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Why the sticky recommends a second opinion on biopsy slides from Epstein or Bostwick

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Posted 10/6/2015 1:52 AM (GMT 0)
I know this has been discussed a million times in HW, but some people are still questioning the sage advice in the sticky. A general pathologist, even at a top institution, just doesn't have the same kind of experience at Gleason grading as a dedicated urologic pathologist like Epstein or Bostwick.

Here's what happened when JH re-evaluated biopsy slides evaluated by general pathologists:

Epstein et al. said...
The overall kappa coefficient for interobserver agreement for these 38 cases was 0.435, barely moderate agreement, with a kappa range from 0.00 to 0.88. There was consistent undergrading of Gleason scores 5-6 (47%), 7 (47%) and, to a lesser extent, 8-10 (25%). In cases with consensus primary patterns, there was consistent undergrading of patterns 2 (32%), 3 (39%), and 5 (30%). Pattern 2 was often (17%) mistaken for pattern 3. Pattern 4 was often undergraded (21%) and also mistaken for pattern 5 (17%).


Interobserver reproducibility of Gleason grading of prostatic carcinoma: general pathologist.

Here's what happened when JH and non-JH pathologists graded biopsy slides and they compared them to RP specimens.

Epstein et al. said...
there was 66% exact correlation between the biopsy and RP for JHH as compared with 45% for non-JHH.


Correlation of prostate needle biopsy and radical prostatectomy Gleason grade in academic and community settings.

Proper grading can make a big difference in treatment decisions.

- Allen
Posted 10/6/2015 2:28 AM (GMT 0)
Allen,

Is there a time limit in which one can have original biopsy samples sent off to have re-evaluated?

More specifically, is 4 years too late?

Thank you.
Posted 10/6/2015 2:40 AM (GMT 0)
I wished I had done this back in 2008 post surgery, have always regretted not doing so.
Posted 10/6/2015 2:49 AM (GMT 0)
I did not get a second opinion primarily because I could not afford it and quite frankly, I don't think it would have made much difference in my case with 11/12 cores positive with 90% involvement and all gleason 9.
Posted 10/6/2015 2:53 AM (GMT 0)
A more recent study shows 87% agreement for G6 and only 31% for 8-10 between JHH and non JHH biopsy pathology grade. Not that bad for G6s.... not so good for g8-10.
Posted 10/6/2015 3:01 AM (GMT 0)
Ms WorryWart-
I'm afraid I don't know how long your urologist keeps his cores. But your DH had an RP and it was pGS8, so why do you want to know what his biopsy was now?

- Allen
Posted 10/6/2015 3:20 AM (GMT 0)
He didn't have RP...he had IMRT.
Posted 10/6/2015 4:47 AM (GMT 0)
Oh yes I see. Maybe call the uro's office - let me know - I'd be curious too.
Posted 10/6/2015 11:05 AM (GMT 0)
Six out of twelve of my cores were positive, all G9. Epstein upgraded two of my high volume cores to 5+4, and found 10% PCa, G9, in the sixth core that the first assessment missed.

This didn't change my treatment plan, but it confirmed what we had planned to do. Maybe changed the prognosis a bit worse, but we're already doing all we can.
Posted 10/6/2015 12:26 PM (GMT 0)
My uro uses Bostwick for everything including all my PSA tests. Thus I didn't feel the need for a second by Epstein as Tall Allen's information confirms.

I just spoke with recently dxd friend and immediately suggested he get a second opinion with either Bostwick or Epstein on his biopsy. I will share Tall Allen's post with him. Great information as always from Tall Allen.
Posted 10/6/2015 1:19 PM (GMT 0)
Dr. Epstein also reports that 3 out of 1000 men get a PCa diagnosis based on their biopsy that isn't PCa at all. Interestingly, we have had 2-3 men on this forum who have had RP only to discover that the post-op pathology showed no cancer. Talk about a bad scenario...

Jim
Posted 10/6/2015 1:23 PM (GMT 0)
Boy howdy,Jim .....dang, can you imagine?
Posted 10/6/2015 1:37 PM (GMT 0)
I don't think much of anything in medicine is 100% accurate, but I believe getting a second opinion from one of the two expert labs in PC is basic due diligence. I was upgrade from a G8 to a G9 by Epstein, which didn't change my treatment plan. But if I had gone from a G8 to a G7, it would have put surgery back on the list as a potential treatment choice...
Posted 10/6/2015 1:49 PM (GMT 0)
Perhaps this would be helpful.

The text cited below is a post I made in June 2013 to a thread entitled "Biopsy second opinion." The link is:

www.healingwell.com/community/default.aspx?f=35&m=2767836

The text below is a description of what a Bostwick report (mine in this case) covers, with a page-by-page description of what it's going to look like.

