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.