Very interesting path report about cribiform

@heavyphil My personal view is twofold:
1. The urologist and pathologist have to be kind of lucky for a narrow-bore (18 gauge) needle to blindly (ultrasound guided), cleanly sample the prostate tumor such that a sheet of tissue with Cribfriform glands can be seen after being processed for examination. It is not impossible but pretty darn close due to the cytocentrifugation used to deposit the cells onto the microscope slide.
2. I am the perfect example like the majority of men whose biopsy said nothing of the presence of Cribriform, but it was in fact present when the entire prostate was removed, followed by specifically-identified tumorous areas of the prostate being placed in paraffin blocks, then sliced in razor thin sections using a microtome, after which the sections are laid on microscope slides and have the slides heated to see the paraffin melt off, leaving the tissue heat-fixed to the slide, which is then stained and examined under the microscope.
So…bottom line…you can have a “clean” biopsy that “can”, but most often does not reveal Cribriform tissue, and can’t reveal EPE, seminal vesicle invasion, etc., but is very much present when the entire prostate is removed and examined.

@jeffmarc There are a variety of articles out on the subject. Here is an article from European Urology...a direct and complete copy/paste so it is here, easy to see vs a link.

Limitations of Prostate Biopsy in Detection of Cribriform and Intraductal Prostate Cancer
Rui M. Bernardinoa,b ∙ Rashid K. Sayyida ∙ Katherine Lajkoszc ∙ … ∙ Alejandro Berlinf,g ∙ Theodorus van der Kwasth ∙ Neil E. Fleshnera … Show more
Affiliations & Notes
Article Info
Cover Image - European Urology Focus, Volume 10, Issue

Background

The presence of cribriform morphology and intraductal carcinoma (IDC) in prostate biopsies and radical prostatectomy specimens is an adverse prognostic feature that can be used to guide treatment decisions.
Objective

To assess how accurately biopsies can detect cribriform morphology and IDC cancer by examining matched biopsy and prostatectomy samples.
Design, setting, and participants

Patients who underwent radical prostatectomy at The Princess Margaret Cancer Centre between January 2015 and December 2022 and had cribriform morphology and/or IDC in the surgical specimen were included in the study.
Outcome measurements and statistical analysis

We used detection sensitivity to evaluate the level of agreement between biopsy and prostatectomy samples regarding the presence of cribriform morphology and IDC.
Results and limitations

Of the 287 men who underwent radical prostatectomy, 241 (84%) had cribriform morphology and 161 (56%) had IDC on final pathology. The sensitivity of prostate biopsy, using radical prostatectomy as the reference, was 42.4% (95% confidence interval [CI] 36–49%) for detection of cribriform morphology and 44.1% (95% CI 36–52%) for detection of IDC. The sensitivity of prostate biopsy for detection of either IDC or cribriform morphology was 52.5% (95% CI 47–58%). Among patients who underwent multiparametric magnetic resonance imaging–guided biopsies, the sensitivity was 54% (95% CI 39–68%) for detection of cribriform morphology and 37% (95% CI 19–58%) for detection of IDC.

Conclusions:

Biopsy has low sensitivity for detecting cribriform morphology and IDC. These limitations should be incorporated into clinical decision-making. Biomarkers for better detection of these histological patterns are needed.
Patient summary

Prostate biopsy is not an accurate method for detecting two specific types of prostate cancer cells, called cribriform pattern and intraductal prostate cancer, which are associated with unfavorable prognosis.

@jeffmarc

This is a direct copy/paste from an "AI" response to the presence of Cribriform tissue and how it may not actually be part of art indicate malignancy, since it is found in normal tissue as well.

Cribriform gland tissue can present in various contexts, often without indicating intraductal carcinoma.

Understanding Cribriform Patterns
Cribriform architecture is characterized by sieve-like structures and can be found in both benign and malignant tissues. It is commonly observed in glandular tissues, including the prostate and salivary glands
.
In the prostate, cribriform lesions may appear as part of physiological processes or benign conditions, such as atypical intraductal cribriform proliferation (AIDCP), which does not meet the criteria for invasive carcinoma
.
Clinical Significance
The presence of cribriform patterns does not automatically imply malignancy. For instance, clear cell cribriform hyperplasia is a benign variant often found in the prostate
.
Accurate diagnosis requires careful histopathological evaluation to differentiate between benign and malignant conditions, especially since cribriform patterns can complicate the diagnostic process

I was curious because my surgical pathology report stated that I had presence of Cribriform tissue, but no intraductal pathology or malignancy noted. It could be that my Cribriform tissue is (hopefully) inconsequential.
.

