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Prostate cancer (view source)

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→‎Gleason grading system
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*[[PIN-like adenocarcinoma]].
*[[PIN-like adenocarcinoma]].


===Gleason grading system===
===Prostate cancer grading===
*[[AKA]] ''modified Gleason grading system''.
{{Main|Prostate cancer grading}}
====Overview====
It covers the ''Gleason grading system'' and the (new) ''Prognostic grade groupings''.
*This system is only one any one talks about and there is consensus on how it is done.<ref name=pmid16096414>{{Cite journal  | last1 = Epstein | first1 = JI. | last2 = Allsbrook | first2 = WC. | last3 = Amin | first3 = MB. | last4 = Egevad | first4 = LL. | title = The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. | journal = Am J Surg Pathol | volume = 29 | issue = 9 | pages = 1228-42 | month = Sep | year = 2005 | doi =  | PMID = 16096414 }}</ref>
*Score range: 6-10.
**Technically 2-10... but almost no one uses 2-5.
*Reported on biopsy (and [[TURP]]) as: (primary pattern) + (highest non-primary pattern) = sum.
**''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.
*Reported as on prostatectomies as: (primary pattern) + (secondary pattern) = sum, (tertiary pattern)
 
*Tertiary Gleason pattern - definition: a pattern that is seen in less than 5% of the tumour (volume), that is higher grade than the two dominant patterns.<ref name=Ref_GUP72>{{Ref GUP|72}}</ref>
**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>
 
Testing yourself:
*There is a nice test-yourself quiz from Johns Hopkins: [http://162.129.103.34/prostate/ http://162.129.103.34/prostate/].
**It was studied in a paper by Kronz et al.<ref name=pmid11014569>{{Cite journal  | last1 = Kronz | first1 = JD. | last2 = Silberman | first2 = MA. | last3 = Allsbrook | first3 = WC. | last4 = Bastacky | first4 = SI. | last5 = Burks | first5 = RT. | last6 = Cina | first6 = SJ. | last7 = Mills | first7 = SE. | last8 = Ross | first8 = JS. | last9 = Sakr | first9 = WA. | last10 = Tomaszewski | first10 = JE. | last11 = True | first11 = LD. | last12 = Ulbright | first12 = TM. | last13 = Weinstein | first13 = MW. | last14 = Yantiss | first14 = RK. | last15 = Young | first15 = RH. | last16 = Epstein | first16 = JI. | title = Pathology residents' use of a Web-based tutorial to improve Gleason grading of prostate carcinoma on needle biopsies. | journal = Hum Pathol | volume = 31 | issue = 9 | pages = 1044-50 | month = Sep | year = 2000 | doi = 10.1053/hupa.2000.16278 | PMID = 11014569 }}</ref>
 
=====Examples=====
*A biopsy with 80% pattern 4, 16% pattern 3 and 4% pattern 5... would be reported as: 4+5=9.
*A biopsy with 92% pattern 4, and 8% pattern 3... would be reported as: 4+3=7.
*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.
 
====Grade groupings====
*[[AKA]] ''prognostic Gleason grade groupings''.
 
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>
{| class="wikitable sortable"  style="margin-left:auto;margin-right:auto"
! Prognostic group
! Gleason score
|-
| I
| 3+3
|-
| II
| 3+4
|-
| III
| 4+3
|-
| IV
| 8 (4+4, 3+5, 5+3)
|-
| V
| 9 or 10 (4+5, 5+4, 5+5)
|}
 
Rationale:
*Patients won't be told they have a 6 out of 10 cancer, and then think it is an intermediate grade cancer that is worrisome. Instead, they will be told they have a 1 out of 5 cancer.<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>
 
====Gleason patterns (modified)====
=====Gleason pattern 1 & 2=====
*Use strongly discouraged by a number of GU pathology experts.
 
Notes:
*Gleason pattern 1 - probably represents what today would be called ''adenosis''.
**Should never be used.
*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>
 
=====Gleason pattern 3=====
*Glands smaller than normal prostate glands + loss of epithelial folding.
*Can draw a line around each gland.
*May have ''gland branching''.
**Glands have a X, U, V or Y shape.
 
Notes:
*Gland lumina should be seen.
*All ''cribriform'' is now, generally, classified as Gleason pattern 4.<ref name=pmid20006878>{{cite journal |author=Epstein JI |title=An update of the Gleason grading system |journal=J. Urol. |volume=183 |issue=2 |pages=433–40 |year=2010 |month=February |pmid=20006878 |doi=10.1016/j.juro.2009.10.046 |url=}}</ref>
 
=====Gleason pattern 4=====
*Loss of gland lumina.
*Gland fusion.
*Benign looking cords ('hypernephroid pattern').
*Cribriform.
*Glomeruloid pattern - resembles a glomerulus.
 
