Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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Prostate Cancer
Our group has been & is involved in a comprehensive prostate cancer diagnosis and treatment program at Lexington Medical Center since 1991-1992, having even invented a highly unique processing technique which has been published.
  • An historical timeline concerning prostate cancer, HERE.
  • Discussion file: 26 page overview paper by Dr. Shaw.
  • Your statistical risk of getting prostate cancer: for the healthy; here's an on-line risk calculator for odds that a man will get (or already have) prostate cancer.
  • How many biopsy cores should be obtained: The transrectal sextant (6 biopsies) pattern approach improved detection beginning in 1989; but actual detection of the cancer depends on variables of PSA production by cancer, cancer location in gland, the size of the gland, & cancer volume. Transperineal "saturation" techniques (20 or more cores) started around 2004 when repeat sessions on heretofore negative biopsy encounters were had with high risk persons so as to sample the anterior area, also. The Vienna nomogram was put forth in 2005 as a way to adjust the number of biopsy cores in men with PSA 2-10 according to their gland size & age.
  • Pretreatment & post-radical surgery nomograms: Some urology practices give link to the "prostate calculator" [HERE]. And there are the MSKCC calculators: (1) click prostate on the MSKCC drop-down menu or left-margin choices & click into the cancer risk calculation tool (I think its based on the several Kattan nomograms) to even check whether you might have likelihood of an "indolent" cancer, allowing you to take real time to weigh decisions or even deliberately enter a "watch & wait" process (very precise data needed &, if your path report does not have it, ask for it ...the pathologist can recheck the slides and obtain the data...the 1992 & 1997 staging of T2 has 3 choices in 1992 [T2a < half of one lobe, & T2b one lobe, & T2c bilateral cancer] & 2 choices in 1997 [T2a one lobe & T2b both lobes]). The CAPRA1 score can predict likelihood of relapse free survival (somewhat as with Kattan) after radical prostatectomy. And the Fleshner nomogram 2 can evaluate low risk cancers...candidates for brachytherapy or watchful waiting (active surveillance) to predict likelihood that findings in prostatectomy of that case would cause a postop Gleason upgrade (nomogram helps avoid potential under-treatment). NOTE: the nomograms do not know how to "back out" the inflammatory portion of elevated PSA, if the case has significant prostatitis [S07-6946]. (2) Or find authoritative discussions...with tables of pros & cons...of each treatment option by Mayo Clinic: click on "treatment decisions" at the page top...scroll down to "Prostate Cancer Guide" and click through "about prostate cancer" & chose "treatment decisions". Currently operable only via Internet Explorer browsers. The Center for Prostate Disease Research (CPDR) has an online calculator to help indicate prognosis AFTER biochemical recurrence following radical prostatectomy. Lexington Medical Center has a comprehensive array of services and interests in prostate cancer:
  • Screening for the cancer:
    • discussion file pages 4 & 5.
    • about the PSA test.
    • about brands of PSA test kits.
    • we have a case example with a 22 gram gland coming to our attention due to PSA going in our lab from 1.3 in 2003 to 5.9 in 2007 for an alarming PSA velocity of 1.16 ng/mL/year and doubling time of 1.82 years and density quite elevated at 0.268 ng/mL/cc of gland. Twelve patterned biopsies found active periglandular lymphocytic chronic prostatitis. This was "positive" for a diagnosis explaining the PSA parameters but "negative" for prostate cancer. Therefore, let's check the...
    • concept of "false positive" & "false negative"  tests & biopsies.
  • Biopsy diagnosis:
  • Is it a SIGNIFICANT cancer (see the above MSKCC on-line risk tool for treatment options)?
    • significance factors...including notes as to May 2007 AUA Treatment Guidelines & the definition of "low risk cancer"...the cancer might be low risk if PSA is 10 or less. And, the report indicates that high risk patients tend to do better on combination treatment.
    • prostate size: by transrectal ultrasound (TRUS), a normal gland averages about 20 cc (20 grams) & is considered enlarged when it gets to 30 cc. The TRUS measurement is a rough measure that is probably better than the clinical measurement by DRE. Gland size is used in some nomograms, as above.
