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This article deals with '''prostate cancer grading'''. | This article deals with '''prostate cancer grading'''. | ||
It covers the '''Gleason | It covers the '''Gleason system''' and the proposed '''Prostate cancer grading system endorsed by the WHO'''. | ||
''Prostate cancer'' is dealt with in the ''[[prostate cancer]]'' article. | ''Prostate cancer'' is dealt with in the ''[[prostate cancer]]'' article. | ||
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**''Gleason score 3+4=7'' means: pattern 3 is present and dominant, pattern 4 is the remainder of the tumour - but present in a lesser amount than pattern 3. | **''Gleason score 3+4=7'' means: pattern 3 is present and dominant, pattern 4 is the remainder of the tumour - but present in a lesser amount than pattern 3. | ||
**''Gleason score 4+5=9'' means: pattern 4 is present and dominant, pattern 5 is present in a lesser amount that pattern 4. Pattern 3 may be present in a quantity less than pattern 4 or is absent. | **''Gleason score 4+5=9'' means: pattern 4 is present and dominant, pattern 5 is present in a lesser amount that pattern 4. Pattern 3 may be present in a quantity less than pattern 4 or is absent. | ||
**If a lower grade pattern is present and less than 5% it is ignored. | |||
***A biopsy with 98% Gleason pattern 4 and 2% Gleason pattern 3 would be graded as 8/10 (4+4). | |||
*Reported as on prostatectomies as: (primary pattern) + (secondary pattern) = sum, (tertiary pattern) | *Reported as on prostatectomies as: (primary pattern) + (secondary pattern) = sum, (tertiary pattern) | ||
*Tertiary Gleason pattern | ====When to use/not to use==== | ||
**The presence of a tertiary patterns adversely affect the prognosis; however, the prognosis is not as bad as when the tertiary pattern is the secondary pattern, i.e. 3+4 tertiary 5 has a better prognosis than 3+5 (with some small amount of pattern 4).<ref name=Ref_GUP72>{{Ref GUP|72}}</ref> | The ''College of American Pathologist'' synoptic (''Cancer Protocol Template'') says:<ref>Srigley JR ''et al.'', "Protocol for the Examination of Specimens From Patients With Carcinoma of the Prostate Gland", College of American Pathologists, Version: 4.0.3.0. (June 2017), Accessed on: 10 October 2018.</ref> | ||
*Grade all prostate specimens with adenocarcinoma except those with prior treatment changes (e.g. radiation therapy changes or anti-androgen changes). | |||
====Tertiary Gleason pattern==== | |||
*Unfortunately there is no consensus definition for ''tertiary Gleason pattern''.<ref name=Koloffa>{{Cite journal | last1 = Koloffa | first1 = ZB | last2 = Hamstrab | first2 = DA | last3 = Weia | first3 = JT | last4 = Montgomerya | first4 = JS ''et al''| title = Impact of tertiary Gleason pattern 5 on prostate cancer aggressiveness: Lessons from a contemporary single institution radical prostatectomy series | journal = Asian Journal of Urology | volume = 2 | issue = 1| pages = 53–58 | month = | year = 2015 | doi = 10.1016/j.ajur.2015.04.007 | PMID = | PMC = | url = http://www.sciencedirect.com/science/article/pii/S2214388215000302 }}</ref> | |||
**The Foundation series GU book (1st Ed.) defines ''Tertiary Gleason pattern'' as:<ref name=Ref_GUP72>{{Ref GUP|72}}</ref> a pattern that is seen in less than 5% of the tumour that is of a higher grade than the two dominant patterns. | |||
**Koloffa ''et al''<ref name=Koloffa/> notes that some define it as: the third most prevalent pattern and most require that it is a higher grade than the two dominant patterns. | |||
***Parsed with the all the subtleties a working definition could be: The third most prevalent pattern ''and'' a higher grade than the two dominant patterns ''or'' a pattern that is seen in less than 5% of the tumour and of higher grade than one pattern that comprises >95% of the tumour. | |||
Significance: | |||
*The presence of a tertiary patterns adversely affect the prognosis; however, the prognosis is not as bad as when the tertiary pattern is the secondary pattern, i.e. 3+4 tertiary 5 has a better prognosis than 3+5 (with some small amount of pattern 4).<ref name=Ref_GUP72>{{Ref GUP|72}}</ref> | |||
Use: | |||
*It is only used for prostatectomies. | |||
====Examples==== | ====Examples==== | ||
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*A biopsy with 98% pattern 4, and 2% pattern 3... would be reported as: 4+4=8. | *A biopsy with 98% pattern 4, and 2% pattern 3... would be reported as: 4+4=8. | ||
