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Gleason 4 5 9 Prostate Cancer

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What Is A Grade Group

Gleason 4+4=8 Prostate Cancer Treatments | Ask a Prostate Expert, Mark Scholz, MD

In 2014, the International Society of Urological Pathology released supplementary guidance and a revised prostate cancer grading system, called the Grade Groups.

The Grade Group system is simpler, with just five grades, 1 through 5.

*Risk Groups are defined by the Grade Group of the cancer and other measures, including PSA, clinical tumor stage , PSA density, and number of positive biopsy cores.

Many hospitals report both the Gleason score and the Grade Group, but there may be hospitals that still report only the old Gleason system.

Active Surveillance For Gleason 6 Cancer

Per the Cancer Care Ontario guideline,1 active surveillance for patients with Gleason 6 disease should include:

  • PSA testing every 3 to 6 months
  • Annual digital rectal exam
  • 12- to 14-core confirmatory transrectal ultrasound biopsy, including anterior-directed cores, within 6 to 12 months of starting surveillance, and then a serial biopsy every 3 to 5 years thereafter

REFERENCES

1. Chen RC, Rumble RB, Loblaw DA, et al: Active surveillance for the management of localized prostate cancer : American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 32:2182-2190, 2016.

2. Cooperberg MR, Broering JM, Carroll PR: Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol 28:1117-1123, 2010.

3. Loeb S, Folkvaljon Y, Curnyn C, et al: Uptake of active surveillance for very low-risk prostate cancer in Sweden. JAMA Oncol 3:1393-1398, 2016.

4. American Cancer Society: Key statistics for prostate cancer. Available at www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Accessed June 26, 2018.

5. Morash C, Tey R, Agbassi C, et al: Active surveillance for the management of localized prostate cancer. Available at www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/2286. Accessed June 26, 2018.

6. Hamdy FC, Donovan JL, Lane JA, et al: 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 375:1415-1424, 2016.

Whats The Best Way To Treat Localized Gleason 9

EBRT plus brachytherapy and ADT appeared to afford the best outcomes.

The most aggressive localized prostate cancer has a Gleason score of 9-10. Whats the best way to treat it? Radiation oncologist Phuoc Tran, M.D., Ph.D., and colleagues recently took part in a multi-institutional study to find out. Their results were published in the Journal of the American Medical Association .

Investigators at 12 hospitals in the United States and Norway compared the clinical outcomes of 1,809 men with Gleason score 9-10 prostate cancer after they had either radical prostatectomy, external-beam radiation therapy with androgen deprivation therapy , or EBRT plus a brachytherapy boost with ADT the men were treated between 2000 and 2013. Of these men, 639 underwent radical prostatectomy, 734 had EBRT and ADT, and 436 had EBRT plus brachytherapy, along with ADT.

We found that treatment with either EBRT and ADT or radical prostatectomy appeared to be equivalent but EBRT plus brachytherapy and ADT appeared to afford the best outcomes of the three.

This work was published with Hopkins co-investigators Ashley Ross, Jeff Tosoian, Stephen Greco, Curtiland DeVille, Todd McNutt, Daniel Y. Song, and Theodore L. DeWeese.

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What Are Grade Groups

Grade Groups are a new way to grade prostate cancer to address some of the issues with the Gleason grading system.

As noted above, currently in practice the lowest Gleason score that is given is a 6, despite the Gleason grades ranging in theory from 2 to 10. This understandably leads some patients to think that their cancer on biopsy is in the middle of the grade scale. This can compound their worry about their diagnosis and make them more likely to feel that they need to be treated right away.

Another problem with the Gleason grading system is that the Gleason scores are often divided into only 3 groups . This is not accurate, since Gleason score 7 is made up of two grades , with the latter having a much worse prognosis. Similarly, Gleason scores of 9 or 10 have a worse prognosis than Gleason score 8.

To account for these differences, the Grade Groups range from 1 to 5 :

  • Grade Group 1 = Gleason 6
  • Grade Group 2 = Gleason 3+4=7
  • Grade Group 3 = Gleason 4+3=7
  • Grade Group 4 = Gleason 8
  • Grade Group 5 = Gleason 9-10

Although eventually the Grade Group system may replace the Gleason system, the two systems are currently reported side-by-side.

Tertiary Grade On Needle Core Biopsy

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In contrast to the original Gleason grading system, it is now recommended that on a needle core biopsy both the most common and highest grade are added together for the Gleason score . For example, if there is 60 % Gleason pattern 3, 35 % Gleason pattern 4, and 5 % Gleason pattern 5, the Gleason score would be 3+5=8. Needle core biopsy is an imperfect, non-targeted, random sampling of the prostate gland. Thus any amount of high-grade tumor sampled on needle biopsy most likely indicates a more significant amount of high-grade tumor within the prostate. In all specimens, in the setting of high-grade cancer, one should not report a lower grade if it occupies less than 5 % of the total tumor. For example, if there is 98 % Gleason pattern 4 and 2 % Gleason pattern 3, the Gleason score would be reported as 4+4=8 .