Notes:
*One gland is not enough to call Gleason 4.
 
======Images======
<gallery>
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)
</gallery>
www:
*[http://www.nature.com/modpathol/journal/v17/n3/fig_tab/3800050f9.html#figure-title Glomeruloid pattern (nature.com)].
 
=====Gleason pattern 5=====
*Sheets.
**Must be differentiated from [[intraductal carcinoma of the prostate|intraductal growth]] (which like in the breast are well circumscribed nests).
*Single cells.
**May be confused with stromal/lymphocytic infiltration.
***Look for nucleoli, cells should be round (prostatic stroma cells are spindle cells).
*Cords (strands).
**Line of cells.
**Should not be intermixed with clumps of cells (pattern 4).
*Nests of cells with [[necrosis]] (at the centre) (comedonecrosis) ''or'' (intraluminal) necrosis in a cribriform pattern.<ref name=pmid16096414/>
**Necrosis:
***Nuclear changes:
****Karyorrhexis (nuclear fragmentation).
****Pynosis (nuclear shrinkage).
****Karyolysis (nuclear dissolution).
***Cell ghosts (cells without a nucleus).
 
Notes:
*Pattern 5 may be under-diagnosed.
*Single cells is the most commonly missed pattern.<ref name=pmid21997691>{{Cite journal  | last1 = Fajardo | first1 = DA. | last2 = Miyamoto | first2 = H. | last3 = Miller | first3 = JS. | last4 = Lee | first4 = TK. | last5 = Epstein | first5 = JI. | title = Identification of Gleason pattern 5 on prostatic needle core biopsy: frequency of underdiagnosis and relation to morphology. | journal = Am J Surg Pathol | volume = 35 | issue = 11 | pages = 1706-11 | month = Nov | year = 2011 | doi = 10.1097/PAS.0b013e318228571d | PMID = 21997691 }}
</ref>
 
======Images======
<gallery>
Image:Gleason_4_and_5_intermed_mag.jpg | Gleason pattern 4 - small glands (left) & Gleason pattern 5 - single cells (right). (WC)
</gallery>
www:
*[http://www.webpathology.com/image.asp?n=17&Case=20 Gleason pattern 5 - sheeting (webpathology.com)].
 
====Special types====
Special types of prostate cancer have suggested Gleason patterns:<ref name=pmid14976541>{{cite journal |author=Grignon DJ |title=Unusual subtypes of prostate cancer |journal=Mod. Pathol. |volume=17 |issue=3 |pages=316–27 |year=2004 |month=March |pmid=14976541 |doi=10.1038/modpathol.3800052 |url=}}</ref>
{| class="wikitable sortable"  style="margin-left:auto;margin-right:auto"
! Special type
! Gleason pattern
! Comment
|-
|Ductal carcinoma
| 4
| may be graded 3 or 5<ref name=bostwicklabs>URL: [https://www.bostwicklaboratories.com/global/physicians/medical-library/articles/gleason-grading.aspx https://www.bostwicklaboratories.com/global/physicians/medical-library/articles/gleason-grading.aspx]. Accessed on: 26 November 2011.</ref>
|-
|Mucinous carcinoma
| 3 or 4 - dependent on morphology<ref name=pmid18487999>{{Cite journal  | last1 = Osunkoya | first1 = AO. | last2 = Adsay | first2 = NV. | last3 = Cohen | first3 = C. | last4 = Epstein | first4 = JI. | last5 = Smith | first5 = SL. | title = MUC2 expression in primary mucinous and nonmucinous adenocarcinoma of the prostate: an analysis of 50 cases on radical prostatectomy. | journal = Mod Pathol | volume = 21 | issue = 7 | pages = 789-94 | month = Jul | year = 2008 | doi = 10.1038/modpathol.2008.47 | PMID = 18487999 }}</ref><ref name=pmid18300802>{{Cite journal  | last1 = Osunkoya | first1 = AO. | last2 = Nielsen | first2 = ME. | last3 = Epstein | first3 = JI. | title = Prognosis of mucinous adenocarcinoma of the prostate treated by radical prostatectomy: a study of 47 cases. | journal = Am J Surg Pathol | volume = 32 | issue = 3 | pages = 468-72 | month = Mar | year = 2008 | doi = 10.1097/PAS.0b013e3181589f72 | PMID = 18300802 }}</ref>
| some advocate grade 4<ref name=pmid14976541/>
|-
|Sarcomatoid carcinoma
| 5
| glands graded separately
|-
|Signet ring cell carcinoma
| 5
|
|-
|Small cell carcinoma
| not graded (ISUP 2005 consensus<ref name=pmid16096414>{{Cite journal  | last1 = Epstein | first1 = JI. | last2 = Allsbrook | first2 = WC. | last3 = Amin | first3 = MB. | last4 = Egevad | first4 = LL. | title = The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. | journal = Am J Surg Pathol | volume = 29 | issue = 9 | pages = 1228-42 | month = Sep | year = 2005 | doi =  | PMID = 16096414 }}</ref>)
| may be graded 5<ref name=bostwicklabs/>
|-
|[[Adenosquamous carcinoma|Adenosquamous]] and [[squamous carcinoma]]
| not graded
|
|-
|[[Lymphoepithelioma-like carcinoma]]
| not graded
|
|-
|[[Adenoid cystic carcinoma]]
| not graded
|
|-
|[[Urothelial carcinoma]]
| not graded
|
|-
|Undifferentiated carcinoma, NOS
| not graded
|
|}
 