Maybe helpful to know.

I got my biopsy evaluation done at the Orlando lab and received a copy of it from my uro at my appointment with him confirming diagnosis.

It is very detailed, and perhaps I could describe it a bit so you may get an idea of what to expect if you do get your report from that lab.

Page 1: "Gross Description": detailed medical text describing the general physical situation and stats of my prostate; a photomicrograph (they call it) of a slice of tissue (like what you would see in a medical text); a "prostate biopsy map" (found this very informative): a schematic of the standard prostate, with black circles entered on it where malignancy was found in my case, along with a number indicating percentages found;

Page 2: "diagnosis, prostate needle biopsies": sector-by-sector account of tissue status in each apex and base, pretty technical, but highly informative; gives Gleason sums for each sector;

Page 3-4: "Patient Empowerment Report": I found this extremely helpful; sums up what was found in easy-to-follow terms, explaining what was done, and how to interpret the results; followed by an "Information and Resources" section, listing some PCa organizations (PC Infolink, UsToo, and more generally NCI and ACS, and a brief bibliography ("ACS Complete Guide to Prostate Cancer," "Prostate Cancer, What Everyman and His Family Needs To Know")

Page 5: "Treatment Options": general description of surgery, RT, HT, AS and Cryotherapy;

It closes with strong encouragement to see one's doctor, and go from there.

It looked very professionally done, and seemed to cover all the bases.
Posted 10/6/2015 4:05 PM (GMT 0)
These finding of very low consensus between verdicts from different pathologies surprises me. Wonder if it is a universal finding. In my case it was a exact agreement between biopsy and RP. I had no second opinions neither on the biopsy nor after surgery.
BTW, the biopsy report even included the EPE. Is it unusual that the biopsy pathology report includes information about EPE? I haven't seen that in others signatures.
Posted 10/6/2015 6:21 PM (GMT 0)
Direct comparison of Johns Hopkins Hospital and needle biopsy Gleason scores elsewhere revealed 81.8% agreement, with 87.1% for Gleason score 5-6, 68.1% for Gleason score 7 and 35.1% for Gleason score 8-10.
So, you are less likely to have a gleason six changed than you are to have the biopsy missed the primary cancer altogether.
Posted 10/6/2015 6:38 PM (GMT 0)
What are the odds of having a biopsy miss the primary cancer? (I really have no idea.) And more important, what are the odds of a targeted/guided biopsy missing missing a significant grade of cancer, which of course, would be the real concern? (Again, I don't know what the stat is...)
Posted 10/6/2015 7:33 PM (GMT 0)
They say 20-30% for TRUS depending upon who you ask. 3TpMRI ? some say as low as 10% I think, the jury is really still out I gather.
Depends somewhat on what you define as primary cancer I guess.
Saturation biopsy ...60 cores? I don't know either but 60 cores in a 40ml vol prostate can't miss much I wouldn't think.
Posted 10/6/2015 9:42 PM (GMT 0)
It has also been my understanding (please correct me if I'm wrong), that post RP pathology is generally good enough to not require 2nd opinions, because they are dealing with the whole gland and many many slices as opposed to a few cores.

I also understand that some 30% of post-RP pathologies indicate an upgrade, regardless of who did the biopsy pathology.
Posted 10/6/2015 9:50 PM (GMT 0)

halbert said...

I also understand that some 30% of post-RP pathologies indicate an upgrade, regardless of who did the biopsy pathology.



It IS dependent upon who does the pre-surgery biopsy, but then again perhaps more importantly, somewhere around 20-25% of post-RP pathologies indicate a DOWN-grade.
Posted 10/6/2015 10:14 PM (GMT 0)
My 2nd opinion from Dr. Epstein was the best money I've spent on PCa (which, having Kaiser, hasn't been a ton....but you get the idea.)

I did not get a 2nd opinion on my biopsy (hadn't been enlightened by the crew here yet), but did get one for my post-op pathology. For me, the confirmation of the reading from Kaiser, as well as the addition of a Tertiary grade 5 (to go with my 4+4), made me more vigilant with uPSA post surgery.

We'll never know if I pull the trigger on SRT sooner than necessary, but the peace of mind and feeling of greater control that I gained from the KNOWLEDGE provided by Dr. Epstein has been priceless for me.

My $.02 on a Tuesday afternoon.....

Rich
Posted 10/6/2015 10:54 PM (GMT 0)
There's a well-known expert on the west coast who now uses only Epstein for requested second opinions on biopsies. In the past another well-known pathology specialist's lab was also used but now it's uncertain who performs the analysis there. In case of different scores between his local pathologist and Epstein, if requested he then sends to Stanford for a tiebreaker.
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