Surgical outcomes for patients with organ-confined, Gleason 6 prostate cancer

Traditionally, we have believed that a small but significant percentage of men with organ-confined, Gleason 6 prostate cancer would have biochemical progression after a radical prostatectomy. New data from Johns Hopkins suggest that such disease progression should be extremely rare.

Miyamoto et al. identified 2,551 patients who received radical prostatectomies at Johns Hopkins between 1983 and 2005 and who, at the time were coded by the urologists as having pathologically organ-confined, Gleason score 6 cancer with more than 1 year of follow-up.

The authors carried out a histopathological re-examination of the serially sectioned and completely embedded radical prostatectomy specimens of 38 men who developed biochemical recurrence — defined as a single PSA level of ≥ 0.2 ng/ml. The results of this re-examinations showed that:

  • In 27/38 cases (71 percent), the patients had a higher Gleason grade or a higher clinical stage than coded by the urologists.
  • 10 patients had organ-confined disease with Gleason pattern 4 as either the primary or secondary pattern.
  • 9 patients had organ-confined disease with Gleason score 6 but with tertiary Gleason pattern 4 (and in 4 cases the tertiary pattern 4 was described in the initial pathology report).
  • 5 patients had a Gleason score of 7 together with extraprostatic extension.
  • 1 patient had a Gleason score of 6 with focal extraprostatic extension.
  • 2 patients had positive surgical margins due to intraprostatic incision (listed in the initial pathology report).
  • 11/38 cases (29 percent) had true organ-confined, Gleason score 6 tumors, and none of these 11 patients developed systemic disease.

The authors conclude that most prior reports of organ-confined, Gleason score 6 with progression have, in fact, been undergraded, understaged, or situations with ambiguous staging. They go on to say that, “Even for the rare true organ-confined, Gleason score 6 (no pattern 4) tumor with supposed biochemical progression, some may be false-positive progression based on low post-radical prostatectomy prostate-specific antigen levels and minute tumors that seem highly improbable to progress.”

Their “take-away” from this study is that, “With accurate pathologic evaluation, men with organ-confined, Gleason score 6 (no pattern 4) prostate cancer can be told that their risk of progression is very rare,” and they estimate that only about 4 men in 1,000 (0.4 percent) who meet these criteria are at risk for progression after radical prostatectomy. The great unanswered question, of course, is how many men with truly organ-confined, Gleason 6 prostate cancer need treatment at all — as compared to conservative management, and is there a good way to identify these patients more accurately?

6 Responses

  1. Another study highlighting the shortcomings of conventional TRUS biopsy. This one says that about three out of four had incorrect Gleason grades.

    The great unanswered question of how many men with truly organ-confined, Gleason 6 prostate cancer needed treatment at all might have been answered by 3D mapping biopsy.

    Take a look at

    Connecting the dots — more needles is better, needles accurately placed using a 5 mm grid better still.

    Seems like you’d want to know the nature of the prostate cancer before choosing to treat or monitor.

    This also makes you wonder if pattern 4 and Gleason scores of 7+ are the disease, and that scores less than that are a condition.

  2. Dear Steve:

    Actually this study says very little about the quality of biopsy data. It is entirely about the accuracy of the pathological assessment of the available tissue. If we start to do 3D mapping biopsies on everyone with an initial diagnosis of Gleason 6 disease, we will undoubtedly bankrupt Medicare nearly twice as fast as already predicted!

    More needles may be better for some patients — but not for everyone.

  3. Ok. This seems like as close to a cure as it gets right now. I had surgery at Johns Hopkins. One of my fears is that I was diagnosed at 42 with Gleason 6. At such a young age I fear I have aggressive Gleason 6 prostate cancer, even though trhe cancer was organ-confined and I had no adverse pathological features post-operatively. I see other people with Gleason 6 disease who have progression just like people with Gleason 8 cancer. Are there any studies about young age being worse, same or what from older people with the same Gleason scores.

  4. Dear Chris:

    Do some men who supposedly have organ-confined, Gleason 6 prostate cancer progress after first-line therapy? Yes, they do. And if one believes the Johns Hopkins data it would appear that in the cases of most of those patients a restrospective analysis of their pathology showed that they actually had a higher grade at the time of treatment. (In other series they may also not have had truly organ-confined disease.)

    Do some men with true Gleason 6 disease progress? Yes they do. And based on the Johns Hopkins data it appears to be 0.4% of their patients. One wonders whether they were, in fact, truly organ-confined. Rare patients with all the indicators of organ-confined, low risk disease do progress because we find out later that they had a small micrometastasis.

    Since you were only 42 at the time of treatment, is it true that you probably have 20+ more years to progress than a similar man diagnosed at age 60? Yes, obviously it is. (But you can’t progress if there are no prostate cancer cells, however long you live!)

    I suppose a crucial question is, what would you do about it today if we could tell you that there was (say) a 21.3% probability that you would progress in 34 years time?

    If the Johns Hopkins data are correct, you have 996 chances out of 1,000 that you will never have biochemical progression. Most men would be happy to accept those odds. If it makes you feel better, ask Hopkins to reassess your surgical pathology slides so that you can be absolutely sure there was no sign of any Gleason 4 cancer.

  5. I’m 68, and have had two prostate biopsies, last one 2 years ago: Gleason 6, 12 needles. How often do I need to do this proceedure? I really don’t know how to proceed in the best way.

  6. Dear Ben.

    Please join our social network and post your question there, where we can deal with this type of personal question more appropriately.

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