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Probing the Common Problems of the Needle Biopsy

Probing the Common Problems of the Needle Biopsy

Updated: 12/21/2015

Getting the right pathology assessment of your prostate biopsy is just as important as getting a second opinion for surgery or radiation. You could have the best surgeon in the world, but if you don't have the right pathology report, you could get the wrong type of treatment.

The Trouble with Prostate Biopsies

Prostate biopsies are probably the most challenging to evaluate, according to Jonathan Epstein, M.D., a world-renowned pathologist at Johns Hopkins Medicine. It’s especially difficult because there’s such a limited amount of tissue, and cancers tend to creep around the benign gland, rather than forming as a solid mass.

Dr. Epstein compares the prostate biopsy to a small piece of candy wrapped in paper. The cancer is like the paper, a veneer over an expanse of healthy tissue. And the veneer is often very ambiguous. Not only can the hollow-core biopsy needle overshoot and miss the cancer, but the cancer cells it does get don't always match the pictures in the textbook.

Results that Are Hard to Evaluate

One result of a prostate biopsy is considered atypical. This diagnosis appears in about 5 percent of biopsies at most institutions. Basically, a pathologist will see something that could be cancer, but he or she is not comfortable labeling it cancer. For many patients, the next step is to have a repeat biopsy, which may or may not be helpful.

Unfortunately, the biopsy can miss cancer cells. So if the biopsy results come back negative, it doesn't mean that the patient is cancer-free. In fact, the cancer can be extensive. Dr. Epstein has seen some cancer cases that the biopsy missed entirely.

A repeat biopsy might be a reasonable option if no cancer is found. However, if there is already a diagnosis of cancer, or even atypical cells, a repeat biopsy may lead to more confusion.

An Abundance of Overdiagnosed Cancer Cases

Unfortunately, many pathologists seem just as likely to overdiagnose cancer. According to Dr. Epstein, there are many mimickers of prostate cancer under the microscope that inexperienced pathologists can misdiagnose as cancer. Each year, about 1.5 percent of patients who go to the James Buchanan Brady Urological Institute with a diagnosis of prostate cancer are found to have been misdiagnosed.

How to Handle Tricky Diagnoses

To address an uncertain diagnosis, send your slides to an expert pathologist. Most of the time, an expert second opinion can resolve the biopsy results as definitively benign or definitely malignant. Even biopsies that seem straightforward deserve another look. Experts at Johns Hopkins Medicine recommend getting a second opinion before undergoing any form of treatment.

Analysis Reveals Glitch in Gleason Scoring

Pathology experts at Johns Hopkins Medicine have conducted numerous studies showing the reproducibility of Gleason scores in the general pathology community, looking at the Gleason grade based on the biopsy and then comparing it to the actual specimen removed during surgery. They have found that the Gleason grading that's initially performed is usually disappointing. Often, it doesn't correlate with the results of the radical prostatectomy. So patients are making important decisions regarding treatment or watchful waiting based on inaccurate information about their health.

You should especially beware of biopsies that are given a low-grade Gleason score. From the standpoint of patient care, the low-grade Gleason score (2 to 4) doesn't exist, and it gives the patient a false sense of optimism. Even if a pathologist identifies a tumor as Gleason 2 to 4 in a biopsy, when the prostate is removed in a radical prostatectomy, it will turn out to be Gleason 5 or greater.

Low-grade Gleason tumors exist in the central transition zone of the prostate, not in the peripheral zone where biopsies are taken. A genuine low-grade Gleason score is more likely to appear in a transurethral resection of the prostate (TURP), a procedure used to treat prostate enlargement. A low-grade Gleason score is valid on a TURP but not on a needle.

Online Course Promotes Expert Pathology

To improve prostate cancer diagnosis, Dr. Epstein is teaching pathologists through an online tutorial. Unlike articles or other resources, this educational tool is designed to reach many pathologists very quickly.

As part of the course, pathologists are asked to grade a set of biopsies. Then, they're shown some of the telltale signs of various grades and taught how to interpret another set of biopsies. Finally, they have to re-evaluate the biopsies. If you are interested in learning more, visit the Department of Pathology at Johns Hopkins University.


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