It is a topic that “men” do not like to talk about and try to avoid – problems with the prostate. Yet, with advancing age, most of all men are affected. From the fifth decade of life, almost 50% show an enlargement of the prostate, with 40% already suffering from symptoms requiring treatment at this age. From 75 years on, prostate enlargement is present in as many as 90% of men. Benign prostate growth is therefore a very common age-related phenomenon and affects almost all men. However, if symptoms persist, it is important to see a doctor so the problem can be treated. Urination difficulties, for example, can be caused by a variety of diseases, but also by malignant tumours. With 473,344 cases diagnosed across Europe in 2020, carcinoma of the prostate is one of the most common cancers in men. If detected early though, it is usually well treatable and even curable.

The National Centre of Pathology (NCP) at the Laboratoire national de santé is dedicated to the diagnostics of cancer and precancerous lesions, inflammatory lesions as well as pseudotumorous lesions and malformations in various organs of a patient. On the occasion of the European Prostate Day, we are interviewing Dr Francisco Javier Alves Ferreira, who is a pathologist at the Anatomic Pathology Service, specialized on hematopathology, uropathology and gastrointestinal pathology.

1. You are pathologist, specialized in uropathology at the LNS. Tell us about your daily work.

The National Center of Pathology of the LNS deals with the diagnosis of biopsies, cytologies and surgical pieces of patients treated in all hospitals, clinics, and private practices of physicians in Luxembourg. These institutions are our “clients” and send us all the material we analyze. At the LNS we are 6 pathologists working in the field of uropathology and implicated in the diagnostic of prostate cancer, with of course a lot of other people, including technicians and administrative personal. The role of the pathologist is to diagnose the different diseases based on morphological and molecular criteria. The diagnosis is therefore the confirmation, or not, of the clinical suspicion for which this biopsy was sent to us. In the case of the prostate, our work consists of analyzing the biopsy cylinders (usually 12) from different areas of the prostate. First, the pathologist and anatomic technicians carry out a macroscopic study of the samples (number, length of the cylinders and appearance). Then the samples are processed in fine cuts, which after adequate staining, will be observed under the microscope in order to decide whether there is a cancer or another type of alteration that can explain the signs and symptoms of the patient. During biopsies, we analyze the presence of cancer, the grade of the tumor with the Gleason score (WHO cancer grading system on a scale of 1 to 5), the extension in mm in each cylinder and its percentage.

It’s important to consider that the diagnostic and treatment of patient with prostate cancer is a multidisciplinary decision. That is why, all our examined cases are discussed in weekly tumor boards (Réunions de Concertation Pluridisciplinaires) which are attended by doctors specializing in urology, oncology, radiotherapy, pathology, radiology, and nuclear medicine, as well as a case manager. After all examination and evaluation, a biopsy report, following a pre-established protocol is sent to the attending physician, including additional information and recommendations, necessary to offer our patients the best possible treatment, adapted to their specific case.

2. What pathologies do you usually deal with when it comes to diseases related to the prostate?

Normally, prostate biopsies are performed to confirm or rule out the existence of a pathology, a disease that justifies the symptoms suffered by the patient (urine retention with difficulty in urination, for example) or the existence of a significant elevation of PSA in an analysis control of a patient, usually over 50 years of age. Cancer is a possibility that can explain these alterations but also benign growths (hyperplasia) or even inflammatory processes (prostatitis).

The work therefore of the National Center of Pathology in general and of pathologists consists in confirming the process that explains the alterations suffered by the patient. For this purpose, we use morphological techniques (macroscopic, microscopic), molecular, and genetic studies.

3. How many men are diagnosed with prostate cancer in Luxembourg every year? What can be done to help them?

In Luxembourg, the incidence of prostate cancer is 71,3 per 100.000 habitants; the second cancer after breast cancer with 99,8 and up of the lung cancer with 29,0 per 100.000 habitants (GLOBOCAN 2020). So, the number of new cases per year is between 350-400 for prostate cancer in Luxembourg. Whereas some men have an aggressive form of prostate cancer, most others have a slow-growing or indolent form of the disease.

Epidemiologic studies of prostate cancer have revealed numerous ways in which individual biology and lifestyle factors influence risk of developing prostate cancer and survival rates. Thus, although there are genetic and family factors that predispose to the disease, we must not forget that the patient himself with his lifestyle can influence the risk of developing prostate cancer and reduce the risk of suffering an advanced disease or worse prognosis. We know that strong risk factors, for example, are obesity and tobacco consumption. On the other hand, risk decreases with frequent physical activity as well as with the intake of certain foods (tomato, fish, or vitamin D…). An important recommendation to detect the presence of cancer early and in its initial stages is to carry out a PSA analysis and a urological review after the age of 50 each 1 or 2 years, depending on the patient’s situation.

4. What partners does the Anatomic Pathology Service collaborate with concerning the diagnosis and treatment of prostate diseases in Luxembourg and beyond?

As initially mentioned, the National Center of Pathology of the LNS is at the service of all hospitals, clinics and practices in Luxembourg. So, our diagnostic work reaches all patients in the country regardless of their pathology or referral center.

In addition, the NCP has been recognized from 2017 with the certification of the German Cancer Society (DKG) “OnkoZert” for the diagnosis and treatment of prostate cancer, and this certification led to the creation of “Prostatakarzinomzentrum”, with the Hôpitaux Robert Schuman and Centre François Baclesse. This has been an additional step towards our overall goal to offer all patients in the Luxembourg area the best possible treatment, characterized by excellence, in keeping with international standards of practice, and in tandem with a process of continuous improvement.