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Comparative Pathology of TRUS Biopsy, Mapping Biopsy and Prostatectomy Specimens

Targeted Focal Therapy Workshop August 16 – 17, 2012. Comparative Pathology of TRUS Biopsy, Mapping Biopsy and Prostatectomy Specimens. Francisco G. La Rosa, MD Francisco.LaRosa@ucdenver.edu Associate Professor, Department of Pathology University of Colorado Denver, Aurora, Colorado.

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Comparative Pathology of TRUS Biopsy, Mapping Biopsy and Prostatectomy Specimens

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  1. Targeted Focal Therapy Workshop August 16 – 17, 2012 Comparative Pathologyof TRUS Biopsy, Mapping Biopsyand Prostatectomy Specimens Francisco G. La Rosa, MD Francisco.LaRosa@ucdenver.edu Associate Professor, Department of Pathology University of Colorado Denver, Aurora, Colorado

  2. SAGITAL SECTION OF THE PROSTATE GLAND Seminal Vesicle Bladder Central Zone Peri-urethral zone Transition Zone Peripheral Zone Anterior Zone Fibro-muscular Urethra

  3. FIBROMUSCULAR STROMA anterior PERI-URETHRAL STROMA EJACULATORY DUCTS CROSS SECTION OF THE PROSTATE

  4. HISTORY OF PROSTATE BIOPSY- 1930, Ferguson: First described prostate biopsy.Obtained cancer cells by aspirating prostate tissue with an 18-gauge needle transperineally.- 1937, Astraldi: First transrectal biopsy- 1963, Takahashi & Ouchi: First TRUS biopsy- 1967, Watanabe: First clinical application of TRUS images- 1980’s Transperineal biopsies

  5. The first sextant prostate needle biopsy scheme was developed by Hodge et al. in 1989 The sextant biopsy scheme consisted of biopsies of the prostate in the midline at the base, mid-gland, and apex. The midline sextant biopsies had a PCa detection rate of 20-30% . However, 25-50% of aggressive PCa remain undetected when using the midline sextant biopsies scheme. J Urol 1989; 142: 71-74 J Urol 2000; 163: 152-157 J Urol 2000; 163: 163-166 Urology 2003; 61: 1181-1186 J Urol 1998; 159: 1260-1264

  6. Stamey et al. in 1995 evaluated radical prostatectomy specimens and found that PCa had a higher likelihood of being found in the anterior horns of the peripheral zone and suggested that laterally directed biopsies may provide better detection. Urology 1995; 45: 2-12

  7. Multiple studies have found that directing prostate needle biopsies more laterally increases the PCa detection rates. J Urol 2000; 163: 152-157 J Urol 2000; 163: 163-166 Urology 2003; 61: 1181-1186

  8. The current recommendation is an extended-biopsy scheme with at least 8-12 cores including lateral biopsies. Transition zone biopsies are not recommended on initial evaluation. Curr Opin Urol 2004; 14: 157-162

  9. It is important to perform both the lateral modified fan-shaped biopsy and the midline sextant biopsies to improve overall PCa detections rates. • Thus, we recommend performing midline sextant biopsies , modified fan-shaped biopsy , and transition zone biopsies based on prostate volume, as follows: • 8 biopsies for ≤15 cc • 14 for those >15 cc but ≤50 cc • 14-20 for those >50 cc • Werahera PN, Sullivan K, La Rosa FG, Kim FJ, Lucia MS, O’Donnell C, Sidhu RS, Sullivan HT, Schulte B, Crawford ED. Optimization of Prostate Cancer Diagnosis by Increasing the Number of Core Biopsies Based on Gland Volume. . Int J Clin Exp Pathol (in press)

  10. TRUS Biopsies

  11. TRANS RECTAL ULTRASOUND (TRUS) GUIDED BIOPSY PROCEDURE

  12. Bad Histology

  13. Good Histology

  14. Peripheral Zone

  15. Central Zone

  16. Central Zone

  17. 40X Seminal Vesicles

  18. Mapping Biopsies

  19. Mapping Grid and its relationship with the Prostate

  20. Grid Alignment in perineal area and Rectal Location of Ultrasound Probe

  21. Pathology Report of Mapping Biopsies

  22. 3D Reconstruction of Prostate With Location of Cancer Lesions

  23. Watch Video “Mapping Biopsy procedure” http://3dprostate.com/videos/mapping-biopsy.html

  24. Whole Mount Prostatectomy Specimenshttp://3dprostate.com/videos/gross-prostate.html

  25. Prostate Cancer: Gross

  26. 3-Dimensional Reconstruction of whole-mounted prostatectomy specimens

  27. Venn-diagram representation of activity of patients between positive results from transperineal mapping biopsies (TPMB) and three-dimensional whole-mounted radical prostatectomies (3D-WMRP). (+) indicates presence of prostatic cancer (-) indicates no cancer

  28. - TPMB with a 5-mm grid is an important staging tool that more closely reflects true PCa disease state as found at RP as 10-12-core TRUSB and other more limited protocols. • TPMB can detect or rule out more aggressive disease, identifying with more accuracy the size and GS of PCa lesions, ensuring that patients are not mistakenly under-treated or unnecessarily over-treated, minimizing treatment-related morbidity.

  29. Case 1 58-year-old man, PSA 4.2 ng/mL,

  30. TRUS guided biopsies • Prostate, right: • - Prostatic adenocarcinoma, Gleason grade 3 + 3 (score = 6)involving <5% of 1 of 12 biopsy core fragments • No evidence of perineural or extra-capsular invasion • Prostate, left, fine needle core biopsies (B): • - Prostatic adenocarcinoma, Gleason grade 3 + 3 (score = 6)involving <5% of 2 of 10 biopsy core fragments- No evidence of perineural or extra-capsular invasion

  31. Radical prostatectomy (after fixation) Length (apex to base): 3.8 cm Width (left to right): 5.2 cm Height (anterior to posterior): 4.0 cm Volume: 50.0 mL Weight: 50.5 g Serial whole-mount sections from apex to base of entire prostate and seminal vesicles submitted in (A1-A9), seminal vesicle complex in A10, A11, right seminal vesicle in A12, A13, left seminal vesicle in A14, A15.

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