Prostate cancer staging and datasets: What determines our The … · 2019. 2. 15. · 06/07/2018 1...
Transcript of Prostate cancer staging and datasets: What determines our The … · 2019. 2. 15. · 06/07/2018 1...
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Dan BerneyMaastricht 2018
Prostate cancer staging and datasets:
The Nitty-Gritty
Biopsy reporting. How not to do it.
The TNM 8th edition. Changes good and bad
Some philosophy….
What determines our pathological reports?
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Left base: Five disrupted prostate cores, three of which contain a moderately to poorly differentiated adenocarcinoma of the prostate gland, Gleason grade 3+4 (=score 7). The approximate ratio of Gleason pattern 3 to 4 is 95:5. The tumour occupies discontinuous lengths of 3 (2.5+0.5)mm (spanning 4mm) 2.5 (2+0.5) mm (spanning 3mm) and 2 (1+0.5+0.5) mm corresponding to to approximately 75%, 50%, and 25% of the areas studied in each core respectively. There is perineural invasion in one core, but no evidence of acute inflammation, high grade PIN, or extraprostatic extension.
Conclusion
Gleason grade 3+4Grade Group 2No of involved cores 18Total tumour length 85mmTotal length of all cores studied: 191mm% of tumour length in all cores 5%Maximum tumour length: 13mmTumour Laterality: Bilateral
Left base: Five disrupted prostate cores, three of which contain a moderately to poorly differentiated adenocarcinoma of the prostate gland, Gleason grade 3+4 (=score 7). The approximate ratio of Gleason pattern 3 to 4 is 95:5. The tumour occupies discontinuous lengths of 3 (2.5+0.5)mm (spanning 4mm) 2.5 (2+0.5) mm (spanning 3mm) and 2 (1+0.5+0.5) mm corresponding to to approximately 75%, 50%, and 25% of the areas studied in each core respectively. There is perineural invasion in one core, but no evidence of acute inflammation, high grade PIN, or extraprostatic extension.
Conclusion
Gleason grade 3+4Grade Group 2No of involved cores 18Total tumour length 85mmTotal length of all cores studied: 191mm% of tumour length in all cores 5%Maximum tumour length: 13mmTumour Laterality: Bilateral
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Biopsy site(Modified BarzellZone)
1Left anterior apex
2Left anterior base
3Right anterior apex
4Right anterior base
5Midline apex
6Midline base
Block number A B C D E FNumber of cores 6 6 8 6 1 1Longest core (mm) 11 10 13 14 12 11Adenocarcinoma present?
Yes Yes Yes Yes No No
Number of cores involved
1 2 7 5 0 0
Largest cancer focus (mm)
1 3 7 7 0 0
Total core length (mm)
55 48 68 50 12 11
Total cancer length (mm)
1 4 32 28 0 0
% cancer in sample 1 8 47 56 0 0Gleason 3+3=6 3+4=7 3+4=7 3+4=7 - -Perineural invasion No No No Yes No NoHigh grade PIN in 1 core?
No No No No No No
SPECIMENS
Left Base: 3/5 prostate cores show adenocarcinoma, Gleason score 3+4=7 without cribriform areas, (5% grade 4) (3mm 75%, 3mm 50%, 2mm 25% discontinuously) Perineural invasion seen.
Conclusion: prostatic adenocarcinoma, Gleason score 3+4=7, Grade Group 2 in 18/25 cores, Perineural invasion seen.
IS THERE CANCER?TYPE IT
GRADE IT MEASURE IT
OTHER FACTORSPNI, LVI, ECE etc
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What do clinicians really (really) want?
Survey Question Responses (percentage)
Surgeon Oncologist Total
Which tumour extent parameter do you use?
Number (+) cores 77 (97) 20 (83) 97 (94)
Number (+) cores each side 35 (44) 8 (33) 43 (42)
% number of cores 73 (92) 24 (100) 97 (94)
mm linear extent 49 (62) 13 (54) 62 (60)
% linear extent 64 (81) 23 (96) 87 (84)
Which mm linear extent do you use? Surg Onc BothDon't use 30 (38) 11 (46) 41 (40)
mm each core 21 (27) 2 (8) 23 (22)
Maximum mm in a core 37 (47) 11 (46) 48 (47)
Aggregate mm 12 (15) 3 (13) 15 (15)
Which % linear extent do you use?
Don't use 24 (30) 3 (12) 27 (26)
% each core 20 (25) 7 (27) 27 (26)
maximum % in a core 25 (32) 8 (31) 33 (31)
Aggregate % 33 (42) 10 (38) 43 (41)
Other 0 (0) 2 (8) 2 (2)
Here is a prostate cancer with 60% core involvement.
And here is one with20% core involvement!
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Percentages are determined by the amount of benign tissue biopsied!
Precise measurements are pointless
• Different levels?!• How long is a stromal gap and
on which level?
Biopsy measurement in age of mpMRI
• Targeted• Biased samples• Should we be counting per SITE
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Peri-Neural Invasion• Is it worth the bother!• Neurosafe
Are we serving the patients, the clinicians or ourselves?
