Practice-Based Differences in Ancillary Stain Usage When Evaluating Prostate Needle Core Biopsies
Brian D Robinson, Rhonda K Yantiss. Weill Cornell Medical College, New York
Background: High molecular weight keratin (HMWCK), p63, and AMACR immunostains are often combined in a triple stain to aid prostatic adenocarcinoma (PCa) detection in needle core biopsies. However, their judicious use is necessary to prevent escalating costs when multiple biopsies are obtained, particularly if the results do not impact patient care. The purpose of this study was to evaluate patterns of ancillary stain utilization among various pathology practice models.
Design: We reviewed 400 recent outside pathology reports for patients referred to our institution from academic centers (n=63), community hospitals (n=68), commercial laboratories (n=158), and private urology groups (n=111). The following features were recorded for each part of the case: total number of cores, diagnosis, number of PCa+ cores, Gleason score (GS), percent PCa involvement, and perineural invasion (PNI). Use of ancillary stains was deemed appropriate in potentially difficult cases (i.e. GS≤7, ≤20% involvement, and no PNI) or when results would alter clinical management, namely definitive therapy versus active surveillance (i.e. ≤2 PCa+ cores with GS≤6 and ≤50% core involvement). Ancillary stains were always considered appropriate in PCa- cases.
Results: A diagnosis of PCa was rendered in 388 cases, including 159 in which at least 1 immunostain was used to facilitate the diagnosis. Of these, academic centers used ancillary stains the least (15%), followed by community hospitals (35%), reference laboratories (44%) and private urology groups (56%). Academic centers used immunostains in an appropriate fashion based on the above criteria, but community hospitals, reference laboratories, and private urology groups frequently obtained triple stains in PCa cases with high GS, extensive disease, or PNI (18%, 20%, 40%, respectively). These groups also used triple stains on multiple additional tissue blocks in situations that did not impact management (17%, 10%, 33%, respectively). There were no significant differences between practice groups with respect to number of cores obtained, PCa+ cores, GS, disease extent, or PNI in cancer cases.
Conclusions: Pathologists may be tempted to confirm a diagnosis of PCa with immunostains even when it is readily apparent on H&E stained sections. The increased costs incurred are often compounded by use of multiple triple stains on other blocks, the results of which may not impact treatment decisions. Pathologists can help contain healthcare costs by understanding the algorithms of prostate cancer management and limiting use of ancillary stains to situations that affect patient care.
Category: Genitourinary (including renal tumors)
Tuesday, March 20, 2012 11:30 AM
Platform Session: Section A, Tuesday Morning