Clinical decision making in urology, particularly urologic oncology, is driven by accurate pathological diagnoses. As in clinical medicine, pathological evaluation is not always “black and white,” and open communication between pathologists and urologists can result in more informed diagnoses and improved outcomes.¹ The rapidly evolving landscape of molecular biomarkers also necessitates closer collaboration between these disciplines.

Conceptualized from a surgeon’s standpoint, the standard workflow of pathology is simply depicted as follows: Sample obtained → gross evaluation of specimen → tissue processed and slide generated → pathological interpretation → final diagnosis and reporting → clinical decision making → additional biomarker testing.

However, each step of this process is nuanced and relies on explicit and implicit communication between the surgeon and pathologist. After a specimen is obtained and sent for evaluation, interpretation is influenced by information provided on the requisition form, details in the operative note and clinical history of the patient provided in the medical record. The historic notion that “all the pathologist needs is a slide” assumes diagnoses are made in a vacuum, a viewpoint that can negatively impact patient care.²

For example, a prostate biopsy obtained following radiotherapy in the setting of biochemical recurrence is a key detail that provides context to the interpreting pathologist. Receipt of prior treatment can not only downstage or eliminate disease (“ypT0”), but also render morphological changes (treatment effect) that may be challenging for a pathologist to conceptualize in the absence of relevant clinical history. Furthermore, providing this information leads to more accurate reporting as cancer showing significant treatment effect should not be assigned a Gleason grade and may otherwise be inaccurately assigned a grade without knowledge of prior treatment.³

In addition, clinical impressions from the surgeon provided in the operative and clinical notes can guide the pathologist in terms of sampling, selection of specific stains, evaluation of further levels and diagnostic considerations. For example, communicating the presence of an elevated serum alpha-fetoprotein in a patient with a testicular tumor that appears to be a pure seminoma on initial pathological evaluation should warrant further sampling for a nonseminomatous component. As such, initial line of communication from the urologist to the pathologist starts even before the specimen arrives to the laboratory in the form of thorough documentation in the medical record and requisitions.

Communication also occurs between urologists and pathologists through standardized synoptic reporting. The College of American Pathologists (CAP) has published standardized reporting forms for a variety of cancers, which simplify the transfer of information to surgeons and patients and should be incorporated into practice.⁴ These synoptics serve as a checklist and ensure documentation of key pathological parameters necessary for staging and treatment decisions. Moreover, as the number of histological entities expands with further characterization of various tumors (ie renal cell carcinoma subtypes) and the complexity of staging and prognostic factors compounds, the importance of utilizing synoptic reports has become increasingly necessary to clearly summarize and communicate data.

Another central arena of communication among surgeons and pathologist occurs in the setting of tumor board conferences. Real-time review of the pathology can lead to important discussions that influence subsequent steps in management via clarification and elaboration of specific elements within a pathology report. This may, for example, include quantification of variant morphologies with poor prognosis (micropapillary or plasmacytoid in urothelial carcinoma, and rhabdoid or sarcomatoid features in renal cell carcinoma, among others) that could result in more aggressive surgical or adjuvant treatments, or changes in surveillance regimens. Furthermore, tumor boards are an important avenue for feedback and education with regard to complex nomenclature and evolving practices (for instance, recent recommendations to report presence or absence of cribriform glands in Gleason pattern 4 prostatic adenocarcinoma).⁵

Other discussions that may arise during these conferences include the role of novel and emerging biomarkers. For example, immunohistochemical staining for PDL1 in urothelial carcinoma may be important in selecting treatments for patients with advanced disease; the same applies for FGFR3 testing, whereby the presence of a mutation will inform selection of novel agents for progressive disease. Multiple new biomarkers are available across the spectrum of all genitourinary tumors.

As the realm of urologic oncology expands in complexity and standards of clinical care change, treatment will continue to be guided by accurate pathological diagnoses. An open line of communication between pathologists and urologists at all levels can inform higher level of care for all patients (see table).