most cases of prostatitis reported on biopsy are not caused by infection and do not need to be treated. In some cases, inflammation may increase your PSA level, but it is not linked to prostate cancer. The finding of prostatitis on a biopsy of someone with prostate cancer does not affect their prognosis or the way the cancer is treated.
Special Tests or Markers: Depending on the tissue sample, the pathologist may conduct tests to further determine whether or not specific proteins or genes are present, as well as how fast cells are growing.
Pathologist Signature: The report is signed by the pathologist responsible for its contents.
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What Is A Pathology Test & Report
When your prostate was biopsied, the samples taken were studied under the microscope by a specialized doctor called a pathologist. A pathologist is a physician specializing in the diagnosis of disease based on examination of tissues and fluids removed from the body. Pathology tests involve evaluation of small samples of cells under a microscope to determine whether they are cancerous by identifying structural abnormalities. The pathologist sends your doctor a report that gives a diagnosis for each sample taken. Information in this report is used to help determine treatment.
What Will You Find On A Pathology Report
The information in the report depends on how the prostate specimen was obtained. Prostate tissue samples can be from a biopsy or surgery. If you have a biopsy of your prostate, the pathologist will receive cores of prostate tissue . If you have surgery, called a prostatectomy, the pathologist will receive samples of the entire prostate gland, seminal vesicles, vas deferens, and lymph node. The report is broken down into a few sections, including:
- Some information about the patient.
- The procedure that was done to get the prostate tissue.
- The date the specimen was collected and when it was received in the laboratory.
- A description of what the specimen looks like to the naked eye .
- A description of what was seen under the microscope .
- A pathologic diagnosis (a diagnosis based on what the pathologist saw under the microscope.
If there are any tissue pieces that have cancer cells, the pathologist will give the Gleason grade and score . The report will also say how much of the sample contained cancer. While all reports will have this information, the words they use may be different. To help you read your report, lets go through each of these sections.
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Figure : Zones Of The Prostate
To help your doctor more precisely determine the location of prostate cancer or another condition, such as high-grade PIN, your pathology report may name specific areas. For example, it may refer to the apex, located at the bottom of the prostate the base, at the top or the mid zone, the area between the apex and base. Alternatively, it may note three zones: the peripheral zone , the central zone , and the transition zone . Seventy percent of prostate cancers arise in the peripheral zone. Few arise in the anterior prostate.
Whats In A Pathology Report
Pathology reports can vary depending on what type of cancer you have. You may read about different tests and terms. But most reports usually have these sections. They use technical medical language and jargon, so check with your doctor if you have any questions.
Identifying information: This has your name, birth date, and medical record number. It also lists contact information for your doctor, the pathologist and lab where the sample was tested. There are also details about your tissue sample, or specimen. It includes what part of the body itâs from and whether it was removed with surgery or a biopsy.
Gross description: The pathologist describes the tissue sample without using a microscope. They may record its size, shape, color, weight, and what it feels like. Cancers are often measured in centimeters. Remember that size is only a part of the whole picture. Sometimes large tumors can grow more slowly than smaller ones.
Microscopic description: The pathologist slices the tissue into thin layers, puts them on slides, stains them with dye, and takes a detailed look with a microscope. The pathologist notes what the cancer cells look like, how they compare to normal cells, and whether theyâve spread into nearby tissue.
This section of your report has a number of details that guide your diagnosis and treatment. They can include:
If your cancer is tricky to diagnose, the pathologist may write extra comments. They can explain the issue and recommend additional tests.
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Do I Need A Repeat Biopsy
For men with a biopsy finding that is atypical or suspicious for cancer, follow up is warranted with blood or urine tests, imaging tests and, in some cases, repeat biopsy. The reason that repeat biopsy is not always done is that most of the cancers found following an atypical biopsy are not life threatening. Ask your treating doctor if and when you should have a repeat biopsy.