@rlpostrp Curiouser and Curiouser! Perhaps Cribriform is in the same ballpark as PNI - present a lot of the time but not an indication of aggressiveness🤞

@rlpostrp
It may not be an accurate method, but it sure seems to work for a lot of doctors that analyze biopsies. Cribriform and intraductal Are frequently found in biopsies.

Are you really trying to say that is not true? Have you ever read biopsy reports? You see reports of cribriform all the time.

I think you have to look into other documentation because the one you quoted is just not representing what is being found in the real world.

More information about cribriform and other problems like intraductal
https://www.urotoday.com/video-lectures/a-journal-club-for-patients-with-prostate-cancer/video/mediaitem/4452-unfavorable-histology-classification-aims-to-reduce-unnecessary-treatment-journal-club-jesse-mckenney-cornelia-ding.html
Great article detailing risk of cribriform larger than .25, frequently found in a biopsy
https://onlinelibrary.wiley.com/doi/10.1111/his.15102

@jeffmarc Thanks for the feedback and follow-up question:

I am not saying that it is "not true." I am just saying that in the article I copied/pasted confirmed what I had read elsewhere as well...and with logic was able to deduce. The article stated that only 52% of men who had Cribriform tissue seen on the serially sectioned (microtome) samples examined microscopically, had Cribriform identified during/from their biopsy. In other words, roughly "half" the time due to the nature of ultrasound-guided punch biopsy and the small amount of tissue extracted in the biopsy, only "half" the men with Cribriform tissue have it revealed during the biopsy. But...basically 100% of the men with Cribriform tissue have it revealed when the entire prostate is removed, tumorous/pathologic areas of the prostate are dissected away and place in paraffin blocks for the process of slicing the tissue with the microtome to yield perfect sections of prostate tissue on the microscope slide. That is why urologists do "12" core samples: besides a cancerous prostate likely having more than one area with cancerous activity, their ultrasound-guided punch biopsy is a partially "blind procedure"...a "hope and a prayer" method that they will sample any/all types of diseased tissue from the sample. Analogy for you:
Think of an apple that has a couple of rotten areas (Cribriform and other cancerous pathology). The apple is covered (for the equivalent example of the unseen prostate). You take 12 needles and punch-biopsy that apple to the best of your ability. Will any of your 12 needles capture the rotten area(s) of the apple, and in sufficient quantity, to capture that rotten apple "tissue"? Likely not. That is why many of us end up with biopsy reports like mine that say: 3 cores normal/no disease, 3 cores 3+3=6, and 6 cores 3+4=7. The skilled urologist does the best they can with their ultrasound-guided probe to identify where they want to do the 12 biopsies, but it doesn't mean that they are going to get examples of "all" of the pathology that exists. The only way that happens is when the entire prostate is removed and undergoes visual inspection with numerous tumorous areas being processed to yield stained microscope slides.
Again, I am what I think is a very typical case: Not one of my 12-core biopsy samples revealed Cribriform tissue. Only the when the entire prostate was sliced and diced by experienced Histotech eyes and hands - and Pathologist review - did the tissue with Cribriform glands reveal itself, along with EPE, left seminal vesicle invasion, etc. becoming known.
So, bottom line again: "Yes"...one or more lucky punch biopsies can reveal Cribriform up to ~50% of the time for those men with Cribriform, but the other ~50% is missed, as in my case. That is why physicians often say that they "practice" medicine. As well trained and scientifically based as it is with incredible technology to assist them, they don't get it "all of the time." Since we're now in Baseball Spring Training, the same analogy comes from baseball: If you're a .333 hitter, you are a great, consistent hitter. But...you fail to get on base .666 of the time.
Thanks for the feedback. It stimulates me to keep researching!

