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Prostate Biopsy
Before You Get a Biopsy
"Free" PSA May Reduce Need for Some Prostate Cancer Biopsies May 20 1998 This article explains why follow-up tests should be done after the basic PSA test before a biopsy is undergone.
For Biopsy, Get Second Opinion (article, December 9 1999). This article remains relevant. If you receive news of a positive biopsy, make sure you get the pathology slides re-read by a specialist. No one should make decisions about cancer on the basis of a biopsy read by any one local pathologist. Some people have been over-treated and others under-treated because of poorly interpreted biopsy slides. Names of some excellent laboratories are listed below.
If You Need a Biopsy
Prostate biopsy and other procedures are often done without pain relief. Some men are not bothered by the sensation if biopsy, some men really are. A Scientific American editorial, A Real Pain August 2002, asks why this problem has not been solved.
Ask your doctor about lidocaine gel before the biopsy. Today some urologists offer their patients light sedation for this procedure.
Gleason grading system
This is commonly used to grade severity of prostate cancer. After the doctor has taken biopsy samples of your prostate tissue, he or she sends them to a pathology lab. The pathologist looks at the samples under a microscope and grades the tissue on a scale of 1 to 5. The low number, 1, is for cells that look almost normal (very slow growing cancer). The high number, 5, is for cells that are least like normal prostate cells. Grades 2 to 4 fall in between.
Prostate cancer tumors often have areas of various grades. The pathologist identifies the two most prevalent grades. These are then added together to make the Gleason score (also called Gleason sum).
The result looks like this: 1 + 2 = 3; or 3 + 2 = 5; or 3 + 3 = 6; or 3 + 4= 7; or 4 + 3 =7; or 4 + 4 = 8, and so on.
Notice that the order of these numbers matters.
3 + 4 = 7 is a different grade of cancer than 4 + 3 = 7.
In a grade 7 made up of 3 + 4, most of the cancer found is moderately aggressive (3), with less that is more highly aggressive (4).
In a 7 made up of 4 + 3, the balance has tilted. The patient may need more aggressive treatment.
The Gleason grading system is named after the physician who formulated it.
Normal body tissue cells are well-formed and differentiated to fit the functions of the specific body part. As you see in this image above, cells at the far right end (5) are quite shapeless and random compared to the moderately differentiated cells in the middle and the quite regular-looking cells at the left (1).
A small tumor with nearly normal structure (well differentiated) will behave in a more normal biological way. It may grow very slowly, with a doubling time of many years, and might never become a serious threat to health. A tumor that is moderately differentiated or undifferentiated is faster growing and more likely to spread.
High-grade tumor cells, having lost the special structure, or "architecture," that made them work as part of the prostate gland, may not even put out much PSA. This is one reason the Gleason grade and score are such key pieces of information for making treatment decisions.
A second opinion about the biopsy results is highly recommended because, firstly, reading the slides is a highly-trained skill and some would say an art. Secondly, treatment decisions depend heavily on the accuracy of the tumor grade.
A number of pathologists at leading cancer centers do second opinion prostate biopsies. Here are three contacts in the USA:
Urologic Pathology Laboratory Johns Hopkins Hospital is a nationally recognized center for prostate biopsy and study of urologic disorders. Vast expertise in the study and diagnosis of the pathology of prostate cancer. Primary consultant, Dr. Jonathan Epstein. Check the web page and call 1-800-997-5475
Bostwick Laboratories (David G. Bostwick, M.D., M.B.A.) is a pathology reference laboratory serving patients as well as physicians and managed care. Services include Primary Biopsy Interpretation; Second Opinion; DNA Ploidy Analysis; Immunohistochemistry (markers include p53, c-myc, and bcl-2 oncogene and tumor suppressor gene products and CD34 angiogenesis marker). Dr. Bostwick is one of the authors of the ACS book Prostate Cancer, What Every Man - and His Family - Needs to Know (1996, 1999, Villard, New York, $14.95).
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