Is there a possibility of missing cancer due to short core lengths in patients with benign pathology reports? Several studies did an in-depth analysis of needle-core prostate biopsy length and how it correlates with a diagnosis. The big question on everyone’s mind was: does size really matter? Yes, yes it does. In this blog post, we’ll discuss each study’s discoveries and what we can do to improve prostate cancer diagnosis.
Prostate Cancer Incidence Rates are Increasing
Prostate cancer is the second leading cause of cancer in men globally and the most commonly diagnosed cancer in the US, excluding skin cancer. One in 8 men in the United States are diagnosed in their lives. Diagnosis is done through a biopsy, often prompted by an elevated PSA level.
Since 2014, prostate cancer incidence rates have increased yearly by around 3%, and incidence rates for advanced-stage prostate cancer increased yearly by 5%.
Even as incidence rates increase, there is a massive amount of prostate cancer underdiagnosis, due to a wide variety of factors. A retrospective analysis discovered that up to 7.1% of men are overdiagnosed, and up to a staggering 30% are being underdiagnosed!
Does Prostate Specimen Size Matter? Yes
Three in-depth studies were carried out on different needle-core prostate specimens to determine just how much size matters in prostate cancer diagnosis. Each study analyzed the overall cancer detection rate within their selection of samples. Then, they recorded the length of each tissue. Finally, they compared the length of the cores that had resulted in a cancer diagnosis with the length of cores that had resulted in a benign diagnosis.
The first study found that biopsy sample length is one of the most important parameters that determine the quality of the biopsy and cancer detection. Specimens with cancer averaged a length of 12.5 mm and specimens without cancer averaged 11.3 mm. They discovered a 2.44 times increased chance of detection of PCa if the biopsy length is >20 mm compared to <10 mm.
The second study had slightly different results but came to the same conclusion. The mean core length taken per cc of prostate and the percentage of sampled prostate volume were determined to be 3.40 ± 0.15 mm/cc in patients with cancer and 2.75 ± 0.08 mm/cc in patients without cancer. Core length taken per cc of the prostate of > 3.31 mm/cc was related to an increase in the rate of prostate cancer diagnosis.
The third study observed that the mean core length in patients diagnosed with cancer was 12.3±2.6. The mean core length in patients without a cancer diagnosis was 11.4±2.4 mm. The cancer detection rate for cores less than 11.9 mm was 23%, while cores greater than 11.9 mm had a 39% cancer detection rate.
What Does This Mean?
Cores of an insufficient length may very likely result in a patient receiving a benign report when they actually have cancer. The implications of false-negatives are staggering. In addition, patients who receive a cancer diagnosis might be in a more advanced stage of that cancer than they realize because of insufficient specimen core length.
What Can We Do?
One solution is whenever a surgeon takes a biopsy shorter than 12 mm they should take an additional biopsy to ensure they are providing the pathologist with sufficient information.
Sometimes, even sufficiently long tissue isn’t enough because it folds, curls, fragments, or gets caught in formalin bottle threads. This results in an uneven plane, so even with the painstaking efforts of the best pathologists’ assistants and histotechs, it’s nearly impossible to get an even plane of tissue in the block. And even when labs cut and stain multiple levels, it’s difficult to get the entire tissue on the slide. The best way to give a patient their best shot is to not only biopsy long cores but also take good care of those cores as they’re transported from the surgery center to the lab. How?
This is where our second solution can help: the BxBoard®. The BxBoard is a replacement for formalin bottles that hold needle-core biopsies in flat lanes on top of a formalin-soaked sponge. The even plane for tissue fixation means less to no tissue folding, coiling, and fragmentation. In addition, the BxBoard has a clear lid so you can easily verify specimen length, even when the container is closed. It also has a blue sponge, creating a contrast to make the tissue more visible. That way, once the specimen is on the sponge, the surgeon can easily and quickly determine whether or not the quality of the tissue is adequate.
BxBoard users have reported that these features have enabled up to a 12% increase in core length compared to when they’ve used formalin jars.
Impact on Treatment Decisions
The importance of prostate biopsy core length cannot be overstated when it comes to cancer diagnostics. The studies discussed above strongly suggest longer core lengths significantly enhance the accuracy of prostate cancer detection, improve the sampling of suspicious areas, and reduce the risk of false-negative results. By maximizing the core length, urologists can provide patients with more precise information about the presence and severity of prostate cancer, enabling informed treatment decisions. As medical advancements continue to evolve, optimizing the biopsy procedure with a focus on core length will contribute to improved outcomes and better management of prostate cancer.
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