Gleason score

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Published on February 11, 2009

Author: azamahk2000

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Gleason grading& Gleason score : Gleason grading& Gleason score DR ,Abdelazim Hussein Khalafalla Gleason grading (pattern) (GP) : Gleason grading (pattern) (GP) The basic of the Gleason grading (pattern) (GP) system for prostate cancer is to provide an overall Gleason score on the basis of the sum of :- 1-the most prevalent (primary) 2- the second most prevalent (secondary) pattern (or grade) in the examined prostate tissue. Gleason score : Gleason score . Gleason realized that most prostatic carcinomas have multiple histologic patterns and found that the prognosis of prostatic carcinoma was intermediate between that of the most predominant pattern of carcinoma and that of the second most predominant pattern. Consequently, in the Gleason system, the most prevalent and the second most prevalent pattern (if at least 5% of the tumor) are added together to obtain a Gleason score - e.g. Gleason grade 3+4=7. Gleason grading (pattern) : Gleason grading (pattern) Gleason and his group separated architectural features into 1 of 5 histologic patterns of decreasing differentiation,:- 1-pattern 1 being most differentiated 2- pattern 5 being least differentiated. These patterns should be assessed at relatively power. The second unique feature of Gleason grading is that the grade is not based on the highest (least differentiated) pattern within the tumor. Gleason pattern 5 tumor has virtually no glandular differentiation. Gleason score : Gleason score The Gleason grading system, as originally devised, does not account for the presence of tertiary or the third most prevalent pattern. However, more than 2 patterns are often present in prostatectomy specimens and in needle biopsies.28 Slide 6: Gleason pattern 5 and, in particular tertiary pattern 5, is infrequently assigned on biopsy in contemporary practice. Limited data exist on the significance of biopsy tertiary pattern 5, and it is uncertain how the overall biopsy Gleason score should be assigned in this scenario Slide 7: Gleason system allows only primary and secondary patterns (or grades) to be included in the overall Gleason score, but prostatic carcinoma often demonstrates heterogeneity of different patterns (or grades) in the same tumor. Primary GP : Primary GP High-grade tumours were defined as having a Gleason score of >=7. Primary GP 4 tumors represented an aggressive subset of GS 7 prostate carcinomas. Primary GP was an easily accessible and clinically relevant predictor of disease recurrence in patients with GS 7 prostate carcinoma. Gleason score 6 from 7 : Gleason score 6 from 7 Differentiating Gleason score 6 from 7 is particularly important because a major shift, in terms of likelihood of having adverse findings in the prostatectomy specimen, or with failure following prostatectomy or radiotherapy, occurs between these two scores. Undergrading : Undergrading The single most important problem in Gleason grading is "undergrading", the major reason for "undergrading", especially in needle biopsies, is the overdiagnosis of Gleason score 2-4. focal carcinoma on needle biopsy, cribriform and fused gland patterns, and "borderline" histology are often undergraded. Overdiagnosis of Gleason Score 2-4 : Overdiagnosis of Gleason Score 2-4 Assignment of a Gleason score 2-4 essentially always means that pattern 1 and/or 2, as opposed to pattern 3, has been diagnosed. Pattern 1 and 2 (see "Gleason Patterns") are mostly seen in transition zone tumors. Both patterns are composed of circumscribed nodules of well defined, round to oval, usually moderate to large-sized glands with abundant pale cytoplasm. In pattern 3, the glands are obviously infiltrating, including extensively infiltrating adjacent benign prostatic tissue. The glands are generally smaller than pattern 1 and 2, and often have amphophilic cytoplasm. Pattern 2 glands may focally infiltrate adjacent benign prostatic tissue, but the infiltration is only minimal. Overdiagnosis of Gleason Score 2-4 : Overdiagnosis of Gleason Score 2-4 It is usually difficult or impossible to evaluate circumscription and minimal invasion on needle biopsies. Further, separating pattern 2 and 3 on the basis of the degree of separation of the glands and the morphology of glands is, at times, very difficult. It is not surprising, therefore, the the interobserver reproducibility of the diagnosis of Gleason score 2-4 in needle biopsies is poor, even amongst urologic pathologists Overdiagnosis of Gleason Score 2-4 : Overdiagnosis of Gleason Score 2-4 For the rare truly low grade carcinoma sampled on needle biopsy, there are three alternate grading approaches that can be taken. First is to diagnose Gleason score 2-4 and add a note stating that "Tumors with a low grade appearance on needle biopsy almost always have higher grade tumor in the prostate and in up to 50% of cases are associated with extra-prostatic extension.” Second, little harm will be done by assigning it a Gleason score 5 (Gleason score 2+3=5). Finally, these cases could be signed out as well to moderately differentiated prostatic carcinoma (Gleason score 2-6). by adopting one of these alternatives, one would not have to worry about the possibility, or implications of "undergrading". At the same time, the needle biopsy grade would more closely correlate with that found at radical prostatectomy and provide prognostically distinct groups to guide therapy. Gleason score 2-4 : Gleason score 2-4 Some clinicians have concluded that since low volume Gleason score 2-4 tumors on transurethral resection (TURP) specimens have a relatively indolent course, all tumors with a Gleason core 2-4, whether on biopsy or TURP, have a low risk of progression. Slide 15: The authors concluded that biopsy Gleason score is sufficiently accurate to justify its use, although the risk of tumour undergrading is real and might affect treatment, especially when watchful waiting is considered. The potential for grading error is higher in the well-differentiated tumours. Slide 16: data suggest that there is a relationship between the rate of high-grade tumours and prostate volume even in biopsy and RP specimens and it is not an artefact related to the biopsy. Slide 17: Routine TZ biopsy is not warranted, although it might be useful in patients with persistent high levels of serum PSA and negative sextant core biopsies. Slide 18: Thank

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