Current gross examination and reporting patterns of post-neoadjuvant chemotherapy cystectomy specimens: Is it time for a standardized approach?

OBJECTIVES: Neoadjuvant chemotherapy (NACT) is recommended for muscle-invasive bladder cancer, and robust treatment response may result in lack of grossly identifiable tumor in the cystectomy specimen. Current gross examination and reporting protocols, however, do not include specific guidance on the approach to these specimens. METHODS: A Qualtrics survey was disseminated by email and X (formerly Twitter). Responses from pathologists and pathologists' assistants (PAs) were included. The survey interrogated demographics, practice settings, prevalence of NACT use, approach to gross examination, and reporting practices in the setting of both grossly visible tumor or ulcer bed and the complete absence of a gross lesion. RESULTS: Based on 55 respondents' experience, identifying gross tumor occurred less frequently than tumor or ulcer bed (40% vs 71%). Lack of identification of any gross lesions was estimated to occur in 29% of cases. Gross examination practices were relatively consistent in cases with residual gross tumor or gross tumor bed, with agreement that gross tumor should be submitted as 1 block per centimeter (66%), and tumor or ulcer bed should be submitted in its entirety (97%). Gross examination practices appeared more varied when no gross lesions were identified. Overall, most responders stated they "definitely" or "maybe" support a standardized gross examination (89%) and reporting (96%) protocol. CONCLUSIONS: With the increased use of NACT, lack of any gross lesion leads to inconsistent gross examination techniques. This study provides insight into the current approach to examination of post-NACT cystectomies and suggests that a desire exists among pathologists and pathologists' assistants for more standardized practice.

Less Is More: Evaluation of Gross Examination Protocol for Cystectomy Specimens Following Neoadjuvant Chemotherapy

OBJECTIVES: Neoadjuvant chemotherapy (NAC) confers a survival advantage for muscle-invasive bladder cancer and is now recommended for chemotherapy-eligible patients. NAC may result in absent gross tumor, and current cystectomy gross examination protocols do not specify approach for these cases. METHODS: We included cystectomies performed from 2010 to 2018, capturing a period pre- and post-NAC recommendations. Gross descriptions were reviewed and slides of patients who received NAC were evaluated for microscopic tumor, number of blocks with tumor, and location of those blocks. RESULTS: We identified 239 radical cystectomies for bladder cancer (147 NAC, 92 non-NAC). Gross lesions were not identified for 91 cases. NAC cases had more total blocks submitted (mean, 17.5) compared with non-NAC cases (mean, 16.6). More NAC cases had additional blocks submitted (20 cases) compared with non-NAC cases (2), which were more frequently additional random sections. Of 108 NAC cases with residual carcinoma, only 2 (1.9%) were upstaged on additional random sections. CONCLUSIONS: At our institution, NAC and non-NAC cases are grossed with similar numbers of initial blocks; however, NAC cases are more likely to submit additional sections of gross lesions and random bladder without significant changes in stage. Our data suggest current gross examination protocols are sufficient for NAC cystectomies.