UROLOGICAL SURVEY   ( Download pdf )

 

PATHOLOGY

Patient and urologist driven second opinion of prostate needle biopsies
Chan TY, Epstein JI
Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
J Urol. 2005; 174 (4 Pt 1): 1390-4; discussion 1394; author reply 1394

  • Purpose: We reviewed second opinion prostate needle biopsies that were patient and urologist driven to determine how often an expert opinion resulted in a different diagnosis.
  • Materials and Methods: Of 3,155 prostate needle biopsy consultations received during a 6-month interval 684 were sent at the request of the patient or urologist. A significant change in outside diagnosis was one that could potentially result in a change in therapy or prognosis.
  • Results: The second opinion was requested by patients (21.6%), urologist (63.9%) and patients plus urologists (14.5%). The distribution of the 684 outside diagnoses was benign in 6.1%, HGPIN in 7.6%, atypical (ATYP) in 29.8% and cancer in 56.5%. In 241 cases (35.2%), a change in diagnosis was rendered upon expert review. We agreed with the majority of outside cancer, benign and HGPIN diagnoses, in contrast to only 36.8% of outside ATYP cases (p <0.0001). Uncommonly did a cancer diagnosis become a benign one or vice versa. Of changes affecting outside cancer diagnoses 73.5% were due to changes in Gleason score. The diagnosis was more likely to be changed when the consultation was requested by the urologist rather than by the patient (41.4% vs 25%, p < 0.0001).
  • Conclusions: Cases diagnosed as ATYP have the highest likelihood of being changed upon expert review. Urologists should consider sending such cases for consultation to attempt to resolve the diagnosis as definitively benign or malignant before subjecting the patient to repeat biopsy.

  • Editorial Comment
    It is a common practice in the United States a second opinion related to pathology reports. In Brazil, is not a common practice but definitely increasing in relation to prostatic needle biopsies. It is worth noting that the diagnosis was more likely to be changed when consultation was requested by the urologist rather than by the patient (41.4% vs 25%, p < 0.0001). Many patients, due to lack of symptoms or for other reasons, ask a second opinion because do not accept or doubt the diagnosis but uncommonly a cancer diagnosis become a benign one after a review.
    A special issue is related to Gleason score. Urologists should be careful with low Gleason scores. A Gleason score of 2 + 2 = 4 in a needle biopsy, frequently corresponds to a Gleason score of 4 + 4 = 8. The reason is that well circumscribed tumors not always correspond to low-grade carcinoma. The pathologist must be aware if there is either invasion of the stroma or fused glands in the middle of the lesion.
    In a consensus conference on Gleason grading of prostatic carcinoma, the International Society of Urological Pathology (ISUP) recommended that the diagnosis of Gleason score 4 on needle biopsy should be made “rarely, if ever” (1). The consensus conference cautioned that, although the potential exists for rendering a diagnosis of Gleason score 4 on needle biopsy, it is a diagnosis that general pathologists should almost never make without consultation. Even when that exceedingly rare Gleason score 4 cancer is diagnosed on needle biopsy by an expert, a note should be added that almost always a higher grade cancer would be seen in the corresponding prostate (if examined at radical prostatectomy).
    There was only a 36.8% of agreement when the consultation referred to atypical lesions. This lesion is also known as ASAP (atypical small acinar proliferation). It is important for the urologist to know that ASAP is not a diagnostic entity and is not synonymous with high-grade prostatic intraepithelial neoplasia (HGPIN). It represents descriptive diagnostic terminology in which there is architectural and/or cytologic atypia that does not reach an individual pathologist’s threshold required for the diagnosis of cancer. In a consensus conference sponsored by the World Health Organization, the committee members recommended designating atypical biopsies as either “suspicious” or “highly suspicious for cancer” (2). The reasons for this, include the equation by some urologists of the term ASAP with HGPIN and because all of the atypical foci are not always “small” acinar but may include glands with larger diameter (such as pseudohyperplastic pattern of cancer or adenocarcinoma with ductal features).
    The conclusion of the paper surveyed is that atypical lesions (“suspicious for cancer”) have the highest likelihood of being changed upon expert review and that urologists should consider sending such cases for consultation to attempt to resolve the diagnosis as definitively benign or malignant before subjecting the patient to repeat biopsy.

References
1. Epstein JI, Allsbrook WC, Amin MB, Egevad LL and the ISUP Grading Committee: The 2005 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma. Am J Surg Pathol. 2005; 29: 1228-42.
2. Amin M, Boccon-Gibod L, Egevad L, Epstein JI, Humphrey PA, Mikuz G, Newling D, Nilsson S, Sakr W, Srigley JR, Wheeler TM, Montironi R: Prognostic and predictive factors and reporting of prostate carcinoma in prostate needle biopsy specimens. Scand J Urol Nephrol. (suppl) 2005; 216: 20-33.

Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil