Tertiary gleason score

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davidg
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   Posted 4/12/2011 1:25 PM (GMT -6)   
is it a standard for all pathologists to report these in those rare cases where they're found?

Steve n Dallas
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   Posted 4/12/2011 1:34 PM (GMT -6)   

I don't recall ever hearing the term.. So for others like me:

A pathologist examines the biopsy specimen and attempts to give a score to the two patterns.

First called the primary grade, represents the majority of tumor (has to be greater than 50% of the total pattern seen).


Second - a secondary grade - relates to the minority of the tumor (has to be less than 50%, but at least 5%, of the pattern of the total cancer observed).


These scores are then added to obtain the final Gleason score.

Increasingly, pathologists provide details of the "tertiary" component. This is where there is a small component of a third (generally more aggressive) pattern. So there could be a Gleason 3+4 with a tertiary component of pattern 5 - this would be considered to be more aggressive than a prostate cancer that was Gleason 3+4 with no tertiary pattern 5.


142
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   Posted 4/12/2011 1:38 PM (GMT -6)   
I've not seen any indication of "standard" reporting. At least in my case, there was no mention.
 
I was just talking with a friend about a recent seminar in which some of the major PCa docs were making the argument that the tertiary values may be much more important than anyone has thought up to now, as they could be seen as indicators of the direction (more aggressive?) that the PCa might be taking.
 
I suspect that there isn't a "rarity" to them, but more a lack of interest from pathologists. Unless the surgeons insist on seeing that information, or a national standard insists on it, ....

daveshan
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   Posted 4/12/2011 3:42 PM (GMT -6)   
Came as part of both my biopsy and post surgery path report. Not sure if it would have been mentioned if I'd have been 3+3= 6 with Teriary 4 but that wasn't the case.

IMO it's important data for future treatment concerns, if there is tertiary 5 (or even 4) it indicates at least some cells may be more aggressive and treatment may need to be more aggressive to match.
Dave in Durango CO

07-06 PSA 2.5
01-08 PSA 5.5 (Dr never told me)
09-09 PSA 6.5
12-09 Biopsy, initial Gleason 9 (4+5) later reduced to 8 with tertiary 5
03-01-10 Age 55 RRP in Durango CO by Dr Sejal Quale and Dr Shandra Wilson
03-16-10 Path' G-8 (4+4+5) Bilateral involving 21% of left lobe, 3% of right lobe, SVI, Focal positive margin, pT3b NO MX

All PSA as of 1-25-11 <0.04

az4peaks
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   Posted 4/12/2011 5:35 PM (GMT -6)   
Since a 2006 protocol update by the College of American Pathologists, it has been RECOMMENDED that Pathologists SHOULD report a tertiary (3rd in a series) Gleason GRADE, if it is greater than the higher of the Primary and/or Secondary GRADE, the sum of which composes the traditional Gleason SCORE.

The same document confirmed that when only one pattern is present in the examined tissue, BOTH the Primary and Secondary should be assigned that number. For example: the most common G-SCORE of 6, is usually composed of (3+3)=6, signifying that ONLY Gleason GRADE 3 was identified in the examined tissue.

I hope this helps the understanding of tertiary Gleason GRADES. - John@newPCa.org (aka) az4peaks

JNF
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   Posted 4/12/2011 5:47 PM (GMT -6)   
My biopsy material was studied by Bostwick.   There was no report of a  tertiary Gleason.   I would thimk that if any lab would be routinely reporting it, Bostwick would be the one.   Perhaps the urologist has to order it.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard shot and daily Jalyn started on 10-7-2010.
IMRT to prostate and lymph nodes 25 fractions started on 11-8-2010, HDR Brachytherapy 12-6 and 13-2010.
PSA <.1 and T 23 on 2-3-2011.

Newporter
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Date Joined Sep 2010
Total Posts : 212
   Posted 4/12/2011 6:06 PM (GMT -6)   
Look at my signature.
65 Dx June-2010 PSA: 10.7, biopsy: Adenocarcinoma, 1 core Gleason 6, 3 cores atypia; Clinical stage T2; CT, Bone Scan, MRI all negative

8-23-10 Robotic RP; Pathology: Organ confined, negative margins, Lymph nodes, Seminal Vesicle clear; PNI present; multiple Adenocarcinoma sites Gleason 3+3 with tertiary Gleason 4+. Stage: pT2,N0,Mx,R0

Catheter out 8-30-10 no incontinence, no ED. 3/2011 PSA: <.1

Purgatory
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Date Joined Oct 2008
Total Posts : 23543
   Posted 4/12/2011 6:09 PM (GMT -6)   
I had never heard of term until after I had been here at HW for more than a year.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

ChrisR
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   Posted 4/12/2011 6:41 PM (GMT -6)   
This was first recommended by ISUP.  International Society of Urological Pathologists.  Epstein at Johns Hopkins headed up some group of pathologists that also recommended the revision to the gleason grading system.  I know that Johns Hopkins reports it if found. If you don't have one then the report says nothing.  Not all pathologists or labs are required to report them.  It is just a recommendation by ISUP.  If you are wondering if you had one you will have to ask your Uro. what guidlines their lab uses to report them. 
 
The whole theory is that if you are say a (3+3)=6 with a tertiary score 4, then you should be treated as if you were 3+4=7.  In other words you would not be a candidate for AS.  ISUP believes that your PCa will behave like a Gleason 7 not 6.  The same would apply if you were say 3+4=7 with tertiary 5.  Then your PCa will behave like a Gleason 8.
 