*A prostatectomy with 80% pattern 4, 16% pattern 3 and 4% pattern 5... would be reported as: 4+3=7 with tertiary pattern 5. | *A prostatectomy with 80% pattern 4, 16% pattern 3 and 4% pattern 5... would be reported as: 4+3=7 with tertiary pattern 5. | ||
Note: | |||
*Based on the various definitions of tertiary pattern:<ref name=Koloffa/> | |||
**A prostatectomy with 75% pattern 4, 15% pattern 3 and 10% pattern 5 could be reported as: 4+3=7 with tertiary pattern 5 ''or'' 4+5=9. | |||
***As there is no consensus on this, it is probably best to report the percentages of the various patterns if this situation arises. | |||
===Gleason patterns (modified)=== | ===Gleason patterns (modified)=== | ||
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Notes: | Notes: | ||
*Gleason pattern 1 - probably represents what today would be called ''adenosis''. | *Gleason pattern 1 - probably represents what today would be called ''adenosis''. | ||
**Should never be used. | **Should '''never''' be used. | ||
*Gleason pattern 2 - used by few GU pathology experts occasionally. | *Gleason pattern 2 - used by few GU pathology experts occasionally. | ||
**Generally, should '''not''' be diagnosed on core biopsies.<ref name=pmid20006878>{{Cite journal | last1 = Epstein | first1 = JI. | title = An update of the Gleason grading system. | journal = J Urol | volume = 183 | issue = 2 | pages = 433-40 | month = Feb | year = 2010 | doi = 10.1016/j.juro.2009.10.046 | PMID = 20006878 }}</ref> | **Generally, should '''not''' be diagnosed on core biopsies.<ref name=pmid20006878>{{Cite journal | last1 = Epstein | first1 = JI. | title = An update of the Gleason grading system. | journal = J Urol | volume = 183 | issue = 2 | pages = 433-40 | month = Feb | year = 2010 | doi = 10.1016/j.juro.2009.10.046 | PMID = 20006878 }}</ref> | ||
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Image:Prostate_cancer_with_Gleason_pattern_4_low_mag.jpg | Gleason pattern 4 - cribriform. (WC) | Image:Prostate_cancer_with_Gleason_pattern_4_low_mag.jpg | Gleason pattern 4 - cribriform. (WC) | ||
Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands & Gleason pattern 5 - single cells. (WC) | Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands & Gleason pattern 5 - single cells. (WC) | ||
</gallery> | |||
<gallery> | |||
Image: Prostatic carcinoma - Gleason pattern 4 -- intermed mag.jpg | PC Gleason pattern 4 - intermed. mag. | |||
Image: Prostatic carcinoma - Gleason pattern 4 -- high mag.jpg | PC Gleason pattern 4 - high mag. | |||
</gallery> | </gallery> | ||
www: | www: | ||
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=====Images===== | =====Images===== | ||
<gallery> | |||
Image: Poorly differentiated prostate carcinoma -- intermed mag.jpg | PDPC (Gleason pattern 5) - intermed. mag. (WC/Nephron) | |||
Image: Poorly differentiated prostate carcinoma -- high mag.jpg | PDPC (Gleason pattern 5) - high mag. (WC/Nephron) | |||
Image: Poorly differentiated prostate carcinoma -- very high mag.jpg | PDPC (Gleason pattern 5) - very high mag. (WC/Nephron) | |||
</gallery> | |||
<gallery> | <gallery> | ||
Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands (left) & Gleason pattern 5 - single cells (right). (WC) | Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands (left) & Gleason pattern 5 - single cells (right). (WC) | ||
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</pre> | </pre> | ||
== | ====Separate nodule upgrades prostatectomy==== | ||
<pre> | |||
A tumour nodule in the left mid portion of the gland (1.2 cm) is predominantly 4+3; the Gleason score for the case is assigned on the basis of the tumour nodule as Gleason score 7/10 (4+3). | |||
Overall, Gleason pattern 3 represents 65% of the cancer in the prostate, and Gleason pattern 4 represents 35% of the cancer in the prostate. | |||
</pre> | |||
==Prostate cancer grading system endorsed by the WHO== | |||
*[[AKA]] ''WHO prostate cancer grading system'' or ''WHO system''. | |||
*[[AKA]] ''ISUP prostate grading''. | |||
*[[AKA]] ''grade groupings''. | |||
*[[AKA]] ''prognostic Gleason grade groupings''. | *[[AKA]] ''prognostic Gleason grade groupings''. | ||
*[[AKA]] ''a contemporary prostate cancer grading system'', abbreviated ''CPCGS''. | *[[AKA]] ''a contemporary prostate cancer grading system'', abbreviated ''CPCGS''. | ||
*[[AKA]] ''Gleason group''.<ref>URL: [http://www.cancer.net/cancer-types/prostate-cancer/stages-and-grades http://www.cancer.net/cancer-types/prostate-cancer/stages-and-grades]. Accessed on: May 1, 2017.</ref> | |||
This system has been proposed. Currently, it is not widely used. The name of the system is ''not'' completely settled. | |||