Is the data we provide of patient benefit?
TNM AJCC/UICC Editions Edition Publication Dates for cancer
diagnosis
1st 1977 78-83
2nd 1983 84-88
3rd 1988 89-92
4th 1992 93-97
5thy 1997 98-02
6th 2002 03-09
7th 2009 10-17
8th 2016 18-
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Changes in 7th edition
• Microscopic bladder neck invasion downstaged from pT4 to pT3a
• Gleason score recognised as preferred grading method
• Prognostic factors: Gleason and PSA incorporated into prognostic stage groups
Changes in AJCC 8th edition
• Pathologically organ confined disease no longer subclassified
• Gleason score by 2014 criteria and grade group given
• AJCC prognostic stage 3 includes some organ confined tumours based on PSA and grade
• Statistical prediction models included
Which?
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Which Errata?
• Present the changes in AJCC TNM 8th edition
• Critically look at the evidence base
• Examine areas of doubt• Potential for further refinements
Clinical cT category
Tx Primary tumour cannot be assessed
T0 No evidence of primary tumour
T1 Clinically inapparent tumour which is non palpable
T1a Incidental finding in 5% or less of tissue resected
T1b Incidental finding in more than 5% of the tissue resected
T1c Tumour found by needle biopsy but impalpable
T2 Tumour is palpable and confined within the prostate
T2a Tumour occupies 1 half of one side or less
T2b Tumour involves more than one half of one side but not both sides
T2c Tumour involves both sides
T3 Extra-prostatic tumour that is not fixed or does not invade adjacent structures
T3a Extra-prostatic extension
T3b Seminal vesicle invasion
T4 Fixed or invades other structures other than SVs (rectum, muscles, pelvic wall)
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Do not use..• MRI• CT• Biopsy information on laterality
Staging of TURP Chips
• T1a 5% involvement• T1b More than 5%• Cantrell BB et al. • Pathological factors that influence
prognosis in stage A prostatic cancer: the influence of extent versus grade. J Urol. 1981;125:516–520
• 117 patients followed for 2 to 15 years• In 14 patients (12%) extensive local (2) or
metastatic (12) disease developed. • Extent and grade of disease accurately
predicted progression.• No patient with Gleason 2 to 4 had progression • Patients with <5 % cancer; 2% had progression. • Patients >5 % cancer; 32% had progression
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How do you measure % involvement?
1. Estimate of area involved overall.2. Count positive and negative
chippings.
HR=2.08, 95% CI=1.8 -2.4 P < 0.0001
0.00
0.25
0.50
0.75
1.00
Sur
viva
l fro
m p
rost
ate
canc
er (%
)
0 2 4 6 8 10Time since entry (years)
cancerous chips <= 10% cancerous chips >10-25%cancerous chips >25-75% cancerous chips >75%
Rajab R et al. An improved prognostic model for stage T1a and T1b prostate cancer by assessments of cancer extent. Mod Pathol. 2011 Jan;24(1):58-63 (Fig. 1).
Conclusions• Preoperative cT staging by TNM
still has huge variability as it uses low level technology and some historic data.
pT staging • Applicable only to men who have
had a radical prostatectomy.
• Not WW, AM, RT, Brachytherapy, hormones etc etc!
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PATHOLOGIC STAGE
CRITERIA
T2 Organ Confined
T3 Extraprostatic extension
T3a Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
T3b Tumour invades seminal vesicles
T4 Tumour is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles and/or pelvic wall
2a
2b
2c
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= pT2b
What’s also not there…• Tumour volume• Extent of extra-prostatic
extension• Surgical margin assessment
The prostatic capsule • A condensed fibromusculr layer
of prostatic stroma• Well formed;
– Posterolateral• Poorly seen
– Apex, anteriorly, bladder neck
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EPE
• The presence of neoplastic glands abutting on or within periprostatic fat or beyond the adjacent fat plane in situations where no fat is present in the immediate area of interest (most useful at the lateral, posterolateral and posterior aspects of the prostate)
• Neoplastic glands surrounding nerves in the neurovascular bundle (posterolaterally) beyond the boundary of the normal prostatic glandular tissue.
• A nodular extension of tumour bulging beyond the periphery of the prostate or beyond the compressed fibromuscular prostatic stroma at the outer edge of the gland.
T3a
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T2 or T3a?
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Subclassification of pT3a disease
F-EPE ‘a few neoplastic glands outside the prostate on1-2 slides’
‘Tumour is found outsidethe prostate to a depth of <1 high-power field in 1-2Sections’
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Other TNM changes
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Risk assessment tools• 15 multivariate models assessed• Only 2 models on metastatic
disease from large Phase 3 studies accepted
• All OC models rejected!
Conclusions• We need to lead and be better in
biopsy reporting with education of clinicians and pathologists .
• TNM Improved from previous but still crude.
• Much further work is necessary to catch up with other organ risk prediction models