Pathology Reports

For the few that will get prostatic cancer, a word on reports.

I think that reports need to be addressed, both biopsy and surgical pathology reports. As a medical student, I was fortunate to spend a 3 month lay-out quarter working in a hospital pathology department. Since it was in the nation's largest privately owned hospital with about 1200 beds, we had plenty to do back in the 60s. I was also lucky to work with four very nice pathologists who were interested in teaching. Other than a dozen autopsies (also very instructive), I spent all my days cutting surgicals. For whatever reason, surgical pathology was not stressed in our general pathology courses, so my mind was a fertile field to plow.

Each day, I was given specimens removed at surgery to describe grossly into a dictaphone, cut sections (I was taught where to cut on a given specimen), and then read with a double microscope the microscopic slides from those that I had cut two days before. The pathologist was on the other side of the double scope to teach me. It was one of the most rewarding periods in my medical education. With this lengthy preamble, I will now try to get to the point.

We saw a lot of prostate specimens, both whole and chips from trans-urethral resections (TUR). I would guess maybe 20-30 specimens per week. Most of these specimens were sent to us because men had prostatism (BPH) and not cancer. In those days, there was no PSA test, and a man with PC usually came to surgery because of a nodule on DRE. The TURs were the majority unless a man with a so-called "median bar" required open prostatectomy, which was treated with complete removal rather than a TUR.

When examined microscopically, often the chips or the sections of the whole prostate would reveal malignant cell structures. These were usually considered as incidental findings and reported to the surgeon. CT scans were unknown, bone scans were so primitive as to be nearly worthless, and the urologist had to watch for new evidence of recurrence. If bone metastasis showed up on x-rays, then an orchiectomy (testicle removal) was done. Biopsies may have been done back then, but I recall seeing none.

OK. Now to the REAL point of this message, When a pathologist looks at sections of prostate tissue with cancer evident, there is not a little sign there down in the tissue that says "Gleason 4+3, 4+4, or some such". This determination is an ESTIMATE, not an absolute, and it is based on cell appearance. Give the same slides to another pathologist and, you may get a different grading, up or down. The same goes with estimates of per cent of the prostate involved. Of course this is a good reason for multiple readings of slides. I suppose one could send slides to a hundred pathologists, and then take the majority opinion as gospel, but that is ridiculous. In our department, it was standard procedure for more than one doc to look at anything questionable. Disputes were judged by the head man. Gleason was yet to set out his system, so the grades were I-IV, with IV being what is now a Gleason 10.

If you are disturbed by your Gleason score or other micro findings remember the doc is looking at a tiny portion of your prostate on biopsy. In a whole specimen, as a rule, the look is not a lot greater (sometimes our guys would tell us to make more slides of other areas to see further cells). Those scores are not written in stone by any means.