Accurate tumor staging and grading are essential requisites to treatment decisions in prostate cancer, avoiding overtreatment in men with low-risk disease and drawing attention to high-risk disease requiring aggressive treatment in other cases.

The authors analyzed the impact of core biopsy fragmentation and the relation between core biopsy taken and pathological information in regard to cancer extension and aggressiveness.

The present study is, to the best of our knowledge, the first in the literature that shows the possibility of core fragmentation, explaining in part over, and under staging(1). Core fragmentation could generate confounders such as inaccuracies on cancer volume, classifying a low-risk or ''indolent'' cancer as a larger volume cancer. It could impact directly the number of positive cores, the cancer percentage of core and Gleason score, which are validated aspects to predict low-risk cancer.

The authors encouraged that the fragment cores from the same site should be sent in a container and that pathologists should add the information of all fragments to give the final report as one unique core. Considering fragmented cores as one unique core could improve biopsy accuracy, mainly in the detection of patients presenting low-risk disease, avoiding overtreatment and unnecessary co-morbidities related to the treatment. This is supported by others and validates the 2005 International Society of Urological Pathology Consensus Conference on Gleason grading of prostatic carcinoma.(2) Still, submitting one core per container might reduce fragmentation and thereby improve the ability to diagnose, quantify, and grade cancer in needle core tissue.(3)

Beyond the absolute number of fragments affected, other techniques may be used to measure cancer in prostate needle biopsy cores including the total length of prostatic adenocarcinoma on a needle core, the percentage of tumor involving a prostatic needle core, the overall percentage of cancer in a specimen and the fraction of needle biopsy cores with cancer.(4, 5)

Other studies showed that is important to assign a separate Gleason score for each intact core, especially in cases with high Gleason score cancer on at least one core.(6, 7) Most of the validated and widely used nomograms (including Partin tables) use the worst Gleason in cases where multiple cores are positive with different scores. In cases where cores are fragmented, an overall global Gleason score should be reported.(7)

References:

1. Reis LO, Reinato JA, Silva DC, Matheus WE, Denardi F, Ferreira U. The impact of core biopsy fragmentation in prostate cancer. Int Urol Nephrol. 2010 Mar 11. [Epub ahead of print].

2. Epstein JI, Allsbrook WC, Jr., Amin MB, Egevad LL. The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. Am J Surg Pathol. 2005 Sep;29(9):1228-42.

3. Gupta C, Ren JZ, Wojno KJ. Individual submission and embedding of prostate biopsies decreases rates of equivocal pathology reports. Urology. 2004 Jan;63(1):83-6.

4. Brimo F, Vollmer RT, Corcos J, Kotar K, Begin LR, Humphrey PA, et al. Prognostic value of various morphometric measurements of tumour extent in prostate needle core tissue. Histopathology. 2008 Aug;53(2):177-83.

5. Sebo TJ, Bock BJ, Cheville JC, Lohse C, Wollan P, Zincke H. The percent of cores positive for cancer in prostate needle biopsy specimens is strongly predictive of tumor stage and volume at radical prostatectomy. J Urol. 2000 Jan;163(1):174-8.

6. Kunz GM, Jr., Epstein JI. Should each core with prostate cancer be assigned a separate gleason score? Hum Pathol. 2003 Sep;34(9):911-4.

7. Kunju LP, Daignault S, Wei JT, Shah RB. Multiple prostate cancer cores with different Gleason grades submitted in the same specimen container without specific site designation: should each core be assigned an individual Gleason score? Hum Pathol. 2009 Apr;40(4):558-64.e

Written by Leonardo Oliveira Reis, MD, MSc and Emerson Luis Zani, MD as part of Beyond the Abstract on UroToday. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations, etc., of their research by referencing the published abstract.

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