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Is a second reading of biopsy slides always justified?

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Posted 3/28/2015 10:44 PM (GMT 0)
This question came up on another thread from a newly diagnosed poster and I didn't want that discussion to hose up his question.

On that thread, I posited that I couldn't see why someone wouldn't do it. Doug had an excellent reply that it's not always so easy outside of the US...
Posted 3/28/2015 10:50 PM (GMT 0)
Personally, I think a second opinion should only be sought when the Bx is questionable or may have an impact on treatment. I don't think it should be done as a matter of course. You guys can argue it out what is questionable or have an impact.

Cheers, Doug
Posted 3/28/2015 11:01 PM (GMT 0)
In my case, I had two reads with the same results. One read was by the lab my local Uro had them sent to, and the second was at the University where the robotic surgeon was based.

The question is a good one, and I'd pose it this way: How significant a difference in the biopsy reading would lead to a change in treatment? If my 2nd read had come back G7 (as my final path did), I still would have chosen the same treatment.

Oh, and on this subject...Why is there rarely a suggestion to get a second read on post surgical pathology?
Posted 3/28/2015 11:12 PM (GMT 0)
In my case, I was originally diagnosed as a G8. My initial treatment preference was for surgery, but I was somewhat reluctant to do it since I was concerned that with a high risk diagnosis I would more likely need SRT as a follow-up and I didn't want to deal with both surgical and radiation SEs. My tentative game plan was to do the surgery if the G8 was downgraded to a G7 (and frankly, I think I would have just breathed easier if that had been the case). Instead, it ended up going to a G9 and that was enough to swing me to the radiation camp.

So in my case, it was a part of my decision process. That said, I don't know how many guys that pertains to--they've landed on a treatment decision regardless. Still, it feels like one more part of the diagnostic process to me and there's not really a downside. (At least in the US.)
Posted 3/29/2015 1:23 AM (GMT 0)
I think it is a personal decision to be made with advice of medical team.
Posted 3/29/2015 1:25 AM (GMT 0)
Logo, I was curious if you would input. Great observation.

Cheers, Doug
Posted 3/29/2015 1:43 AM (GMT 0)
I think it depends. What type of pathologist did the first tests? Do they work in a small community hospital and do all kinds of path, or do they work in a top ten teaching hospital, and only do genito-urological cancers?

I asked if we should send my husband's path out and our internist said it wasn't necessary. Treatment wouldn't have changed. And I trust the guy. We've been seeing him for almost thirty years.
Posted 3/29/2015 3:46 AM (GMT 0)
Carrying this over here from Gregs "Newly Diagnosed, so as not to hijack his thread......

sheepguy said...
You could , like me , have a competent pathologist even though not a "PC only pathologist" whom your uro trusts based on hundreds of PC cases over 25 years. Other than that, who do you trust if it is downgraded? That is what it takes away from a second opinion ,Pratoman,the second opinion may itself underestimate the final pathology and be trusted implicitly because it came from "epstein" or "bostwick".

Sheepguy, I don't take that as the implication at all.

As far as incompetent MDs, the exist.
The initial pathologist in my case called GLeason grade 5 based on existence of "xxx necrosis" (don't recall what xxx was)

Epstein countered , stating ""xxx necrosis is not indicative of GLeason grade 5 in a well formed gland"
He effectively said that the very premise the original pathologist was using, was invalid, and he confirmed this to me in a phone call.
His diagnosis was then confirmed by MSKCC Pathology.
My surgeons said that if Epstein says its g6, its G6

So I don't think he underestimated the grade, I think there was g7 that was missed on biopsy.

But the point is, there are incompetent pathologists. We have no way of knowing whether the local pathologist our Uro uses is competent, experienced, or looks only at Genuitory slides. So why wouldn't one get a second opinion. Why not know exactly what we are dealing with?

it doesn't cost a ton, and more knowledge is better.

JMHO
Posted 3/29/2015 4:13 AM (GMT 0)
We have no way of knowing? If our uro has used the same pathologist 100s of times and the clinical and post surgery pathologies almost always coincide then we certainly do know.
When the responses are " the very first thing you MUST do before taking any action is get a second opinion from epstein"...you are right , it is not implied..it is more explicit than that.
Posted 3/29/2015 4:36 AM (GMT 0)
My biopsy was read by Bostwick. It was so bad that a second read could have been 50% better and changed nothing.

Post-op was by Bostwick and the local hospital pathologist. They matched..

Since insurance paid, and my deductible/out of pocket was exhausted by tens of thousands of dollars, it was to my benefit to spend the insurance company's money to calm my mind.
Posted 3/29/2015 6:44 AM (GMT 0)
Unless I'm missing something, we just discussed this ad nauseum 2 weeks ago:

www.healingwell.com/community/default.aspx?f=35&m=3353669
Posted 3/29/2015 12:42 PM (GMT 0)

Michael_T said...
In my case, I was originally diagnosed as a G8. My initial treatment preference was for surgery, but I was somewhat reluctant to do it since I was concerned that with a high risk diagnosis I would more likely need SRT as a follow-up and I didn't want to deal with both surgical and radiation SEs. My tentative game plan was to do the surgery if the G8 was downgraded to a G7 (and frankly, I think I would have just breathed easier if that had been the case). Instead, it ended up going to a G9 and that was enough to swing me to the radiation camp.

So in my case, it was a part of my decision process. That said, I don't know how many guys that pertains to--they've landed on a treatment decision regardless. Still, it feels like one more part of the diagnostic process to me and there's not really a downside. (At least in the US.)

Hey Michael_T,
Was it your choice to have your results re-examined? As you know, you and I had pretty well the same DX and treatments and the only choice I was given was when to start. The only advice given to me, by my URO, was he would only recommend surgery if the patient had a chance of "hitting a home run"....which I assumed to be a lower risk DX?
Posted 3/29/2015 2:23 PM (GMT 0)
Well, yeah TA, but different guys are participating and brought the subject up again. With some new people that might have missed the discussion. It doesn't hurt to revisit it and it will probably be revisited again. Besides, isn't every thread here discussed ad nauseum?
Posted 3/29/2015 4:08 PM (GMT 0)

FoxRun said...
Hey Michael_T,
Was it your choice to have your results re-examined? As you know, you and I had pretty well the same DX and treatments and the only choice I was given was when to start. The only advice given to me, by my URO, was he would only recommend surgery if the patient had a chance of "hitting a home run"....which I assumed to be a lower risk DX?

My uro originally told me that he "recommended surgery for high risk guys like me." When I asked him if that meant that he would have had a different recommendation if I wasn't high risk he said that no he pretty much always recommended surgery no matter what the diagnosis. It was only after seeing Dr Lam (a recommendation I had here) and he did some more sophisticated staging (and he was the one that sent my slides to Epstein for a second reading) that he felt like there was about a 50% chance I would need SRT afterwards if I chose surgery with my profile. I think your uro did a better job than mine of assessing your overall risk.
Posted 3/29/2015 4:21 PM (GMT 0)
Sheepguy- LOL- Very true!
Posted 3/29/2015 6:35 PM (GMT 0)

Michael_T said...

FoxRun said...
Hey Michael_T,
Was it your choice to have your results re-examined? As you know, you and I had pretty well the same DX and treatments and the only choice I was given was when to start. The only advice given to me, by my URO, was he would only recommend surgery if the patient had a chance of "hitting a home run"....which I assumed to be a lower risk DX?

My uro originally told me that he "recommended surgery for high risk guys like me." When I asked him if that meant that he would have had a different recommendation if I wasn't high risk he said that no he pretty much always recommended surgery no matter what the diagnosis. It was only after seeing Dr Lam (a recommendation I had here) and he did some more sophisticated staging (and he was the one that sent my slides to Epstein for a second reading) that he felt like there was about a 50% chance I would need SRT afterwards if I chose surgery with my profile. I think your uro did a better job than mine of assessing your overall risk.

Always recommending surgery no matter what the diagnosis, does not sound very responsible for a URO, IMO.
Posted 3/29/2015 6:56 PM (GMT 0)
It seems to me that every recommendation to get a 2nd opinion is accompanied by "use Bostwick or Epstein" so it appears they are really the only fully trusted pathologists.

If that is the case then why not get the initial biopsy analysed by them, so bypassing the need for a 2nd opinion?

I realise the implications of that in terms of workload, but are they really the only pathologists who can be trusted?
Posted 3/29/2015 7:02 PM (GMT 0)
Yeah, and is the uro going to do it because you said you saw the recommendation on the internet?
Or should the actual biopsy be done only at JH too?
Posted 3/29/2015 7:03 PM (GMT 0)

Chask said...
It seems to me that every recommendation to get a 2nd opinion is accompanied by "use Bostwick or Epstein" so it appears they are really the only fully trusted pathologists.

If that is the case then why not get the initial biopsy analysed by them, so bypassing the need for a 2nd opinion?

I realise the implications of that in terms of workload, but are they really the only pathologists who can be trusted?

That is exactly the implication, and it's fair to challenge it. I'd suggest this idea: If a top surgeon/RO in the PC world trusts their "guy down the hall" to give good information, shouldn't we? After all, the pathologist is as much a part of the team as the anesthesiologist or the technician who sets up the MRI.

It's one thing to use an outfit like quest diagnostics, and quite another to have the treatment team use 'their' pathologist who they trust.
Posted 3/29/2015 7:23 PM (GMT 0)
Halbert, I think the key part in your sentence is the "top surgeon/RO." Most of us are biopsied by the uro that we happened to see and it's unlikely they are the rock star quality that many of us seek out for treatment. Statistically speaking, we're likely to be using an average uro and an average pathologist. Now I will admit I'm taking it on faith that Epstein and Bostwick are above average, but certainly the fact that's all they do gives certainly gives them experience.

I'm still trying to come up with the downside of doing this. Here's what I see as possibilities: Extra cost, although it's not significant. The patient already knows what treatment they're selecting so it doesn't make a difference. Perhaps not possible outside the US. Ticking off you uro since it implies you don't trust his or her judgment. What other downsides am I missing?
Posted 3/29/2015 7:35 PM (GMT 0)
Michael: my point exactly. If we're telling people on here (and we are, repeatedly) to seek and find a top notch expert for treatment, then at some point we have to trust the team that top expert has put around them. In my case, my local uro did the biopsy and sent the samples to Quest. When he referred me to Washington University/Barnes Jewish in St. Louis for treatment, the slides, cat scan and bone scan files also went down there. They 2nd opinioned the slides and did the post surgery biopsy.
Posted 3/29/2015 7:50 PM (GMT 0)
Sheepguy, I understand and respect where you are coming from on this issue. With that said, here's my thinking: Not all Uro's use the one pathologist down the hall that's part of their team. Sort of like Michael said.
I'll go back to my case again, since its the only experience I have, and its the experience that convinced me that its often, the right thing to do....

My Uro at the time, who diagnosed me, is the Chairman of Urology at a large hospital system, and took that position 2 years ago. Prior to that he was at Columbia Presbyterian, ranked #5 Uro department in the nation by U.S. News and World Report. He was very well known and reputed, particularly for his approach to integrative medicine.

He sent my tissue samples to his pathology department, and I have to believe, based on the results, that it wasn't to a highly qualified, and trusted pathologist that he uses all the time. Because it was that pathologist that gave a diagnosis based upon an incorrect premise, which was confirmed by Epstein and MSKCC. I think that's enough cred right there, to refute the premise used by the local pathologist. I no doubt, that as a Department Chairman, my Uro (not any more) was sort of obligated to send the slides to the hospital pathology dept, and the next person up in the que, that was a genuotory specialist got the slides.

So I believe, after that experience, why should I, or anyone diagnosed, trust that their great Uro is sending their all important sample tissue to a great pathologist.

Now, as far as Epstein and Bostwick are concerned, you are correct ,I am sure there are many other highly qualified Prostate cell Pathologists out there. For some reason, these two guys are considered the gold standard, so they are the ones we know and the. ones we refer to. But I'm sure there are other good ones out there.

What would be useful, would be if we could know who the "Epsteins" of Canada, Australia, UKand other countries are so we could help our brothers from those countries who arrive here newly diagnosed.

Just my humble opinion. I trust pretty much nobody, unless I have good reason to.
Posted 3/29/2015 7:53 PM (GMT 0)
Halbert, I would think in that case yes, there's not really a case to be made for sending your slides out yet again. You already had a great team on your case.

But in the typical situation here when someone here is newly diagnosed and hasn't selected a treatment yet, it seems to make sense. At least I'm not understanding the downside...
Posted 3/29/2015 7:58 PM (GMT 0)
In my case I was a 7 (4+3) at bx.
After surgery it was a 9 (5+4). Should I have had the biopsy slides re-read...Maybe...? (I would probably recommend it to anyone else). But after getting the news of being a 9 I figured it wouldn't make much difference if it was 4+5, 5+5 or 4+4. End result would be the same. My Uro even mentioned that the post surgery numbers through everyone off. I guess I was the talk of the pathology department for awhile.
Posted 3/29/2015 8:18 PM (GMT 0)
Let me recount my biopsy pathology experience.

 

My prostate cancer was incidental, diagnosed after a TURP removed 25g of my prostate. The pathology was done at the same hospital where my TURP procedure was done. The hospital pathologist graded the cancer as Gleason 7.  Consequently, the urologist recommended treatment. No indication was conveyed to me that the Gleason score was not absolutely definitive and a second opinion should be sought.

 

I feel that if my surgeon had recommended that I seek a second opinion, it would call into question the competence of his colleague "down the hall." As it turned out when I finally did have my biopsy slides  to JHU, the results were sent back to the hospital along with the biopsy slides. When I contacted Johns Hopkins for the result of the pathology, I was told that I would need to fill out permission forms to get the information. I figured I could avoid the hassle by contacting my hospital and have it send me a copy of JHU's results. When I  called the pathology department of the hospital to get this information, I was told that, since they were not the ones who initiated the request for a second opinion, they just threw away the JHU result. It seems they were not happy that I questioned the work of their pathologist.

 

As a matter of fact, the surgeons I contacted when I still thought the Cancer was GL7 were ready to operate on me without questioning the Gleason score. It was only a fellow cancer survivor who I met on-line who suggested getting a second opinion from Epstein at JHU. (At that time, I was not aware of this site.)

 

I find it interesting that men who seek the most experienced surgeons to treat them are willing to leave key information that would decide the type of treatment necessary in the hands of a pathologist "down the hall" from their urologist. Jonathan Epstein is widely considered to be the pre-eminent prostate pathologist in the world. In addition to publishing, among his more than 700 papers, the primary textbook on Prostate pathology, he also chaired the International Society of Urological Pathology consensus conference in 2005 where the Gleason grading system for prostatic carcinoma underwent its first major revision.

 

 

 

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