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Clinical Significance Of Subtypes Gp 4

The clinical outcome of GS 7 prostate cancer is highly variable. Improvement in risk stratification might be of great clinical importance especially to identify patients with GS 7 cancer who might have a more favorable prognosis and be considered for active surveillance protocols . There is some evidence in the literature that suggests that discrimination of the different GP 4 morphologies could help stratify patients with different clinical prognoses .

A study based on RP findings reported that cribriform pattern is a major predictive factor for distant metastasis and disease-specific death . In this study, cribriform morphology was the strongest predictor for adverse clinical events in multivariate analysis, where they adjusted for both established clinicopathologic parameters and for contemporary additional pathologic parameters such as IDC and tertiary GP 5. Another study found an association between cribriform glands at RP and rate of metastasis . Finally, similar results were seen in a study on âlatentâ prostatic adenocarcinomas in cystoprostatectomy and autopsy. This study examined 320 autopsy specimens and 248 cystoprostatectomy specimens and found that cribriform architecture was significantly associated with increased tumor volume and extraprostatic extension . Small fused glands had a strong negative association with EPE in the autopsy series .

Prognostic Grouping Of Prostate Cancer

TNM prognostic grouping for prostate cancer is based on the stage, PSA level and Gleason score. This grouping is more accurate in predicting a prognosis than TNM staging alone. It goes without saying that the lower the scores, the best outlook and chance that your cancer can be successfully treated without the cancer coming back .

In contrast, if the prognosis is darker for men with higher scores, there may still be treatment options to control your cancer, improve your quality of life and prolong your survival.

Doctors also use nomograms to predict a prostate cancer prognosis. Nomograms are predictive tools.

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What Does It Mean When There Are Different Core Samples With Different Gleason Scores

Cores may be samples from different areas of the same tumor or different tumors in the prostate. Because the grade may vary within the same tumor or between different tumors, different samples taken from your prostate may have different Gleason scores. Typically, the highest Gleason score will be the one used by your doctor for predicting your prognosis and deciding on treatment options.

Stage 2 Prostate Cancer

Gleason 4+4=8 & Hormone Therapy | Ask a Prostate Cancer Expert, Mark Scholz, MD

In stage 2, the tumor is still confined to your prostate and hasnt spread to lymph nodes or other parts of your body. A doctor may or may not be able to feel the tumor during a prostate exam, and it may appear on ultrasound imaging. The survival rate is still .

The PSA score for stage 2 is less than 20 ng/mL.

Stage 2 cancer is further divided into three phases depending on the grade group and Gleason scores:

  • Gleason score: 6 or less

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Grading In Different Prostatic Tissue Samples

Gleason grading should be performed in all prostatic tissue samples, including needle core biopsy specimens. Indeed, of Gleasonâs original series of 2911 patients, 60% were graded solely on the basis of a needle biopsy. A Gleason grade should be assigned even to needle biopsy cases with minimal prostatic carcinoma, defined as less than 1mm of tumor., Of importance, a small amount of carcinoma in needle biopsy tissue should not be equated with well-differentiated Gleason score 24 adenocarcinoma. Most minimal adenocarcinomas in needle biopsy tissue are intermediate Gleason grade, usually of a score of 6. Comparisons of Gleason grade in needle biopsy with Gleason grade in the matched whole prostate gland indicate exact correlation in 43% of cases and agreement to within±1 score unit in 77% of 3789 cases . Undergrading of tumor in the needle biopsy, with a higher Gleason score in the matched whole gland, is the most common problem, occurring, on average, in 42% of all cases. Overgrading of carcinoma in needle biopsy tissue also takes place, but with a much lower mean of 15% of all cases. For needle biopsy cases, there are several sources of grading error, including difficulty in appreciation of an infiltrative growth pattern, tissue sampling error , tissue distortion, pathologist experience, and observer variability.

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Prostate Cancer Risk Groups

In addition to stage, doctors may use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Examples of these include the National Comprehensive Cancer Network risk group categories and the Cancer of the Prostate Risk Assessment risk score from University of California, San Francisco.

Information about the cancers stage and other prognostic factors will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.

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What Is The Gleason Grade Or Gleason Score What Do The Numbers In The Gleason Score Mean For Example 3+4=7 Or 3+3=6

Pathologists grade prostate cancers using numbers from 1 to 5 based on how much the cells in the cancerous tissue look like normal prostate tissue under the microscope. This is called the Gleason system. Grades 1 and 2 are not often used for biopsies most biopsy samples are grade 3 or higher.

  • If the cancerous tissue looks much like normal prostate tissue, a grade of 1 is assigned.
  • If the cancer cells and their growth patterns look very abnormal, a grade of 5 is assigned.
  • Grades 2 through 4 have features in between these extremes.

Since prostate cancers often have areas with different grades, a grade is assigned to the 2 areas that make up most of the cancer. These 2 grades are added to yield the Gleason score . The highest a Gleason score can be is 10.

The first number assigned is the grade that is most common in the tumor. For example, if the Gleason score is written as 3+4=7, it means most of the tumor is grade 3 and less is grade 4, and they are added for a Gleason score of 7. Other ways that this Gleason score may be listed in your report are Gleason 7/10, Gleason 7 , or combined Gleason grade of 7.

