Treatment outcomes and the importance of Gleason pattern 5 in biopsy cores

D’Amico and colleagues have conducted a retrospective analysis of data from > 300 patients in an attempt to compare biochemical (PSA-based) outcomes of men with high-risk prostate cancer based on the presence or absence of any amount of Gleason pattern 5 cancer in their initial biopsy findings (as a primary, secondary, or tertiary pattern). The results emphasize the importance of the presence of tertiary Gleason pattern 5 tumor in patients with an overall Gleason score of 7.

The study cohort examined by Nanda et al. consisted of 312 men with T1c-T3N0M0 prostate cancer. All patients had Gleason scores of 7 (with tertiary Gleason pattern 5), 8, 9, or 10, and were treated by either radical prostatectomy or external beam radiotherapy with or without androgen suppression.

Patients were followed for a median of 5.7 years, at which time the following results were evident:

  • Men with a biopsy-based Gleason score of 8 had a lower risk of PSA recurrence than those with a Gleason score of 9-10 (hazard ratio, 0.74; p = 0.09).
  • Men with a Gleason score of 7 (with tertiary Gleason pattern 5) had a similar risk of PSA recurrence as men with a Gleason score of 9-10 (hazard ratio, 1.08; p = 0.81).
  • Median times to PSA failure for men with Gleason scores of 9-10, 7 (with tertiary Gleason pattern 5), and 8 were 4.5, 5.0, and 5.4 years, respectively.

There is a clear implication in these data that a tertiary Gleason pattern of 5 in men with a base Gleason score of 7 is a significant potential indicator of increased risk for (relatively) early biochemical progression.

Nanda et al. very reasonably suggest that these data substantiate the importance of further substratification of the high-risk Gleason score categories to take account of the presence or absence of tertiary Gleason pattern 5, particularly in those patients whose base Gleason score would otherwise be a 7. They particularly stress that such substratificiation is important in the development of future clinical trials.

5 Responses

  1. I wonder how many pathologists report a tertiary score with prostate cancer biopsy reports? If they are not reporting them yet, why not?

  2. The reporting of tertiary Gleason scores of 5 was recommended in the 2005 International Society of Urologic Pathology Gleason Grading Consensus score (ISUP GS). However, to date it has not been adopted by the broader pathology community. For more information, see the last section of the page entitled “Gleason score and what it means.”

    As a consequence, teriary Gleason scores of 5 are reported by some of the more sophisticated urologic pathology laboratories (Johns Hopkins, Bostwick Laboratories, etc.) but not by the “average” pathologist and probably not by the major commercial pathology labs such as Quest Diagnostics. One more reason to get a second opinion on your pathology slides, especially if you are a Gleason 7.

  3. I had tertiary Gleason 5 in both my biopsy in 10/05 and on both sides of my prostate in the path report after RP in 12/05. It was reported in both by MSKCC (NY). My pathologic stage was pT3bN1MX.

    However I have repeatedly asked every one of the doctors I have seen, “What does that mean”. To date the best answer I received was “we don’t know.” The worst “it does not matter”.

    It seems even if the pathologists report, the doctors do not seem to know how to discuss with the patients.


  4. Bill: I would suggest you showed the above commentary to your doctors next time you see one of them. It would appear that Dr. D’Amico and his colleagues DO have some idea what the implications of a tertiary Gleason pattern 5 are now.

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