Large blocks in prostate and bladder pathology

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1 Large blocks in prostate and bladder pathology Farkas Sükösd Department of Pathology, University of Szeged

2 The history of the large block technique in radical prostatectomy and cystectomy The first large block evaluation of prostate and urinary bladder was performed more than half a century ago1 During a period of 15 years, 45 cases were studied in this way It was concluded that: the perspective of bladder cancer obtained from these studies has been worth this investment of time and energy. 2 1 Baker, K.: Correlation of circumferential lymphatic spread of vesical cancer with depth of infiltration: Relation to present methods of treatment. J.Urol. 73: , S E.A. Soto, G.H. Friedell, A.J. Tiltman: Bladder cancer as seen in giant histologic sections. Cancer. 1977;39:

3 Large blocks in radical prostatectomy

4 A large block can provide important information In cases where the tumour is not visible its boundaries are not clear

5 A large block can provide important information In cases where the tumour is not visible its boundaries are not clear

6 A large block can provide important information In cases where the tumour is not visible its boundaries are not clear

7 A large block can provide important information A large slide can show the localization of the microscopic extraprostatic spread of the tumour in every cases

8 A large block can provide important information Determination of the localization and the extent of the positive surgical margin precisely, which is to be measured in millimetres

9 A large block can provide important information Assessment of an anteriorly localized tumour better prognosis than that of a peripheral tumour

10 A large block can provide important information The quantitative assessment of nervesparing surgery Characterization of the resection surface quality

A large block can provide important information Possibility of measurement of the tumour volume Reporting of some quantitative measure of the tumour volume in a prostatectomy specimen is needed4 4

11 A large block can provide important information Possibility of measurement of the tumour volume Reporting of some quantitative measure of the tumour volume in a prostatectomy specimen is needed4 4 van der Kwast T, Amin MB, Billis A, et al. International Society of Urological Pathology (ISUP) consensus conference on handling and staging of radical prostatectomy specimens. Working group 2: T2 substaging and prostate cancer volume. Mod Pathol 2011;24:16 25

A more precise measurement of the tumour size Computer-assisted measurements are considered the most precise assessment of the tumour volume5 The previous computer programs have their limits We have

12 A more precise measurement of the tumour size Computer-assisted measurements are considered the most precise assessment of the tumour volume5 The previous computer programs have their limits We have developed a program which combines the tumour volume measurement with a mathematical approach to the Gleason score 5 Sherwin, J.C., et al., Tumor volume in radical prostatectomy specimens assessed by digital image analysis software correlates with other prognostic factors. J Urol, (5): p

14 The most precise measurement of the tumour size The program on the classical drawing of Gleason

The most precise measurement of the tumour size The program on the classical drawing of Gleason Following exclusion of the luminal surface of the glands, division by the

15 The most precise measurement of the tumour size The program on the classical drawing of Gleason Following exclusion of the luminal surface of the glands, division by the whole surface of the tumour will result in a ratio which we extrapolate to the density of tumour The tumour density can fit a mathematical approximation to the Gleason score

16 The most precise measurement of the tumour size Density values on a chart

A more precise measurement of the tumour size In our 65 prostate specimens, the median value of density correlated with density assessed in the Gleason drawing Our preliminary

17 A more precise measurement of the tumour size In our 65 prostate specimens, the median value of density correlated with density assessed in the Gleason drawing Our preliminary examinations suggest that the volume combined with the density can be a more precise parameter than the volume alone Differences can arise from the existence of a tertiary grade

18 Large blocks in radical cystectomy

Current mortality rates of urinary bladder cancer in men The incidence and mortality rates in general have decreased in most western countries, but increased

19 Current mortality rates of urinary bladder cancer in men The incidence and mortality rates in general have decreased in most western countries, but increased in some eastern European and developing countries. 6 6Chavan, S., et al., International Variations in Bladder Cancer Incidence and Mortality. Eur Urol, 2013.

20 The samples of radical cystectomy Therapy of a muscleinvasive organ-confined tumour is radical cystectomy The most important information concerning radical cystectomy samples is the stage prognosis postoperative therapy

, Computerized tomography for detecting perivesical infiltration and lymph node metastasis in invasive bladder

21 The samples of radical cystectomy Imaging technology does not give an accurate stage assessment 7 7Baltaci, S., et al., Computerized tomography for detecting perivesical infiltration and lymph node metastasis in invasive bladder carcinoma. Urol Int, (4): p The pathological stage is decisive8 8Cheng, L. et al., Staging and reporting of urothelial carcinoma of the urinary bladder. Mod Pathol, Suppl 2: p. S

The current cut up protocol of radical cystectomy The most important step in the pathological work is the selection of the areas to be processed for microscopic

22 The current cut up protocol of radical cystectomy The most important step in the pathological work is the selection of the areas to be processed for microscopic examination Current cut-up guidelines involve a significant degree of subjectivity It is basically left to the pathologist to select the areas which may be important

23 The limits of the the current cut up protocol A microscopic extra-organ spread (pt3a) can be detected only incidentally Infiltration into the dense tissue of the prostate (from pt2 to pt4a) is most often invisible to the naked eye It is difficult to assess of dysplasia/in situ carcinoma Determination the involvement and distance of the circumferential resection margin is uncertain The verification of pt0 tumour is impossible The protocol is not useful in the assessment of tumour volume or to estimate the extent of a unicellular or tentacular infiltrating tumour edge or in the examination of tumour heterogeneity

