BRCA Testing in Prostate Cancer: A Histopathologist's Perspective

BRCA1/2 alterations have emerged as clinically relevant biomarkers in prostate cancer because of their prognostic significance and predictive value for response to poly(ADP-ribose) polymerase inhibitors. As indications for molecular testing expand, histopathologists play a pivotal role in ensuring the quality and reliability of somatic BRCA testing. This narrative review provides a histopathologist-oriented overview of the principal pre-analytical, technical, and morphological issues influencing BRCA testing in PC, with emphasis on tissue selection, specimen processing, nucleic acid preservation, and genotype-phenotype correlations. The success of somatic BRCA testing depends on several pre-analytical variables, including fixation, storage time, tumor cellularity (generally ≥10-20% neoplastic cells for reliable NGS analysis), specimen type, and DNA quality. Bone metastasis specimens require special attention because decalcification procedures may compromise nucleic acid integrity and molecular testing performance. From a morphological perspective, BRCA-associated PCs, especially those harboring BRCA2 alterations, are characterized by adverse clinicopathological features, including a higher grade and stage at diagnosis. Although intraductal carcinoma of the prostate and cribriform architecture are associated with genomic instability and poor prognosis, their value as surrogate markers of BRCA1/2 alterations remains uncertain. Histopathologists play a central role in optimizing BRCA testing through appropriate specimen selection, tissue handling, and multidisciplinary collaboration, thereby supporting precision medicine in prostate cancer.