Prostate cancer management is often based on biopsy findings but conflicting recommendations by different expert groups have led to significant reporting variation. In this lecture, an alternative approach focusing on optimal communication of histopathological data is described. Communication is critical as clinicians rarely view histological material and are therefore dependent on the information included in the histopathology report. Pathologists tend to focus on precise and reproducible reporting of tumour grade and extent, but precision/reproducibility would be less important if the biopsy findings are effectively conveyed by the pathologist and correctly interpreted by the clinician. Strategies to effectively communicate the message in contentious scenarios such when a prostate needle biopsy set contains prostate cancer that is either discontinuous, of borderline grade, of disparate grades or associated with intraductal carcinoma of the prostate will be outlined. Terminology issues will also be discussed and use of ambiguous diagnostic terminologies such as "atypical small acinar proliferation" and "atypical intraductal proliferation" discouraged.
References
1. Varma M, Warren AY, Delahunt B. Communicating prostate biopsy results. Diagn Histopathol 2021;27:283-9.
2. Borges AM, Varma M. Personalized Histopathology Reporting for Personalized Medicine. Diagn Histopathol 2021;27:275-8.
3. Christian A, Shah VI. Pathology reporting: communication is key. Diagn Histopathol 2021;27:279-82.
4. Dallmann A, Varma M. Prostate biopsy reporting: the case for a pragmatic approach. https://www.rcpath.org/profession/publications/college-bulletin/october-2021/prostate-biopsy-reporting-the-case-for-a-pragmatic-approach.html
 

Erectile dysfunction and urinary incontinence are common side effects of radical prostatectomy. These side effects can be minimised by nerve sparing, dissecting within the fascial layers that surround the prostate and contain the microscopic cavernosal nerves. Nerve sparing in the presence of capsular involvement risks positive surgical margins (PSM) with impaired oncological outcomes. Thus the surgeon is presented with a competing desire to spare nerves where possible but ensure cancer clearance is complete. Whilst useful for localising prostate cancer, MRI lacks the resolution to identify microscopic capsular involvement.

NeuroSAFE is a well established intra-operative technique for evaluation of surgical margins during radical prostatectomy with frozen section. It is designed to promote safe nerve sparing, without compromising cancer control. Whilst thousands of patients have been treated worldwide using NeuroSAFE, level 1 evidence of benefit has been lacking. My team have developed and successfully completed recruitment to the NeuroSAFE PROOF RCT (NCT03317990) with primary endpoints of patient reported outcomes of potency and continence. We are looking forward to publishing the results. The technique requires careful collaboration between surgical and histopathology teams.

Whilst carrying out the study we found that NeuroSAFE, although accurate, was time and labour consuming. As a potential alternative we have developed a technique called LASERSAFE using a confocal laser microscope (Histolog scanner- Samantree) to evaluate surgical margins intraoperatively . The LASERSAFE technique is simple to perform and generates H&E like, en-face images of the entire postero-lateral, neurovascular bundle adjacent, prostate surface, in a few minutes. The images can be viewed remotely by expert pathologists, obviating the need to transport the tissue to the laboratory for evaluation. I will present our initial experience using this technique including demonstration of the equipment, a blinded multi-user accuracy evaluation as well as plans for next steps in formally evaluating this exciting new technology.