Background:
Extended biopsy schemes are becoming standard of care at most centers for the diagnosis of prostate cancer. Submitting each biopsy core individually to a pathology department raises the cost of pathologic evaluation significantly. Bundling the biopsy cores in a few containers precludes the identification of important prognostic features, such as percent of positive cores, site of positive cores, and site of highest Gleason score, that are thought to be predictors of extra-capsular extension, response to therapy and disease recurrence. We devised a protocol for bundling the specimens to reduce the cost while maintaining our ability to identify important prognostic information from individual cores.
Methods:
382 consecutive male patients undergoing a prostate biopsy between December 2002 and May 2005, based on a prospectively designed biopsy and tissue-marking protocol, were evaluated. The median number of cores obtained was 12, including the lateral peripheral zone. The lateral peripheral cores were marked using India ink soaked cotton swab. The cores from the sextant site (unmarked) and from the corresponding lateral site (marked) were combined and placed in one container (total containers= 6). We also quantified any additional time required for the tissue-marking protocol. The potential cost savings were calculated based on an average Medicare charge of per container. The data were tabulated to determine whether prognostic information could be obtained from each core.
Results:
Tissue-marking protocol did not add any additional time to the procedure. The marked and unmarked cores were easily identifiable in all cases, without introducing any tissue artifacts that could interfere with grading of cancer. By reducing the number of containers from 12 to 6, the potential cost savings in over 850 million dollars nationally. Cancer was detected in 149 (39%) patients. The mean Gleason score was 7.0 (range 5-9). A single biopsy core was positive in 43 (30%), two biopsy cores in 29 (21%), and greater than 2 cores in 71 (49%) of men with cancer. Of the 149 men diagnosed with prostate cancer, 54 (36%) underwent a radical prostatectomy. Of these, 11 (20%) patients demonstrated extracapsular extension on their prostatectomy specimens. The margin positive rate was approximately 16%.
Conclusions:
Our tissue-marking protocol allows us to perform extended prostate biopsies in a cost-effective manner, without sacrificing our ability to glean important prognostic information from each core. While cost of pathologic evaluation varies amongst regions, this technique can result in potential savings of tens of millions.

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