How to remember the ones that aren't graded - think of '''Ur''' '''L'''ung carcinomas ('''Ur'''othelial carcinoma, '''L'''ymphoepithelioma-like carcinoma):
*Small cell carcinoma.
*Squamous cell carcinoma.
*Adenosquamous carcinoma.
*Adenoid cystic carcinoma.
 
====Biopsy-prostatectomy concordance of Gleason score====
*Discordance is common.
**Upgrade on prostatectomy: 25-40%.
**Downgrade on prostatectomy: 5-15%.
 
Selected studies on concordance:
{| class="wikitable sortable"  style="margin-left:auto;margin-right:auto"
! Study
! Upgrade
! Downgrade
! Notes
|-
| Sfoungaristos et al.<ref name=pmid22277633>{{Cite journal  | last1 = Sfoungaristos | first1 = S. | last2 = Perimenis | first2 = P. | title = Clinical and pathological variables that predict changes in tumour grade after radical prostatectomy in patients with prostate cancer. | journal = Can Urol Assoc J | volume =  | issue =  | pages = 1-5 | month = Jan | year = 2012 | doi = 10.5489/cuaj.11067 | PMID = 22277633 }}</ref>
| 42.1%
| 13.7%
| high volume of tumour predicts upgrade
|-
| Thomas et al.<ref name=pmid21592293>{{Cite journal  | last1 = Thomas | first1 = C. | last2 = Pfirrmann | first2 = K. | last3 = Pieles | first3 = F. | last4 = Bogumil | first4 = A. | last5 = Gillitzer | first5 = R. | last6 = Wiesner | first6 = C. | last7 = Thüroff | first7 = JW. | last8 = Melchior | first8 = SW. | title = Predictors for clinically relevant Gleason score upgrade in patients undergoing radical prostatectomy. | journal = BJU Int | volume = 109 | issue = 2 | pages = 214-9 | month = Jan | year = 2012 | doi = 10.1111/j.1464-410X.2011.10187.x | PMID = 21592293 }}</ref>
| 38.1%
| 4.7%
|
|-
| Truesdale et al.<ref name=pmid20840549>{{Cite journal  | last1 = Truesdale | first1 = MD. | last2 = Cheetham | first2 = PJ. | last3 = Turk | first3 = AT. | last4 = Sartori | first4 = S. | last5 = Hruby | first5 = GW. | last6 = Dinneen | first6 = EP. | last7 = Benson | first7 = MC. | last8 = Badani | first8 = KK. | title = Gleason score concordance on biopsy-confirmed prostate cancer: is pathological re-evaluation necessary prior to radical prostatectomy? | journal = BJU Int | volume = 107 | issue = 5 | pages = 749-54 | month = Mar | year = 2011 | doi = 10.1111/j.1464-410X.2010.09570.x | PMID = 20840549 }}</ref>
| 23%
| 11%
|
|}
 
=====Sign out=====
=====Upgrading=====
<pre>
Gleason score upgrading on prostatectomy is considered relatively common; it is reported
to occur in 23% to 42.1% of cases.[1][2]
 
1. BJU Int. 2011 107 (5): 749-54.
2. Can Urol Assoc J. 2012 Jan 24:1-5.
</pre>
 
=====Downgrading=====
<pre>
Gleason score downgrading on prostatectomy is considered uncommon; however, it is reported
in 4.7% to 13.7% of cases.[1][2]
 
1. BJU Int. 2012 Jan; 109(2):214-9.
2. Can Urol Assoc J. 2012 Jan; 24;1-5.
</pre>
 
=====Order of Gleason score components changed=====
<pre>
COMMENT:
The change in the order of the Gleason score components (3+4 on prostatectomy
versus 4+3 on core biopsy) may be explained by sampling.
</pre>


===Staging parameters, margins and more===
===Staging parameters, margins and more===
Michael
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