  • Prostate cancer types:
    • acinar: the classical common type.
    • signet ring: an acinar variant that is aggressive [S-03-4765].
    • mucinous (colloid): at least 25% of the cancer in pools of mucous: an aggressive acinar variant.
    • hypernephroid acinar pattern is a Gleason 4 + 4 = 8.
    • prostatic duct (endometrioid) adenocarcinoma: columnar cells in papillary (sometimes as clear cells) or cribriform pattern...sometimes solid or comedo-like. No Gleason scoring. PSA positive.
    • transitional cell:
    • neuroendocrine: (implies chemotherapy)
      • pure: neuroendocrine & pan keratin pos. but not any PSA evidence.
      • neuroendocrine variant of acinar: via serum PSA elevations, IHC-PSA. positivity, and/or ProstaScint positivity...the tumor has mixed positivities [S-04-1315].
    • mixed: acinar plus ductal adenocarcinoma not too uncommon; we had one that also had some neuroendocrine [L-06-4430].
    • spindle cell lesions of prostate: see Epstein JI, Modern Pathology p 149, Jan. 2007.
  • GLEASON Grading the cancer (how "bad" is it?):
    • grading basics @ JHU: taught discussion & many nice photos [HERE].
    • discussion file pages 10-13.
    • A Gleason 4 + 3 = 7 is much worse than 3 + 4 = 7 (JHU study of 2404 cases...U. Clin. NA 28(3):555-565, August 2001).
    • if 3 Gleason patterns seen in biopsies, the primary and the worst patterns are combined to give the "sum" or score, 3(50%) + 5(4%) + 4(46 %) = 8. In the prostatectomy, Gleason 7 with any minor 5 component has an even greater PSA failure rate than a 7 with primary pattern 4.
    • Johns Hopkins U. (JHU) grading tutorial for pathologists.
    • about DNA testing on biopsies; digital image analysis (DIA) reference labs (if your core contains enough cancer) [here] and [here] (these can do DNA on any malignancy).
  • Staging the cancer (how far has it gone?):
    • discussion file pages 8-10, e-coil MRI, etc.; and see above about treatment options on-line tool, as above.
    • an example of a staging graphic where we map the biopsy findings for viewing with e-coil trans rectal MRI.
    • bone mets: if no bone pain and PSA less tahn 20, almost always no bone mets.
    • Hamburg algorithm to check preoperative odds that your case is pelvic lymph node negative (you only need your pathology report data...but it must be very precise as to each cancerous biopsy).
    • ProstaScint nuclear medicine pre-op imaging/scan to see if nodes positive or extra-prostatic extension (we have this at our hospital & it noted one case with only a metastasis to the skull). Performed with injected radioactive-labeled anti-PSMA antibodies as markers to image benign and malignant prostate acinar glandular tissue.
    • the updated Partin tables (nomogram at Johns Hopkins U.) for odds of where cancer has gotten to ...with calculator (you need to know your PSA, cancer stage, and overall Gleason sum/score [example, 3+4=7]).
  • Treatments & post-treatment notes:
    • discussion file pages 16-24 about each mode of treatment  (and at the above Mayo Clinic site).
    • post-treatment PSA monitoring & confusion by PSA "bounce", etc.
    • post-treatment histopathology confusion.
    • recurrence: Use the CPDR web-based nomogram to calculate when PSA recurrence happened and PSA doubling time thereafter and the 5 & 10 year survival predictions following your recurrence. Here is a list of factors pathologists might quantitate in their reports that could increase the risk of recurrence [HERE] & references3,4.

References:

  1. May M, et. al., "Validity of the CAPRA Score to Predict..." , The J. of Urology 178:1957-1962, November 2007.
  2. Kulkarni GS, et. al, "Clinical Predictors of Gleason Score Upgrading...", Cancer 109(12):2432-2438, May 2007.
  3. Gustavo F. Carvalhal, M.D., Peter A. Humphrey, M.D., Ph.D., Phataraporn Thorson, M.D., Yan Yan, M.D., Ph.D., Christian G. Ramos, M.D., William J. Catalona, M.D."Visual estimate of the percentage of carcinoma is an independent predictor of prostate carcinoma recurrence after radical prostatectomy", Cancer 89(6):1308-1314, 2000.
  4. Humphrey PA, Frazier HA, Vollmer RT, Paulson DF, "Stratification of pathologic features in radical prostatectomy specimens that are predictive of elevated initial postoperative serum prostate-specific antigen levels", Cancer. 71(5):1821-7, 1 March 1993.
(posted Feb. 2001; latest addition 3 January 2011)

 
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