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Old 09-13-2010, 07:44 PM   #1
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Biopsy facility tour - lessons learned

There are not a whole lot of people who would get excited about touring a prostate cancer biopsy facility, but I'll admit I'm one of them. Before today, what I knew about biopsy analysis came from books and presentations, but today I actually saw biopsy cores being processed. It was amazing stuff!

A group of us survivors was invited to tour one of the world's main biopsy processing and analysis sites, and our guide was one of the senior pathologists. We saw the show from beginning to end. This site was most likely quite different from the kind of processing that would be done at a hospital facility as the site we toured was set up for mass production. That said, each minute core got a lot of individual attention!

It started with the boxes that come in with specimens for a patient. One typcial box we saw had a dozen small jars, each containing a small needle-thin worm-like biopsy core a little over a centimeter long, floating in a fluid environment. We saw where each jar was labelled with bar codes and other patient identification information, all put into a computerized tracking system.

We then watched as the cores, after removal from the jars (I think I've got the sequence right), were put in a huge, special, very expensive microwave machine that stabilized each core so that it would not deteriorate. After that, the cores were put in a parafin soup in a small container. The parafin was hardened, and after that the cores were each sliced, extremely finely, lengthwise. Each core was sliced into four to six extremely thin strips. Next these thin strips were put on a microscope slide, and, after liquid glue was added by a machine, another slide was glued on top. Some cores, not all, went through a special dyeing process. At that point, after quality control, the slide was ready for the pathologist.

The pathologist inserted the slide on the table of an expensive looking microscope, and the image was projected, greatly enlarged, onto a computer screen. At that point the pathologist assessed the Gleason grades, measured the extent of the cancer (with the computer automatically projecting lengths and percent of cancerous tissue based on his input), and checked for any of the very rare and dangerous prostate cancer types, such as "small cell" prostate cancer. Apparently its not hard to spot those rare types, and pathologists are extremely diligent in checking for them.

I learned I had a misconception about the Gleason scoring, my concept once accurage but now obsolete. The Gleason score used to be based on the Gleason grade that made up the largest portion of the cancer in the core as the first grade, with the second grade coming from the cancer that occupied the next greatest proportion. Any grade five cancer was highlighted as a third grade, I thought, at least in leading pathology labs like the one we toured.

Well, that was true for my biopsy back in late 1999, and it was true up until 2005. That's the concept described in "A Primer on Prostate Cancer--The Empowered Patient's Guide," that likely went to press in late 2004 or early 2005 for its publication in 2005.

However, sometime in 2005 the pathologists medical association issued a guideline that changed the scoring. The new scoring retains the most prominent grade as the first grade, but the second grade is the most aggressive grade remaining, even if it is just a small percentage of the remaining cancer. Therefore, if you had cancer in a core that was 60% grade 3, 35% grade 4, and just 5% grade 5, the new style Gleason score would be 3+5=8. The thinking is that it's important to indicate that higher grade, even if small, because such aggressive cancer will very likely grow to the point that it becomes a much greater percentage of the cancer.

One of us asked about the expense of doing pathology for a saturation biopsy where a great many cores are taken. The pathologist confirmed that there is no discount for quantity; saturation biopsies get to be quite expensive, especially where a great many cores have to be analyzed.

I was impressed with the amount of automation and computer assistance to handle many of the more routine aspects of processing the biopsy cores, but I was also impressed with the amount of hands on effort required at numerous points in the process.

I had not expected to learn so much. I could not help thinking how many hopes and fears were depending on the outcomes of their work. It was a moving experience.

Jim

 
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Old 09-14-2010, 12:48 AM   #2
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Re: Biopsy facility tour - lessons learned

Thanks for the tour info, Jim. Never thought I'd say it ... but fascinating stuff. Such a vital part of the whole process. (Sure wish I'd known enough when diagnosed to send my biopsy cores to a more experienced lab. So much rides on the results.)

 
Old 12-02-2010, 06:10 PM   #3
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Re: Biopsy facility tour - lessons learned

FDA INSISTED ON MODIFIED GLEASON SCORING IN RECENT CLINICAL TRIAL

Yesterday I watched an FDA webcast of a discouraging FDA advisory committee hearing that turned thumbs down on giving a green light for prevention of PC using finasteride and Avodart. I'm still resolving a few issues, and when done, I intend to post about the hearing and what it means for us, our families and those we care about, but the hearing did draw attention to the change that has taken place in Gleason scoring.

The first trial reviewed was the Prostate Cancer Prevention Trial, involving finasteride, and though the trial was started well before official modification of the Gleason scoring system in 2005, the new methods were used in the trial.

The other trial was the REDUCE trial for Avodart as a preventive agent, but that trial employed the old system. However, during the trial the chief pathologist passed on, and the FDA requested that all the biopsy samples be rescored using the modified Gleason scoring sytem. That was done.

I also learned that the official revision was declared in 2005 by the WHO, which I believe is the UN's World Health Organization.

Jim

 
Old 12-03-2010, 01:57 PM   #4
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Re: Biopsy facility tour - lessons learned

Hey Jim -
Glad you're out there keeping an eye on them.
I know there are different cell types that show up with different dyes, but I wonder what they see on un-dyed tissues that they wouldn't see with at least some kind of dyed tissue.
- Allen

 
Old 12-03-2010, 05:59 PM   #5
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Re: Biopsy facility tour - lessons learned

Hi Allen,

We saw and heard something about that on the tour, but I don't recall the detail. I think it makes it a lot easier to see the key features of the cells.

Jim

 
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