If a tumor is all the same grade , then the Gleason score is reported as 3+3=6.

The higher the Gleason score, the more likely it is that your cancer will grow and spread quickly.

Tests To Identify Prostate Cancer Stage

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After a prostate cancer diagnosis, your doctor will do tests to see how far the cancer has spread. Not all men need every test. It depends on the results of your biopsy, a test that checks tissue from your prostate gland for cancer. Tests that help your doctor figure out the stage of your prostate cancer include:

  • CT scan of the abdomen and pelvis to see if the cancer has spread
  • Nuclear medicine bone scan to see if the cancer has spread to your bones
  • Surgery to check the lymph nodes in your pelvis for prostate cancer spread

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What Does It Mean

A Gleason score of 6 is low grade, 7 is intermediate grade, and a score of 8 to 10 is high grade cancer.

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Its also important to know whether any cells rated at Gleason grade 5 are present, even in just a small amount, and most pathologists will report this. Having any Gleason grade 5 in your biopsy or prostate puts you at a higher risk of recurrence.

But because many prostate cancer cases are extremely slow-growing, the Gleason system didnt necessarily do a good job of communicating the risks for these cases. Patients with scores of 6 and 7 didnt have a clear picture of the nature of their particular cancer.

Prostate Cancer Grading & Prognostic Scoring

The Gleason Score is the grading system used to determine the aggressiveness of prostate cancer. This grading system can be used to choose appropriate treatment options. The Gleason Score ranges from 1-5 and describes how much the cancer from a biopsy looks like healthy tissue or abnormal tissue . Most cancers score a grade of 3 or higher.

Since prostate tumors are often made up of cancerous cells that have different grades, two grades are assigned for each patient. A primary grade is given to describe the cells that make up the largest area of the tumor and a secondary grade is given to describe the cells of the next largest area. For instance, if the Gleason Score is written as 3+4=7, it means most of the tumor is grade 3 and the next largest section of the tumor is grade 4, together they make up the total Gleason Score. If the cancer is almost entirely made up of cells with the same score, the grade for that area is counted twice to calculated the total Gleason Score. Typical Gleason Scores range from 6-10. The higher the Gleason Score, the more likely that the cancer will grow and spread quickly.

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An enlarged prostate can also be the cause of other problems. If the enlarged prostate is causing symptoms, the best treatment would be a natural remedy. In the meantime, there are treatments for a wide range of conditions that cause a man to experience pain. A common surgical procedure involves an electric loop, laser, or electro-stimulation. The procedure is a safe and effective option for treating enlarged or symptomatic BPH.

Grading After Radiation And Hormonal Therapy

Understanding The Gleason Score | Prostate Cancer Staging Guide

In general, the Gleason grading system should be applied only to tumor that shows no evidence of treatment effect. For radiation therapy cases, where there is no evidence or minimal evidence of therapy effect, Gleason grading may be utilized. Hormonal therapy can cause pattern alterations resembling high Gleason grades. Overall, the consensus view is that one should not report histologic grade after hormonal therapy.

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Stage Iv Prostate Cancer Prognosis

Prostate cancers detected at the distant stage have an average five-year survival rate of 28 percent, which is much lower than local and regional cancers of the prostate. This average survival rate represents stage IV prostate cancers that have metastasized beyond nearby areas to lymph nodes, organs or bones in other parts of the body.

How We Treat Prostate Cancer

The prognosis for metastatic prostate cancer can be discouraging, but some treatment centerslike the Johns Hopkins Precision Medicine Center of Excellence for Prostate Cancerspecialize in innovative, individualized therapy with the potential to improve outcomes.

What The Numbers Mean

The pathologist who examines the cellstaken during your biopsywill look at their patterning in the samples. Each area is graded on a scale of 1 to 5, and the two numbers are added together to get the Gleason score.

If a Gleason score is written in your pathology report as 3+4=7, this means most of your tumor is grade 3 and less of it is grade 4. These numbers are then added together for a total Gleason score of 7.

Grades 1 and 2 are not usually used to describe cancer these grades are for tissue that almost looks normal and isn’t considered cancerous. The lowest possible Gleason score of a cancer found in a prostate biopsy is 6cancer with the least risk of spreading quickly. The highest score is 10cancer with the most risk of being aggressive.

Because a scoring system that starts with the number 6 can be confusing, recently the Gleason Grade Grouping were introduced. This group number is based on the numbers used to create a samples Gleason score, but start with 1 instead of 6 and range from 1 to 5 .

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Risk Groups For Prostate Cancer

Prostate cancer is divided into risk groups.

Before planning your treatment, your cancer doctor will look closely at your risk group. This helps you and your doctors to decide on the best treatment for you. The treatment options for each risk group can be different.

Prostate cancer was previously grouped into low, intermediate or high risk groups. Doctors now use a more detailed system to work out your risk group. This is called the Cambridge Prognostic Group . It divides prostate cancer risk into 5 different groups. Your doctor may still describe your risk as low, moderate or high.

To work out your CPG risk group, your doctors look at:

  • the stage of the cancer
  • your Gleason score.

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