(Note: Dr. Ming Zhou’s column provides a short course on prostate pathology for patients with prostate cancer. His “The Pathology Report” column demystifies the prostate biopsy pathology reports to help patients like you and me understand how the pathology results may influence prostate cancer management decisions. At a reader’s request, how he is providing here a primer on biopsies for those of us who get them. This is Part 2.—Howard Wolinsky)
How Prostate Biopsy Specimens Are Processed: From Patients to Pathologists (Part 2)
5.Diagnosis of Prostate Cancer
Pathologists diagnose prostate cancer based on the presence of cancerous cells in the biopsy specimens. They assess the histological characteristics of the tumor, including Gleason grading, tumor extent, and other features such as perineural invasion and intraductal carcinoma.
A. Grading of Prostate Cancer: Prostate cancer is graded using the Gleason system, which evaluates the architectural patterns of cancer cells observed under the microscope. The Gleason score ranges from 6 to 10, with higher scores indicating more aggressive cancer. Pathologists assign a primary and secondary Gleason grade based on the most and second most predominant patterns observed in the biopsy specimen. The Gleason score is then integrated into a simpler Grade Group system for prostate cancer grading:
Grade Group 1: Gleason score 6 or lower
Grade Group 2: Gleason score 3+4=7
Grade Group 3: Gleason score 4+3=7
Grade Group 4: Gleason score 8
Grade Group 5: Gleason score 9-10
(Gleason score 3+3=6 [grade group 1]
(Gleason score 3+4=7 (grade group 2)
(Gleason score 5+5=10 (grade group 5)
6. The Role of Pathologists in Prostate Cancer Diagnosis and Management
Pathologists play a critical role in diagnosing and managing prostate cancer. They examine prostate biopsy cores under a microscope and assign a Gleason score based on cancer gland patterns. However, the interpretation of these patterns can vary among pathologists due to differences in experience, training, and individual judgment.
A. Complexity of Morphological Features: Prostate cancer can exhibit a wide range of morphological features, which may not always fit neatly into the established Gleason grading system, leading to discrepancies in interpretation.
B. Interobserver Grading Variability: Studies have shown significant variability in Gleason grading among pathologists. For example, I studied the diagnostic reproducibility and the quantitative threshold of grading as Gleason pattern 4 "poorly formed cancer glands," which is the most common Gleason pattern 4, and found it challenging even for urological pathologists, with poor agreement among them (Reference 1). Similarly, grading Gleason pattern 5 prostate adenocarcinoma on core needle biopsy also showed disagreement among urological pathologists (Reference 2).
With training and education, pathologists have significantly improved in Gleason grading, but they are not perfect. The advent of artificial intelligence tools holds tremendous promise for enhancing Gleason grading accuracy. In the meantime, second-opinion reviews of prostate biopsy pathology by another pathologist are crucial for ensuring accurate diagnosis and grading. These reviews do not have to be conducted by the world's best urological pathologist but by an experienced one who can confirm the assigned Gleason score and mitigate the risk of grading errors.
References:
1. Zhou M et al. Diagnosis of "Poorly Formed Glands" Gleason Pattern 4 Prostatic Adenocarcinoma on Needle Biopsy: An Interobserver Reproducibility Study Among Urologic Pathologists With Recommendations. Am J Surg Pathol. 2015 Oct;39(10):1331-9. doi: 10.1097/PAS.0000000000000457. PMID: 26099009 DOI: 10.1097/PAS.0000000000000457
2.Shah R et al. Diagnosis of Gleason pattern 5 prostate adenocarcinoma on core needle biopsy: an interobserver reproducibility study among urologic pathologists. Am J Surg Pathol. 2015 Sep;39(9):1242-9. doi: 10.1097/PAS.0000000000000442. PMID: 25929349 DOI: 10.1097/PAS.0000000000000442
(Note: Dr. Ming Zhou’s column provides a short course on prostate pathology for patients with prostate cancer. His “The Pathology Report” column demystifies the prostate biopsy pathology reports to help patients like you and me understand how the pathology results may influence prostate cancer management decisions. At a reader’s request, Ming here is pr…
NBA Hall-of-Famer gets radical after Gleason 8 diagnosis
By Howard Wolinsky
Naismith Basketball Hall of Fame center Alonzo Mourning underwent a prostatectomy after being diagnosed with Stage 3 prostate cancer, the star told ESPN.
Mourning—a seven-time All-Star, NBA champion and Olympic gold medalist in his 15-year career—is the latest sports figure to be diagnosed with or die from prostate cancer. Notorious NFL Hall of Famer O.J. Simpson died earlier this year from prostate cancer, and Chicago Cubs Hall of Famer Ryne Sandberg just announced scans found no signs of cancer since finishing chemotherapy.
(Alozno Mourning urges prostate cancer screening.)
NBA great Bill Walton just died from “cancer,” according to the league.
But news reports were divided on whether he had had prostate or colon cancer. Richard Sandomir,New York Times obit writer and former sports reporter, told me that an NBA spokesman informed him that the Walton family told them Walton died from colon cancer. The New York Daily News and many sports outlets pointed to prostate cancer.
Maybe the truth will come out. A loss either way.
(BTW, it’s possible to get both prostate and colon cancer, such as Lynch syndrome, an inherited cancer.)
"What scares me about this disease [prostate cancer] is that there are so many men walking around feeling great and have that cancer in them and they don't know it," Mourning told ESPN. "The only way to find out is to get their blood tested and get their PSA checked. There are 3.3 million men living in the U.S. with prostate cancer, and many don't even know it. I was one of those guys."
Mourning, who resumed his NBA career after a successful kidney transplant 21 years ago, recounted how a random conversation at a social event three years ago made him mindful to begin regular visits to a urologist in South Florida. In the back of Mourning's mind, he was aware that he had a family history of prostate cancer, including his father and grandfather.
Mourning, who had worked as Miami Heat’s director of player programs and development since his retirement in 2008, has been rehabilitating and returning to normal after his prostate procedure in March. That procedure allowed the removal of his cancer before it could spread outside of the prostate capsule.
“…if I had ignored getting checked and let this go, the cancer would've spread through my body," Mourning told ESPN. "Unfortunately, as men, we don't like to go to the doctor, but this is the only way to find out what's going on in your body. Prostate and even colon cancer are silent killers, and many men won't get that diagnosis until it's too late.
If there were a Pulitzer Prize for covering prostate cancer in athletes, a sure winner would be ESPN journalist Adrian Wojnarowski, who interviewed Mourning and his doctors. I often have complained here about the poor quality of reporting on prostate (and probably other) cancers especially by beat reporters for sports, politics, and entertainment. They usually don’t know what questions to ask.
However, like a veteran medical reporter, Woj was all over the PSA test and Gleason scores. He got some assists from Dr. Sanoj Punnen, at the University of Miami.
Great reporting.
Maybe Woj can ferret out the cause of Bill Walton’s death?
Also, kudos to Mourning for showing how A-listers can use their celebrity status to help educate the public about prostate cancers and other diseases.
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