The Critical Role of the Pathologist in Determining Eligibility for Active Surveillance as a Management Option in Patients With Prostate Cancer: Consensus Statement With Recommendations Supported by the College of American Pathologists, International Society of Urological Pathology, Association of Directors of Anatomic and Surgical Pathology, the New Zealand Society of Pathologists, and the Prostate Cancer Foundation

Amin, Mahul B.; Lin, Daniel W.; Gore, John L.; Srigley, John R.; Samaratunga, Hemamali; Egevad, Lars; Rubin, Mark A.; Nacey, John N.; Carter, H. Ballentine; Klotz, Laurence; Sandler, Howard M.; Zietman, Anthony L.; Holden, Stuart; Montironi, Rodolfo; Humphrey, Peter A.; Evans, Andrew; Epstein, Jonathan I.; Delahunt, Brett; McKenney, Jesse K.; Berney, Daniel M.; Wheeler, Thomas M.; Chinnaiyan, Arul M.; True, Lawrence D.; Knudsen, Beatrice S.; Hammond, M. Elizabeth H.

doi:10.5858/arpa.2014-0219-sa

Cited by 119 publications

(89 citation statements)

References 173 publications

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“…Due to known interobserver variability associated with the identification of minor Gleason pattern 4 elements, prospective intradepartmental consultation with colleagues should be considered a cornerstone of quality assurance in this area. 26,27 Pathologists should use uniform methodology when assessing and reporting the extent of cancer involvement in biopsy cores, especially when dealing with discontinuously involved cores 26 since volume and distribution of disease in prostate biopsies are also selection criteria for AS.…”

Section: Recommendationmentioning

confidence: 99%

Active surveillance for the management of localized prostate cancer: Guideline recommendations

Morash

Tey

Agbassi

et al. 2015

CUAJ

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195

131

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Introduction: The objective is to provide guidance on the role of active surveillance (AS) as a management strategy for low-risk prostate cancer patients and to ensure that AS is offered to appropriate patients assessed by a standardized protocol. Prostate cancer is often a slowly progressive or sometimes non-progressive indolent disease diagnosed at an early stage with localized tumours that are unlikely to cause morbidity or death. Standard active treatments for prostate cancer include radiotherapy (RT) or radical prostatectomy (RP), but the harms from over diagnosis and overtreatment are of a significant concern. AS is increasingly being considered as a management strategy to avoid or delay the potential harms caused by unnecessary radical treatment. Methods: A literature search of MEDLINE, EMBASE, the Cochrane library, guideline databases and relevant meeting proceedings was performed and a systematic review of identified evidence was synthesized to make recommendations relating to the role of AS in the management of localized prostate cancer. Results: No exiting guidelines or reviews were suitable for use in the synthesis of evidence for the recommendations, but 59 reports of primary studies were identified. Due to studies being either non-comparative or heterogeneous, pooled meta-analyses were not conducted. Conclusion:The working group concluded that for patients with low-risk (Gleason score ≤6) localized prostate cancer, AS is the preferred disease management strategy. Active treatment (RP or RT) is appropriate for patients with intermediate-risk (Gleason score 7) localized prostate cancer. For select patients with low-volume Gleason 3+4=7 localized prostate cancer, AS can be considered.

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Section: Recommendationmentioning

confidence: 99%

Active surveillance for the management of localized prostate cancer: Guideline recommendations

Morash

Tey

Agbassi

et al. 2015

CUAJ

Self Cite

195

131

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“…In addition to practical considerations, the use of biopsy is limited by sampling error and a dependence on subjective grading. 86 Conversely, Long et al 86 have demonstrated consistent gene expression across multiple biopsy cores in a single patient, supporting previous work revealing limited variation in gene expression levels of highly expressed genes across multiple biopsy cores, including both malignant and benign stromal tissue. 88 As others have noted, such consistent gene expression, despite tissue and tumor heterogeneity, supports the notion that one can be confident in the overall prostate biology based on analysis of a limited sample.…”

Section: Molecular Testing In Active Surveillancementioning

confidence: 56%

Active Surveillance of Prostate Cancer: Use, Outcomes, Imaging, and Diagnostic Tools