 

davidg
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   Posted 4/12/2011 7:00 PM (GMT -6)   
I went from a 3+3 to a 3+4

I was told not to worry by someone I trust because her research showed that what used to be a 6 is now a 7 and that all the previous studies/stats on 6 were actually equivalent to today's 7s.

Wasn't able to explain that well.

davidg
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   Posted 4/12/2011 7:14 PM (GMT -6)   
Thank you, Questioaoutit.

From your link:

"Gleason Grade Migration

Gleason grade migration refers to the observation that prostate cancers are today commonly graded higher, in the contemporary era, than in previous decades, resulting in a greater percentage of higher grade prostate cancers.1 A number of studies have evaluated Gleason grade migration and its impact on important clinical measures such as the risk of the cancer recurrence and cancer-related deaths (prostate cancer specific mortality). "

This is what I was trying, albeit badly, to say.

Also from your link:

"Therefore, this reassessment demonstrates a definite shift to higher grade prostate cancers, when a contemporary pathologist reads the same specimen that was read 10-15 years ago."

Doesn't this mean that the vast majority of those 10-15 year old studies we read about are terribly flawed? In other words, if I'm a 7 and I look at the stats for 7s in those studies I should really be looking at the stats for the 6s because 7s then are 8s now.

Post Edited (davidg) : 4/12/2011 7:27:31 PM (GMT-6)


Purgatory
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Total Posts : 23543
   Posted 4/12/2011 7:51 PM (GMT -6)   
" if I'm a 7 and I look at the stats for 7s in those studies I should really be looking at the stats for the 6s because 7s then are 8s now."

How did you possibly draw that conclusion? I don't understand where you get some of your information.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

Fairwind
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Date Joined Jul 2010
Total Posts : 2200
   Posted 4/12/2011 9:57 PM (GMT -6)   
The Gleason scoring system is due for another overhaul as knowledge and understanding builds to force the issue..Doctors tend to treat the most aggressive cancer found, as well they should..
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA 0.0

Newporter
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Date Joined Sep 2010
Total Posts : 212
   Posted 4/12/2011 11:51 PM (GMT -6)   
ChrisR,

Just a clarification: You were talking about tertiary Gleason score, it should be tertiary Gleason glade?

Indeed, in my pathology report, tertiary was reported as "tertiary Gleason glade 4" and not "tertiary Gleason score 4"

az4peaks
Regular Member


Date Joined Feb 2011
Total Posts : 88
   Posted 4/13/2011 2:08 AM (GMT -6)   
Hi JNF, - You probably did not have a tertiary GRADE present and that is why it wasn't mentioned. Again, a Tertiary GRADE is only present if there are more than 2 GRADES involved in the examined tissue and has significance ONLY if it is a greater numerical number than the higher of the Primary or Secondary GRADES that make up the traditional Gleason SCORE. I agree, if it was present, and met the above criteria, Bostwick would have mentioned it.

Statistically, tertiary involvement is relatively low in Biopsy samples but are rather common in pathologic tissue from Radical Prostatectomy (RP) - John@newPCa.org (aka) az4peaks

BB_Fan
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Date Joined Jan 2010
Total Posts : 967
   Posted 4/13/2011 5:16 AM (GMT -6)   
I had my pathology specimin looked at 3 times with 3 different outcomes. Hartford Hospital 4+4, tertiary 3, Hopkins 4+4 no tertiary, and Dana Farber 4+4, tertiary 5. I guess that with a G8 that I have enough to worry about.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

JNF
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Date Joined Dec 2010
Total Posts : 1484
   Posted 4/13/2011 6:05 AM (GMT -6)   

Thanks John, that makes sense.

The whole Gleason system appears to be somewhat variable as it is not as clear cut as we patients would like.   My docs all said we treat it as if it were a bit worse than it is showing in the biopsy, scans, DRE, etc. 

This is in lline with Meyers , who contends that the cancer is usually worse than the diagnostics are showing, thus his more aggressive approach.


PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard shot and daily Jalyn started on 10-7-2010.
IMRT to prostate and lymph nodes 25 fractions started on 11-8-2010, HDR Brachytherapy 12-6 and 13-2010.
PSA <.1 and T 23 on 2-3-2011.

STW
Regular Member


Date Joined Jun 2009
Total Posts : 271
   Posted 4/13/2011 12:17 PM (GMT -6)   
My sig line rarely appears but if it did it'd say that my after surgery Gleason was 3+4=7 with tertiary 5. I had read and talked with some doctors that believe that score should be treated like a Gleason 8. Others don't believe so. My first meeting with the radiation oncologist for SRT told me that he believes it is more like an 8 then a 7, my uro, not so much.

The problem seems to be that there is little hard data. I read one study shortly after I got the results with (as I recall) over 1500 men. In that whole group there were six with tertiary 5 as part of their biopsy. You get a sample size of six and the statistics just fall apart.

I can confidently say, however, that I'd rather not have tertiary 5 than have it. Of course that goes for this whole PCa thing and look how well that worked out for me. rolleyes

Fairwind
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Date Joined Jul 2010
Total Posts : 2200
   Posted 4/13/2011 12:24 PM (GMT -6)   
Grade 4 is Grade 4 and Grade 5 is Grade 5...."But there was just a tiny little bit of it..."

Not for long....Get rid of it!! JMHO...
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA 0.0
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