Figure 4 Algorithm for when to determine PTEN

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Figure 4 Algorithm for when to determine PTEN status on diagnostic biopsy material using IHC and FISH Figure 4 | Algorithm for when to determine PTEN status on diagnostic biopsy material using IHC and FISH. Prostate biopsy is indicated to confirm or exclude cancer in patients with elevated serum PSA levels and/or abnormal digital rectal exam (DRE). Patients with persistent PSA elevation might require repeat biopsy. If cancer is detected and is low-to-intermediate risk (Grade Group 1 or 2; Gleason score 3 + 3 or 3 + 4), phosphatase and tensin homologue (PTEN) status can be ascertained using immunohistochemistry (IHC) staining. If PTEN protein expression is intact, the prognosis reflects the patient's clinicopathological variables (for example, Grade Group, PSA, age, DRE). If IHC demonstrates complete PTEN loss, biomarker status should be considered in the patient's prognosis along with clinicopathological variables and fluorescence in situ hybridization (FISH) is not necessary. However, if PTEN loss is incomplete or ambiguous (for example, negative PTEN staining in cancer glands along with negative PTEN expression in internal control, such as benign glands and/or stroma), FISH is recommended and bears similar connotations to PTEN loss determined by IHC. If cancer is detected and is high risk (Grade Group 3, 4 and 5; Gleason score 4 + 3 and 4 + 4, ≥4 + 5), PTEN status does not need to be determined because the prognosis will be strongly driven by clinicopathological variables. Jamaspishvili, T. et al. (2018) Clinical implications of PTEN loss in prostate cancer Nat. Rev. Urol. doi:10.1038/nrurol.2018.9