This system has been proposed. Currently, it is not widely used. The name of the system is ''not'' completely settled. | |||
===Gleason score | ===WHO prostate cancer grading system & Gleason score=== | ||
Proposed new system and old (modified) Gleason score:<ref name=jhu2014>URL: [http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php]. Accessed on: 28 March 2015.</ref><ref name=pmid26166626>{{Cite journal | last1 = Epstein | first1 = JI. | last2 = Zelefsky | first2 = MJ. | last3 = Sjoberg | first3 = DD. | last4 = Nelson | first4 = JB. | last5 = Egevad | first5 = L. | last6 = Magi-Galluzzi | first6 = C. | last7 = Vickers | first7 = AJ. | last8 = Parwani | first8 = AV. | last9 = Reuter | first9 = VE. | title = A Contemporary Prostate Cancer Grading System: A Validated Alternative to the Gleason Score. | journal = Eur Urol | volume = | issue = | pages = | month = Jul | year = 2015 | doi = 10.1016/j.eururo.2015.06.046 | PMID = 26166626 }}</ref> | Proposed new system (endorsed by the WHO<ref name=pmid26492179>{{Cite journal | last1 = Epstein | first1 = JI. | last2 = Egevad | first2 = L. | last3 = Amin | first3 = MB. | last4 = Delahunt | first4 = B. | last5 = Srigley | first5 = JR. | last6 = Humphrey | first6 = PA. | title = The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: Definition of Grading Patterns and Proposal for a New Grading System. | journal = Am J Surg Pathol | volume = 40 | issue = 2 | pages = 244-52 | month = Feb | year = 2016 | doi = 10.1097/PAS.0000000000000530 | PMID = 26492179 }}</ref>) and old (modified) Gleason score:<ref name=jhu2014>URL: [http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_19.php]. Accessed on: 28 March 2015.</ref><ref name=pmid26166626>{{Cite journal | last1 = Epstein | first1 = JI. | last2 = Zelefsky | first2 = MJ. | last3 = Sjoberg | first3 = DD. | last4 = Nelson | first4 = JB. | last5 = Egevad | first5 = L. | last6 = Magi-Galluzzi | first6 = C. | last7 = Vickers | first7 = AJ. | last8 = Parwani | first8 = AV. | last9 = Reuter | first9 = VE. | title = A Contemporary Prostate Cancer Grading System: A Validated Alternative to the Gleason Score. | journal = Eur Urol | volume = | issue = | pages = | month = Jul | year = 2015 | doi = 10.1016/j.eururo.2015.06.046 | PMID = 26166626 }}</ref> | ||
{| class="wikitable sortable" style="text-align:center;margin-left:auto;margin-right:auto" | {| class="wikitable sortable" style="text-align:center;margin-left:auto;margin-right:auto" | ||
! | ! WHO grade | ||
! Gleason score | ! Gleason score | ||
|- | |- | ||
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===Prognostication=== | ===Prognostication=== | ||
Recurrence free progression stratified by | Recurrence free progression stratified by the system endorsed by the WHO:<ref name=pmid26166626/> | ||
{| class="wikitable sortable" style="text-align:center;margin-left:auto;margin-right:auto" | {| class="wikitable sortable" style="text-align:center;margin-left:auto;margin-right:auto" | ||
! | ! WHO grade | ||
! Hazard ratio<br>compared to Group I | ! Hazard ratio<br>compared to Group I | ||
|- | |- | ||
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| 11.7 | | 11.7 | ||
|} | |} | ||
===Sign out=== | |||
*The language is still evolving as this is relatively new. | |||
*As of 2017, many pathologists continue to predominantly use (modified) Gleason grading, and add a comment about (the equivalent grade in) the new grading system. | |||
====Reporting examples==== | |||
Within a synoptic report: | |||
<pre> | |||
Grade group: Grade Group 3, Gleason score 4+3=7. | |||
</pre> | |||
As a comment: | |||
<pre> | |||
The World Health Organization (WHO) grade is: 3 out of 5. Gleason pattern 3 represents 30% of the tumour, and Gleason pattern 4 represents 70% of the tumour. | |||
</pre> | |||
=====Alternates===== | |||
<pre> | |||
The World Health Organization (WHO) prostate cancer grade is: 3 out of 5. Gleason pattern 3 represents 30% of the tumour, and Gleason pattern 4 represents 70% of the tumour. | |||
</pre> | |||
<pre> | |||
Gleason pattern 3 represents 30% of the tumour, and Gleason pattern 4 represents 70% of the tumour. | |||
The World Health Organization (WHO) endorsed prostate cancer grade grouping is: 3 out of 5. | |||
</pre> | |||
==See also== | ==See also== | ||
*[[Prostate cancer]]. | *[[Prostate cancer]]. | ||
*[[Prostate cancer staging]]. | |||
*[[Cancer staging systems]]. | *[[Cancer staging systems]]. | ||
*[[Cribriform pattern within invasive prostate carcinoma]]. | |||
*[[Apparent diffusion coefficient]]. | |||
==References== | ==References== |
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