Short survey analysis. What is the Gleason score and the grade group?. An opportunity for digital p

I invited a few pathologists from my LinkedIn network or directly by e-mail to participate in a short survey to report the Gleason score of one picture. The picture was published in a case report of a 65-year-old Nigerian man who had facial nerve palsy as a primary presentation of advanced prostate cancer. Grade Group was 3 (Gleason Score (GS) 4+3=7). The case report can be freely accessed here: http://www.sciencedirect.com/science/article/pii/S1110570416300297

In Africa, prostate cancer is frequently diagnosed in advanced stages and the treatment is often palliative. PSA screening is costly and not covered by insurance companies or universal health care coverage. In addition, there is a severe shortage of pathologists, with less than 1 pathologist per 1 000 000 population in most African countries. In that scenario, digital pathology might offer new opportunities to improve the quality of prostate cancer diagnosis and become a good educational tool to train new pathologists.

Fourteen pathologists kindly participated in my test and reported the Gleason score of that picture. They lived in different countries: Europe (Belgium, Italy, Kosovo, Serbia and Spain), Africa (Bostwana, Kenya and Morocco), Asia (Palestine and Syria), and America (Nicaragua, Uruguay and the USA). I had an special interest to get feedback from underserved countries.

The final results were:

- Grade Group 2: 1 (GS 3+4)

- Grade Group 3: 3 (GS 4+3)

- Grade Group 4: 4 (GS 4+4)

- Grade Group 5: 6 (GS 4+5: 3; GS 5+4: 3)

The results had only a 21.4% agreement with the original result published in the case report.

There are two main reasons for such high discordance rates:

1.- The quality of the image was not good enough to analyze the picture for diagnostic purposes.

The picture was shown through two different ways:

a) direct access through this link

b) attached and sent through LinkedIn or by e-mail to the participants.

The quality of the e-mail attachment was poor and a few colleagues refused to participate. The quality of the link was slightly better and had more acceptance but still many comments about the quality of the image. Most Grade Group 5 grading were by pathologists who looked at the attachment and not at the website.

2.- Participation of specialists with different levels of expertise in prostate pathology

According to a study published by Chen et al [1], non-genitourinary pathologists trend to overgrade Gleason score more than genitourinary pathologists. The same happened in this survey: No genitourinary pathologist gave a Grade Group 5 in this survey, and they often gave the same Grade Group (3) as in the published case report.

I asked four colleagues from Kenya, Palestine, Syria and Venezuela about the speed of their Internet connection, by showing them an image of a whole slide scanned image publicly available at the University of Leeds website:

http://www.virtualpathology.leeds.ac.uk/slides/library/view.php?path=%2FResearch_4%2FSlide_Library%2FMISCELLANEOUS%2FACP%2FMAY2007%2F38548.svs

All three confirmed they had high-internet speed access and could study the image through a web browser. They confirmed the quality of the whole-slide scanned image was much better than the static picture published in the case report.

Conclusions:

1.- Digital pathology (whole-slide scanning + virtual microscopy (WSI+VM)) could contribute to fix the issue of shortage of pathologists in Africa and other underserved areas, where high-speed internet access is available in academic institutions.

2.- WSI+VM would be much better than static pictures to request second opinion of difficult cases. Classic telepathology image sharing should be progressively discarded and substituted by whole-scanned images.

3.- LinkedIn is an interesting tool for professional networking online. During the study, I got feedback and advice from many colleagues that was very helpful to proceed with my test. I noticed a high interest in collaboration and participation in international research initiatives specially by those colleagues working in underserved areas.

Many ideas have arisen from that small test, which will generate new projects and scientific publications in the future.

I would indeed like to thank all the participants to this test and those colleagues who gave me positive feedback and advice.

For further comments e-mail me at: xaviprostate@gmail.com or xfarre@fulbrightmail.org.

You can also contact me through LinkedIn.

Reference:

[1] Chen SD, Fava JL, Amin A. Gleason grading challenges in the diagnosis of prostate adenocarcinoma: experience of a single institution. Virchows Arch 2016; 468: 213-218.