The meaning of tertiary Gleason pattern 5

Trpkov et al. have reported on recent findings related to the significance of a tertiary finding of Gleason pattern 5 prostate cancer in a biopsy core or cores from men diagnosed with prostate cancer of otherwise lower Gleason grade. In other words, what does it mean if a man should be diagnosed as having, for example, Gleason 4 + 3 = 7 disease (based on his two most extensive Gleason patterns being Gleason grade 4 and Gleason grade 3) but there is also a small amount of evident Gleason grade 5 cancer?

A recent consensus conference of the International Society of Urological Pathology recommended that biopsy Gleason scores should clearly inform the clinician about the existence of such tertiary Gleason 5 cancer, but what it means is still open to question.

In the current study, Trpkov et al. examined the preoperative clinical and biopsy findings in 53 patients with biopsy tertiary pattern 5 and 119 patients with primary and/or secondary biopsy pattern 5. They also analyzed the post-surgical findings and prostate-specific antigen (PSA) failure rates among the surgically treated patients. A total of 20 patients underwent prostatectomy and 152 were treated nonsurgically. Thweir basic findings are as follows:

  • Patients treated by prostatectomy were younger, had lower PSA levels at diagnosis, and less cancer on biopsy.
  • Pathological findings post-surgery and PSA failure rates were not significantly different in patients with tertiary pattern 5 versus patients with primary and/or secondary pattern 5.
  • In the non-surgically treated patients, patients with primary Gleason pattern 5 had a significantly higher risk of all-cause mortality and cause-specific mortality compared with patients who had only tertiary pattern 5.
  • However, also in the non-surgically treated patients, those with secondary Gleason pattern 5 had a comparable all-cause mortality risk to patients with tertiary pattern 5 and a marginally higher risk of cause-specific mortality than patients with tertiary pattern 5.

While these data expand our understanding of the potential significance of tertiary Gleason pattern 5 in a newly diagnosed patient, trhis is a small, retrospective analysis. A larger, prospective study would be needed to get clearer insight into the clinical significance of tertiary Gleason pattern 5.

2 Responses

  1. Medical Oncologist Stephen Strum has long advocated that pathologists, when declaring Gleason scores, include the recognition that tertiary Grade 5 is also present. This is not provided by most pathologists … they more often only provide the predominant and secondary grades. Knowing that Grade 5 is present should require further testing to determine the aggressiveness of the disease as well as the possibility of metastases, since metastases is more likely when this higher grade is present. What one finds in biopsy is often elevated with pathology of the excised gland. Elevated results from blood serum tests such as PAP, CGA, CEA, and NSE would provide the physician recognition of disease aggressiveness, of possible metastases, be the impetus for further testing and evaluation, and for developing appropriate strategy for treatment.

  2. Chuck: Dr. Strum (and you) are entirely entitled to the opinions you express above. However, the available data appear to suggest that the presence of tertiary Gleason 5 is only imporrtant in some, as opposed to all, patients. I would respectfully suggest that, while I agree that the presence of tertiary Gleason 5 cancer should be made known in all pathology reports, the subsequent work-up of the patient, and the treatment decisions, are a matter of individual discussion between the physician and the patients, and depend on a whole range of factors starting with the precise quantity of Gleason pattern 5 relative to other cancer identified.

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