Uropathology expert Dr. Ming Zhou shares responses to most common Qs from his patients
Check out the AS calendar--join me for lunch at Chicago Area Active Surveillors
Editor’s note: Pathology Report columnist Ming Zhou, MD, PhD, shares his most commonly asked questions from his patients—and his answers. He is one of the few pathologists who will discuss his findings with you and will recommend a course of management.
He has moved to Mount Sinai Health System in New York City. If you have questions for him, please contact him directly at Email: Ming.zhou@mountsinai.org. HW
Prostate Cancer Pathology: Understanding Your Biopsy Report
1. What is the Gleason score, Grade Group and ISUP grade, and what does it mean?
Gleason score assesses the aggressiveness of prostate cancer based on how abnormal the cancer glands appear. It ranges from 6 to 10, combining the most common and worst patterns seen in the biopsy.
This is also categorized into Grade Groups 1 to 5:
• Grade Group 1 (Gleason score 6): Low-grade prostate cancer
• Grade Group 2 (Gleason score 3+4=7): Intermediate risk cancer
• Grade Group 3 (Gleason score 4+3=7): Intermediate risk cancer
• Grade Group 4 (Gleason score 8): High-grade cancer, more aggressive
• Grade Group 5 (Gleason score 9 and 10): High-grade cancer, more aggressive
Grade group is sometimes referred to as ISUP grade. They are interchangeable; however, Grade Group is the preferred term to use.
What is the clinical stage?
The clinical stage describes how extensive the prostate cancer is based on the physical exam and imaging:
• T1 (Tumor not detectable by digital rectal examination (DRE) or imaging)
• T1a: Cancer found incidentally during surgery for benign prostatic hyperplasia (BPH), and in <5% of tissue.
• T1b: Found incidentally during BPH surgery, but in >5% of tissue.
• T1c: Found by needle biopsy due to elevated PSA, but not palpable or visible on imaging.
T2 (Tumor can be felt on DRE or seen on imaging but is confined to the prostate)
• T2a: Tumor in less than half of one lobe of the prostate.
• T2b: Tumor in more than half of one lobe, but not both lobes.
• T2c: Tumor involves both lobes of the prostate.
T3 (Tumor extends outside the prostate)
• T3a: Extracapsular extension (outside the prostate gland), but not into the seminal vesicles.
• T3b: Tumor invades seminal vesicles.
T4 (Tumor invades adjacent structures)
This includes invasion of the bladder neck, rectum, external sphincter, etc. Indicates locally advanced prostate cancer.What is the NCCN risk category?
NCCN risk groups categorize prostate cancer into risk levels based on PSA levels, prostate biopsy findings (Gleason score, tumor extent, etc.), and clinical stage to guide treatment options and predict clinical outcomes.
• Very Low / Low Risk
• Favorable / Unfavorable Intermediate Risk
• High Risk
• Very High RiskWhat information do prostate biopsy reports contain?
Prostate biopsy reports contain a plethora of information that is important for patient management and include the following:
• Number of biopsy samples taken and biopsy cores containing cancer, and percentage of cancer in each involved core.
Biopsies usually take 10–14 core samples and additional MRI-guided biopsy cores. The number that contain cancer and % of each positive core involved by cancer help assess tumor burden and guide management.
• Gleason score and grade group in cases that contain cancer (see Q1).
• Other significant findings, including the presence of intraductal carcinoma, cribriform cancer, high-grade neuroendocrine carcinoma, extraprostatic extension or seminal vesicle involvement, and perineural invasion.Should the slides be reviewed by another pathologist or at a specialized center?
If the diagnosis and grading may significantly impact the management, it is often helpful to have the slides reviewed by a specialist in genitourinary pathology, especially at a high-volume cancer center. For example, if you are diagnosed with Gleason score 3+3=6 cancer and you are considering active surveillance, a re-review can ascertain the diagnosis and grading for personalized treatment.How does the pathology report affect treatment options?
Pathology guides treatment:
• Low-grade, low-volume cancer → Active surveillance
• Intermediate → Radiation or surgery, may also consider active surveillance
• High-grade or advanced → More aggressive treatment (multi-modal therapy)Based on the pathology reports, what questions should I ask my urologist or oncologist?
• What are my treatment options?
• What are the pros/cons of surgery vs radiation vs active surveillance?
• Is my cancer likely to grow or spread?