If My Biopsy Report Does Not Say That Prostate Cancer Was Found Can I Be Sure That I Dont Have Prostate Cancer
A biopsy only removes a small amount of the prostate tissue, so it is possible for a biopsy to miss a cancer. This is one of the reasons that doctors typically remove several cores from different parts of the prostate when they do a biopsy. But even when removing several cores, it is still possible for prostate cancer to be missed.
If a biopsy does not find cancer but your doctor still thinks that prostate cancer is likely , they may recommend that your prostate be biopsied again at some time in the future. Your doctor is the best person to discuss this with you.
What Does The Gleason Score Mean
The Gleason Score is an indicator of how aggressive the prostate cancer may be. The pathologist will identify the primary pattern and the secondary pattern and those cells are given a grade. The Gleason System uses numbers from 1 to 5.
- Grade 1 means the cancerous tissue is close to normal.
- Grades 2 through 4 show the cancerous tissue is between normal and very abnormal.
- Grade 5 means the cancerous tissue and the pattern of growth are very abnormal.
The primary and secondary cell pattern are graded independently, and the two grades are added to find the final Gleason Sum. A report might indicate the tumor is graded 2+4=6. The first number, in this case 2, is reflective of the majority of the cells. The second number, in this case 4, reflects the second most seen cells. The highest rating that can the Gleason Sum can be is 10.
The Gleason Score will indicate the potential behavior of a cancerous tumor and will be used by the oncologist to decide on the plan for treatment. However, the doctor will also take into consideration other factors such as rectal exam results, PSA level , MRI findings, and whether the cancer has spread beyond the prostate.
Table : Gleason Score Risk Assessments
Total Gleason score Points to consider when assessing risk 2 to 4 Lower risk
- Total Gleason scores of 2 to 4 are rare. Less than 2% of men who undergo a prostate biopsy have a score in this range.
- Pay attention to the first value assigned, as this is based on the preponderant area of cancer. That is why a Gleason score of 7 has a worse prognosis if it is based on the values 4 + 3 than if it is based on the values 3 + 4.
- Most cancers detected as a result of PSA screening are Gleason 6 or 7 .
5 to 6 Higher risk
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What Is The Diagnosis On A Surgical Pathology Report
The diagnosis section of a pathology report is the pathologists summary of all the findings of their visual and microscopic examination of the tissue specimen, in combination with relevant clinical information. It is in this section that the cancer type will be identified, including the tumor grade, lymph node status, margin status, and stage.
Understanding A Prostate Cancer Diagnosis
A prostate cancer diagnosis can turn your world upside down. Not only the prostate cancer diagnosis itself but the results of the multiple tests you will have received, which may be returned to you at different times and in different formats. One example of this is a pathology report which is sent to your doctor to outline the results of a tumour sample. This information can be overwhelming and it can be difficult to process it all. Thats why we have created a comprehensive resource that can be used as a reference to help you better understand the information you have been given.
A pathology report is not always given to you by your clinical team, however it is important to ask your doctor or nurse for a copy, as it can help you better understand your prostate cancer diagnosis and treatment plan. This information is key for you to be able to better discuss with your doctor which treatment suits you best, make informed decisions and ask detailed questions.
Not all reports will include the same amount of information and there may be variation among hospitals in the layout and terms used. This blog provides an outline of the most commonly included aspects of a pathology report but take note that it may not look identical to yours. We also explain the other factors that are considered when diagnosing prostate cancer, outline how the prostate cancer is diagnosed, as well as the procedures that it may involve.
What is a pathology report?
What is a PSA level?
What is an mpMRI?
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Grade Group Or Gleason Score
In general, prostate cancer is called adenocarcinoma of the prostate. Almost all prostate cancers fit within this cell type and the focus of this post will be to review this.
The pathologist will look at the samples of tissue and how the cells are arranged and give it two scores. The primary pattern that they see will be given the first score and the second most common pattern they see will be given the second score. These patterns will be graded 1-5 with five being the most serious. These numbers are then added up to give a score. The lowest score that we call prostate cancer is a six and the highest score is a ten and this is your GLEASON SCORE.