24 Gross Dissection Protocol for Radical Cystectomy (GDPRC) Sukosd, F., B. Ivanyi, and L. Pajor, Accurate Determination of the Pathological Stage with Gross Dissection Protocol for Radical Cystectomy. Pathol Oncol Res, 2014

25 Gross Dissection Protocol for Radical Cystectomy (GDPRC) Removial of the urethral stump Orientational incision Sukosd, F., B. Ivanyi, and L. Pajor, Accurate Determination of the Pathological Stage with Gross Dissection Protocol for Radical Cystectomy. Pathol Oncol Res, 2014

Gross Dissection Protocol for Radical Cystectomy (GDPRC) The basal block (BB) serves for the evaluation of the bladder base and the prostate base in toto Due to anteflexion of the axes of the

26 Gross Dissection Protocol for Radical Cystectomy (GDPRC) The basal block (BB) serves for the evaluation of the bladder base and the prostate base in toto Due to anteflexion of the axes of the prostate and the bladder the transverse resection level of the urethra and the BB are not parallel The wedge-shaped cross section made from the prostate yields a BB enclosed by parallel planes Sukosd, F., B. Ivanyi, and L. Pajor, Accurate Determination of the Pathological Stage with Gross Dissection Protocol for Radical Cystectomy. Pathol Oncol Res, 2014

Gross Dissection Protocol for Radical Cystectomy (GDPRC) Processing of the BB: Completion of the orientational incision creats a right and a left portion This is followed by halving the right and

27 Gross Dissection Protocol for Radical Cystectomy (GDPRC) Processing of the BB: Completion of the orientational incision creats a right and a left portion This is followed by halving the right and left parts and trisecting the resulting quarters The 12 radial cut-offs can be placed into standard cassettes. Sukosd, F., B. Ivanyi, and L. Pajor, Accurate Determination of the Pathological Stage with Gross Dissection Protocol for Radical Cystectomy. Pathol Oncol Res, 2014

Gross Dissection Protocol for Radical Cystectomy (GDPRC) The GDPRC can be implemented in a flexible fashion The most frequent modification is visualization (reflection) in two cutting levels (blue

28 Gross Dissection Protocol for Radical Cystectomy (GDPRC) The GDPRC can be implemented in a flexible fashion The most frequent modification is visualization (reflection) in two cutting levels (blue double arrow) The lesion can be observed on adjacent cutting surfaces (red double arrow) The arrow indicates the BB The arrowheads shows the frontal processing of the dome Sukosd, F., B. Ivanyi, and L. Pajor, Accurate Determination of the Pathological Stage with Gross Dissection Protocol for Radical Cystectomy. Pathol Oncol Res, 2014

29 Gross Dissection Protocol for Radical Cystectomy (GDPRC) Sukosd, F., B. Ivanyi, and L. Pajor, Accurate Determination of the Pathological Stage with Gross Dissection Protocol for Radical Cystectomy. Pathol Oncol Res, 2014

30 Benefits of the GDPRC The volume, pt3a,crm and its distance can be determined

31 Benefits of the GDPRC The volume, pt3a,crm and its distance can be determined

32 Benefits of the GDPRC The volume, pt3a,crm and its distance can be determined

33 Benefits of the GDPRC Badder neck and prostate involvement can be determined

34 Benefits of the GDPRC Badder neck and prostate involvement can be determined

35 Benefits of the GDPRC Badder neck and prostate involvement can be determined

36 Benefits of the GDPRC The extent of dysplasia and in situ carcinoma can be determined

37 Benefits of the GDPRC The extent of dysplasia and in situ carcinoma can be determined

38 Benefits of the GDPRC The extent of dysplasia and in situ carcinoma can be determined

39 Benefits of the GDPRC Stage pt0 can be identified with certainty hemosiderin and granulomatous area the entire preparation is tumour-free

40 The incidences of the pathological stages in the literature The incidence determined on the basis of a large number of cases must reflect the actual incidence 15,586 stages of 27,394 cystectomies presented in 15 publications from the period between 1971 and 2010

41 Benefits of the GDPRC Accurate determination of the pathological stage No. of cases (%) Total no. of lymph nodes Average no. of lymph nodes No. of metastatic lymph nodes pt0 pta ptis 12 (8.7) (1.5%) 1 (0.7) (2.9) pt1 pt2 pt3 pt4 21 (15.2) 29 (21) 48 (34.8) 23 (16.7) (0.5%) 18 (8.1%) 123 (28.7%) 58 (23.31) The stage distribution in 138 consecutive radical cystectomy assessments with the GDPRC

42 The incidences of the pathological stages in the literature and with the GDPRC GDPRC quite accurately reflected the statistical averages of the data based on a large number of cases

43 The incidences of the pathological stages in the literature and with the GDPRC GDPRC quite accurately reflected the statistical averages of the data based on a large number of cases

44 The incidences of the pathological stages in the literature and with the GDPRC GDPRC quite accurately reflected the statistical averages of the data based on a large number of cases

In summary During the past 6 years, we have studied 206 cases in this way Preparation of the (large block) material for histologic examination is time-consuming and requires a high degree of skill,

45 In summary During the past 6 years, we have studied 206 cases in this way Preparation of the (large block) material for histologic examination is time-consuming and requires a high degree of skill, and the pathologist in turn must be willing to spend an appreciable amount of time in reviewing the material. From our standpoint, however, the perspective of bladder cancer (and prostate) obtained from these studies has been worth this investment of time and energy 2S E.A. Soto, G.H. Friedell, A.J. Tiltman: Bladder cancer as seen in giant histologic sections. Cancer. 1977;39:

46 Thank you for your attention!

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