• Would you recommend genetic testing or advanced genomic testing?Should I have a Decipher Prostate test done on the specimens?
The Decipher Prostate test is a genomic test that assesses risk of progression. It can help decide between active surveillance and treatment, or guide post-surgery therapy for better outcomes.Active Surveillor calendar
—Dr. Jonathan Epstein talks in a free webinar. Epstein is presenting a program entitled, “What you need to know about your prostate biopsy—the new news.”
The Active Surveillor newsletter is hosting the event. Co-sponsors are Active Surveillance Patients International and AnCan, key organizations in prostate cancer support and education.
The program will be on from noon to 1:30 p.m. Eastern on Saturday, May 17. Register for the meeting: https://us02web.zoom.us/meeting/register/JwtdomJnT3mJttTI8urvuQ
Please send questions in advance to: Howard.wolinsky@gmail.com.
—Chicago Area Active Surveillors meet in person 11:30. a.m.-1 p.m. May 21,
Be there or be square. But you gotta’ be there in person.
The newly formed Chicago Area Active Surveillors is meeting at
Seasons 52 in the Napa Room
3 Oakbrook Center
Oak Brook, IL 6052If you want to join us, let me know at howard.wolinsky@gmail.com.
We have drawn members from as far away as Columbia, Missouri, for the meeting of what we believe is the largest in-person AS-only support group on the planet—certainly in the Chicago area.
—ZERO’s town hall meeting on ZOOM. Prostate cancer research—along with research on other diseases—has taken a body blow.
Attend a ZERO Prostate Cancer town hall at 7 p.m. Eastern May 20 by ZERO to discuss the status of funding cuts under the proposed federal budget and what can be done about it. Register for the session here. More background on the cuts proposed for CDC here.
—UMiami’s Sanoj Punnen takes on the debate over transperineal vs. transrectal biopsies. Active Surveillance Patients International (ASPI)’s monthly webinar will focus on these issues in a program entitled, “The great biopsy debate: Where do we stand on transperineal vs. transrectal?”
The program will be on Saturday, May 24 from noon to 1:30 pm Eastern.
Register here:
https://zoom.us/meeting/register/UZVDHmq9Rlyw6y_mqmK0hg#/registration
Check out Punnen’s presentation of the MAST AS study at the recent meeting of the American Urological Association: https://news.med.miami.edu/improving-prostate-cancer-prediction-during-active-surveillance/
Please send questions in advance to: contactus@aspatients.org
Letter from a reader
I recently wrote an article about the importance of heart health for prostate patients. I heard from Guylaine:
“I usually only read prostate-related articles currently, but this was very informative and uplifting. Just had an appointment with my husband at Mass General with urologist, did my best to sit there and not say too much. He did not say one thing that I did not fully understand, thanks to the education I have received here.” (Emphasis added.)
Thanks, Guylaine. That’s one of the things I hope for in writing the blog. But don’t be shy about asking questions. I also suggest recording these visits. Howard
Sir Ian McGeechan: ‘I have prostate cancer’—Rugby’s ‘Lion King’ treated for PCa, urges players to get tested
By Howard Wolinsky
Sir Ian McGeechan, rugby’s so-called “Lion King,” former head coach of Scotland, British and Irish Lions, has gone public with his diagnosis and treatment of prostate cancer. He also offered his players some advice—get tested.
The United Kingdom is in the midst of a debate on whether the UK National Health Service should launch a national screening program for prostate cancer, Right now, screening is “opportunistic” in UK, meaning a patient typically asks for a PSA rather than the NHS or his GP recommending screening to the broad population.
The 78-year-old is currently consultant director of rugby at Championship club Doncaster Knights. The former center and fly-half—a half-fly position is the “brains” of the backline— won 32 Scotland caps, captaining them nine times, and toured with the Lions in 1974, winning the series in South Africa, and in 1977. He coached Scotland to the Five Nations Grand Slam in 1990 and led the Lions to series victories as coach in 1989 and 1997.
McGeechan told The Telegraph he had just completed a six-week course of radiotherapy. There was no mention in the media of his PSA levels, Gleason score, or PI-RADS so we don’t know if he was a candidate for Active Surveillance.
That’s par for the news coverage.
"I don't want to make a big thing of it, but it is important to get the message out about urging people to go and get tested," he said. "I said that to our players here, to make sure they get themselves tested.”