Lets walk through an example. When we see a result that says 3+4=7, the pathologist is saying that the most common pattern is a 3 and the second most common pattern is a 7. So then we add up those two numbers and will tell you that you have Gleason 3+4=7 prostate cancer. Now, Gleason 3+4=7 is less aggressive than 4+3=7 and that is why many have started to adopt a newer system to rate people as below:
How Will I Find Out What’s In My Surgical Pathology Report
The doctor in charge of a patients treatment will tell the patient about the findings in the pathology report and can help the patient understand the report and what it means for their situation. A patient can also ask to discuss their report with the pathologist.
Patients should be aware that pathology report results will often appear in the patient portal at the same time the doctor receives them. This means that patients may see their report before their doctor has had a chance to review it and discuss it with them.
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Figure : The Gleason Score
The Gleason score is a numerical value that grades prostate tumor cells according to how they appear compared to normal prostate cells . Because tumors often consist of multiple types of cells, the pathologist assigns two values: the first to the predominant cell type, and the second to the next-most-prevalent cell type. These two values are added to come up with the Gleason score.
The Gleason score is one of the most important factors in determining whether the cancer is likely confined to the prostate and how aggressive it is .
What Should I Expect My Urologist To Review Next If It Did Show Cancer
There are a lot of details within the biopsy report and this will really really help guide your treatment options. For prostate cancer, one of the most difficult aspects of coming up with a treatment plan is that there are choices. Its sometimes easier when there is only one option but oftentimes there are multiple excellent treatment choices that you can fall back on. If you want more details about choosing between surgery or radiation for prostate cancer, then click over here.
I am going to walk through how I review a biopsy report with my patients who have been diagnosed with cancer.
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What Does It Mean To Have A Gleason Score Of 6 7 8 Or 9
Because grades 1 and 2 are not often used for biopsies, the lowest Gleason score of a cancer found on a prostate biopsy is 6. These cancers may be called well differentiated or low-grade and are likely to be less aggressive that is, they tend to grow and spread slowly.
Cancers with Gleason scores of 8 to 10 may be called poorly differentiated or high-grade. These cancers are likely to grow and spread more quickly, although a cancer with a Gleason score of 9-10 is twice as likely to grow and spread quickly as a cancer with a Gleason score of 8.
Cancers with a Gleason score of 7 can either be Gleason score 3+4=7 or Gleason score 4+3=7:
- Gleason score 3+4=7 tumors still have a good prognosis , although not as good as a Gleason score 6 tumor.
- A Gleason score 4+3=7 tumor is more likely to grow and spread than a 3+4=7 tumor, yet not as likely as a Gleason score 8 tumor.
What Makes It Cancer
Although PSA levels or a digital rectal exam may hint at cancer, only a pathologist looking at cells in tissue samples can make the diagnosis. The following are among the key features they look for:
- Proliferation of relatively uniform small glands lined by a single layer of cells
- Cells with prominent nucleoli, components of the nucleus that help build proteins
- Enlarged nuclei
- Lack of basal cells, which sit below the epithelium in normal tissue
- Cells that stain readily with dyes
- Evidence of perineural invasion .
There is no consensus about the correct terminology to use for such lesions. Often youll see the term atypical small acinar proliferation, or ASAP, but it could also be labeled atypical hyperplasia, atypia, atypical glands, or focal glandular atypia.
Fortunately, such atypical findings are reported in only about 8% of pathology reports, according to a review of 39 studies involving needle biopsy specimens. But the trend toward doing more biopsies and finding smaller cancers has led to an increase in atypical diagnoses. Studies have shown that nearly half of the men who receive such an atypical diagnosis initially will find they have prostate cancer during a follow-up biopsy. This happens regardless of PSA levels or results of a digital rectal exam , which appear to be unrelated. In addition, compared to other pathologic diagnoses, atypical findings have the highest likelihood of being changed on expert review, usually to a diagnosis of cancer.
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