@rlpostrp
I understand exactly what you are saying and yes, the after surgery biopsy is really the best way to find out about cribriform. A biopsy of 12 cores Getting only about 1% of the prostate is very unlikely to find everything going on. The interesting thing is they do find cribriform relatively frequently. This could be because an MRI is done ahead of time and they use a guided biopsy, which then does hit the spots where there is a higher chance of finding cancer. This is definitely a newer technique that was not done a few years ago and is not done all the time nowadays.

@heavyphil - YES INDEED. I was rather shocked when I finally read - well into this journey - that Cribriform tissue can be found in normal, benign prostate tissue. It is also found elsewhere in the body: 1) in the Cribriform Plate (base of the ethmoid bone forming the roof of the nasal cavity); 2) salivary glands; and 3) breast tissue.
Because Cribriform tissue in prostate cancer is usually associated with Intraductal Cancer, I am now researching statistics on how many men with prostate cancer and with Cribriform tissue identified - but WITHOUT Intraductal cancer identified, may have the Cribriform tissue as a casual, benign, "ride-along" observation during the histological/pathology review of the cancerous prostate that was removed? In other words: Does presence of Cribriform tissue in a cancerous prostate, but without Intraductual cancer, mean that the Cribriform tissue is still an ominous sign, or..."MUST" Intraductal cancer be present in order for the Cribriform tissue to be related to the presence of the cancer? Thus far I have found the following (quote):
"Cribriform glandular formations are characterized by a continuous proliferation of cells with intermingled lumina and can constitute a major or minor part of physiologic (normal central zone glands), benign (clear cell Cribriform hyperplasia and basal cell hyperplasia), premalignant (high-grade prostatic intraepithelial neoplasia, borderline (atypical intraductal Cribriform proliferation), or clearly malignant (intraductal, acinar, ductal, and basal cell carcinoma) lesions. Each displays a different clinical course and variability in clinical management and prognosis." Now I need to take the "deep dive" into all of this. I'll offer a follow-up later. I will either feel a lot better about "my" Cribriform glands identified in the surgical pathology report, or I will feel a lot worse. There will be no "in between"...of that I am certain.

@rlpostrp FWIW, I have a copy of my surgical pathology report at the bottom of a file cabinet. I looked at it once, and only briefly, while I was convalescing after surgery; that was 7 yrs ago and way before joining this forum and learning probably too much about this disease.
Over the past two years, and since my recurrence, I have often wanted to dig out that path report and look for the dooming word ‘cribriform’…but I have resisted.
What would be the point? Would anything have changed for me? NO. Would my recurrence have happened with or without that pattern? YES. Would my SRT have differed? NO.
Would my future treatment differ if needed? NO.
Many on the forum might rush in and say, ‘Oh! But you need to know this, this and that! What about mutations, etc?”
Yup, there’s all that. But I don’t believe anything would change the way I am treated.
The numbers, the PSA’s, velocities, scans, etc will determine what drugs, ADT or radiation will be used- and there’s not that big of a variety to choose from.
So don’t feel one way or the other about a lot of the words you’ll find in that surgical report; sure, IDC would be scary, but again it doesn’t mean you are doomed and maybe next year, IDC will be found to mean something else, or is not as important as previously thought.
Everything I read told me that PNI was ‘associated with poorer outcomes’ until I read a paper co-authored by a young RO at Sloan who - as luck/fate would have it - turned out to be my treating radiologist! At our first meeting I told him that I had read his paper explaining why PNI was NOT deadly; he seemed rather surprised and then laughed and told me “Yeah, PNI, don’t worry about it…”. And just like that, the death sentence was no more…Best of Luck to you,
Phil

@heavyphil
Have not seen that article about PNI that you are referring to. I had PNI, so many biopsies I’ve read report it. I’ve been telling people for a while that it really isn’t a big deal. There are much more severe problems to be concerned with when it comes to a biopsy. Good To hear a doctor agrees with that.

I have all of my biopsies in the Note app on my iPhone and iPad. I can quickly pull it up if I happen to forget something. That was from 16 years ago and I also have all my biopsy reports in that same note. I just requested my doctor send me that information a few years ago. Since he did in an email I was easily able to capture it. PNI is the only “aggressive” Thing in my prostate biopsy. My BRCA2 found in 2020 was a lot more aggressive.