Tosoian¹,

Loeb²,

Epstein³

et al. 2016

American Society of Clinical Oncology Educational Book

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Active surveillance (AS) has emerged as a standard management option for men with very low-risk and low-risk prostate cancer, and contemporary data indicate that use of AS is increasing in the United States and abroad. In the favorable-risk population, reports from multiple prospective cohorts indicate a less than 1% likelihood of metastatic disease and prostate cancer-specific mortality over intermediate-term follow-up (median 5 to 6 years). Higher-risk men participating in AS appear to be at increased risk of adverse outcomes, but these populations have not been adequately studied to this point. Although monitoring on AS largely relies on serial prostate biopsy, a procedure associated with significant morbidity, there is a need for improved diagnostic tools for patient selection and monitoring. Revisions from the 2014 International Society of Urologic Pathology consensus conference have yielded a more intuitive reporting system and detailed reporting of low-intermediate grade tumors, which should facilitate the practice of AS. Meanwhile, emerging modalities such as multiparametric magnetic resonance imaging and tissue-based molecular testing have shown prognostic value in some populations. At this time, however, these instruments have not been sufficiently studied to consider their routine, standardized use in the AS setting. Future studies should seek to identify those platforms most informative in the AS population and propose a strategy by which promising diagnostic tools can be safely and efficiently incorporated into clinical practice.

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“…Ductal cancer's occasional central (non-peripheral zone) location may also result in undersampling. 6,16 In our study, 1/18 tumours were located exclusively in the transition zone, which was undersampled or not sampled at all during routine template TRUS-guided biopsies.…”

Section: Discussionmentioning

confidence: 74%

“…3,4 Ductal cancer detected on transrectal ultrasound (TRUS)-guided biopsy specimens warrants therapy and is considered a contraindication for active surveillance (AS). 5,6 The clinical and microscopic detection of ductal cancer can be challenging. Ductal adenocarcinoma secretes less prostatic serum antigen (PSA) than acinar adenocarcinoma and it can appear occult on some magnetic resonance imaging (MRI) sequences.…”

Section: Introductionmentioning

confidence: 99%

Prostatic ductal adenocarcinoma: An aggressive variant that is underdiagnosed and undersampled on transrectal ultrasound (TRUS)-guided needle biopsy

Gulavita

Hakim

Schieda

et al. 2015

CUAJ

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Introduction: We sought to determine if prostatic ductal adenocarcinoma is undersampled and/or underdiagnosed at transrectal ultrasound (TRUS)-guided biopsy. Methods: With institutional review board approval, we searched our pathology database between 2008 and 2014 for patients with a diagnosis of ≥10% ductal adenocarcinoma on radical prostatectomy and available TRUS-guided needle biopsy specimens. Three blinded genitourinary pathologists independently examined the biopsy slides. The presence or absence of ductal adenocarcinoma was determined. Diagnostic accuracy was calculated using consensus diagnosis as the reference standard. Inter-observer agreement was assessed using Cohen's kappa coefficient. Results: Based on consensus review, 66.7% (12/18) biopsy specimens demonstrated ductal adenocarcinoma and 33.3% (6/18) demonstrated conventional acinar prostatic adenocarcinoma. The sensitivity/specificity for each reader (R) was: 83/100% (R1), 100/83% (R2) and 58/83% (R3) and the inter-observer agreement was only fair (K=0.32). Only two of the original needle-biopsy reports correctly identified ductal adenocarcinoma (sensitivity = 17%). The main limitations of the study are the relatively small sample size and the potential for selection bias since we could only examine patients who underwent radical prostatectomy. Conclusions: Prostatic ductal adenocarcinoma may be undersampled at TRUS-guided biopsy and in this study was under-reported in routine clinical practice. This highlights the importance of increased awareness of ductal adeoncarcinoma and the need for clear diagnostic criteria. These findings have significant clinical impact especially when determining candidacy for active surveillance protocols.

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Cited by 119 publications

References 173 publications

Active surveillance for the management of localized prostate cancer: Guideline recommendations

Active surveillance for the management of localized prostate cancer: Guideline recommendations

Active Surveillance of Prostate Cancer: Use, Outcomes, Imaging, and Diagnostic Tools

Prostatic ductal adenocarcinoma: An aggressive variant that is underdiagnosed and undersampled on transrectal ultrasound (TRUS)-guided needle biopsy

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