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Standardized pathology "synoptic reporting"

1. Needle biopsies

  • comment on the adequacy of the specimen, number of cores (six cores preferable) from each side of the gland
  • absence/presence of carcinoma
  • an estimate of the amount of tumour (length of positive core in mm, location, number of  positive cores) from each side separately
  • histologic type
  • histologic grade (Gleason grades 1-5 out of 5; Gleason score, which is the sum of the two most prevalent grades)
  • presence of lymphatic, vascular or perineural invasion
  • invasion into or through prostatic capsule
  • presence of prostatic intraepithelial neoplasia (PIN), grade

2. Transurethral resection of prostate (TURP)

  • should include the above information as well as an estimate of the percent of prostatic tissue involved with carcinoma

3. Radical prostatectomy

  • absence/presence of carcinoma 
  • size of carcinoma (at least 2, preferably 3 dimensions) 
  • location within the prostate 
  • Gleason grades and score 
  • presence of PIN, grade 
  • presence of lymphatic, vascular or perineural invasion 
  • presence of extracapsular extension, location, extent (into vs. through the capsule) 
  • status of resection margins, extent and location of involvement 
  • seminal vesicle involvement 
  • number of lymph nodes examined, number involved, laterality, extent of involvement, presence of extranodal extension

Standardized Radiology Reporting

1. Reports from CT scans of the pelvis

  • size of prostate in 3 dimensions
  • presence of obvious extracapsular extension, seminal vesicle involvement 
  • evidence of invasion of local structures, e.g. bladder, rectum, pelvic sidewall 
  • pelvic lymph nodes: number, size, location, presence of necrosis 
  • presence of bony metastasis, location

2. Reports from transrectal ultrasound (TRUS) examinations 

  • size of the prostate in 3 dimensions, estimated volume 
  • presence, location, size of any intraprostatic lesions, appearance (benign vs. malignant) 
  • evidence of extracapsular extension, seminal vesicle invasion 
  • number of core biopsies taken and location


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