Gleason Scoring

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Tudpock18
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Date Joined Sep 2008
Total Posts : 4183
   Posted 9/14/2010 9:50 AM (GMT -6)   

A poster on another thread quoted some statistics that showed the percentage breakdown of Gleason scores by grade.  It turned out that the breakdown was from the mid-1990’s so I asked if anyone had a more current breakdown.  Another poster (An, I believe – thank you) responded with a reminder that the Gleason grading system had been revised after the 2005 International Society of Urological Pathology (ISUP) conference that year.  One of the primary implications of the revised grading system was that the new system produced a much greater number of G7 readings with a corresponding drop in G6.  At that point I probably should have just accepted my new found knowledge with gratitude and moved on to another subject…but, stupid me, I just could not leave it alone.

 

So, I was curious as to whether the lab where my biopsy slides were read was using the revised system.  My lab was Bostwick Laboratories which is world renowned and frequently suggested on this forum as one of the experts from whom second opinions should be sought.  Well, imagine my surprise when I received a return email from the Director of Client Services at Bostwick Labs. She told me that Bostwick Labs uses the original Gleason scoring system. In quoting Dr. Bostwick she stated, “…the new Gleason scoring system has not been validated yet….it adds no value to the Gleason scoring and there is no reason to change at this time.”

 

OK…I guess that means that the big, well respected labs didn’t change?  Wrong.  I emailed Dr. Epstein at Johns Hopkins yesterday and this is his response from last night: “We use the current Gleason system which is the widely accepted updated modification to the 1967 Gleason System.  There have been many changes in prostate cancer detection and diagnosis since 1967and the updated system has been shown in multiple studies to be superior to the 1967 system”.

 

So, what we have here is two of the best known and most respected pathology labs using different scoring systems to determine a Gleason score.  If you get a G6 from Dr. Bostwick it might have been a G7 from Dr. Epstein and vice-versa.  I guess in addition to all of the other analysis that a newly diagnosed patient must do is to find out which Gleason scoring system is used by his lab and then assess which scoring system is better!

 

If two of the best labs in the business can’t agree on how to determine a Gleason score then what is a poor slob to do when he learns he has prostate cancer.  For those of you who doubt zufus when he talks about the “jungle” and the “twilight zone” please listen up…

 

Tudpock (Jim)


Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/14/2010 10:00 AM (GMT -6)   
Another great post, but sad in a way, why can't there be a single agreement with anything PC? This adds so much anxiety to the average newly dx person. No matter what they are asking, it seems like there are conflicting views even by the experts. Thats why at the patient level, no one should come across so rigid or dogmatic in their personal opinions. You have to stay open minded at the least.
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 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 9/14/2010 10:00 AM (GMT -6)   
I've always had the suspicion and that all it is, that many pathologists post-op are likely to "round up" call close gleason slides to make the patient feel better with his decision. I'm not saying a conspiracy exists but that would be human nature IMHO.

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3838
   Posted 9/14/2010 10:17 AM (GMT -6)   

prostate snatchers, fried by radiation and now this.  man this kind of doom and gloom thinking just can't be good for you......

F8


age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
ADT, brachy and IGRT

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4237
   Posted 9/14/2010 10:19 AM (GMT -6)   
When Gleason 1st developed the grading system it was set up that 90% of the pathologists would agree on any given slide. So you also have a built in 10% error rate if everything goes right.

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6982
   Posted 9/14/2010 10:23 AM (GMT -6)   
Looks like a 5 is still a 5, so my 4+5 is still pretty definitive.

Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 9/14/2010 10:35 AM (GMT -6)   
Interesting.
 
This may explain two things that I have wondered about at odd moments:
 
1. In my case Bostwick read my biopsy slides as 3 + 3, whereas M. D. Anderson read the same slides as 3 + 4.
 
2. The strong majority of a growing - albeit still unscientific - sampling of men I have talked to who had surgery at M. D. Anderson in the last couple of years have reported that they had a post-op Gleason score of 7, not 6.
 
I had attributed both phenomena to M. D. Anderson probably simply grading higher (something my surgeon mentioned in passing once), but it could also simply be a case of comparing apples and oranges.  
 
This could also affect the results obtained by using nomograms, i.e., plugging in a "new" Gleason score into a nomogram developed using "old" Gleason scores.
 
Zen9 

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 9/14/2010 10:52 AM (GMT -6)   
I maybe wrong, but before surgery I played with the nomograms with various combinations of 6 and 7 total gleason scores and didn't find much variance in the outcomes. I still think in my mind, that gleason 7's are the most difficult to plot. A 3+4 behaves generally as a Gleason 6, and the 4+3 behaves generally like a Gleason 8. So the difference of a Gleason 6 and a (3+4) Gleason 7 aren't too much different from what I see on the nomograms that I looked at.

Just seems like the new grading is more or less not much different than the introduction of the ultra sensitive PSA tests. They have a purpose, but often is used for something it was never intended for.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009     .06
                   6 month Apr 2009     .06
                   9 month Jul  2009     .08
                 12 month Oct 2009     .09 
                 18 month April 2010   .19

Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 9/14/2010 11:04 AM (GMT -6)   
LV-TX said...
A 3+4 behaves generally as a Gleason 6, and the 4+3 behaves generally like a Gleason 8. So the difference of a Gleason 6 and a (3+4) Gleason 7 aren't too much different from what I see on the nomograms that I looked at.

Not true with my numbers, at least on the nomograms I use.
 
Zen9

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3786
   Posted 9/14/2010 11:08 AM (GMT -6)   
Yet another reason that those considering AS, Active Surveillance as their response to a diagnosis of prostate cancer must be very careful in doing their homework so they don't end up making a bad situation even worse.

If the only thing you knew about PC was derived from the "Snatchers" book, you could easily develop a Pollyanna attitude about the disease which for many men could turn out to be tragic..JMO..
Age 68.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA age 66 9.0 DRE "normal", 2ed biopsy, negative, BPH, Proscar
PSA at age 67 4.5 DRE "normal"
PSA at age 68 7.0 third biopsy positive, 4 out of 12, G6,7, 9
RRP performed Sept 3 2010

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/14/2010 12:09 PM (GMT -6)   
Les, there are doctors that think the way you describe, that a 3+4 is safer than a 4+3, but there are plenty, who feel that any Gleason 7 is an intermediate agressive cancer, and that its any component of the "4" cells that make a Gleason 7 case touchy and unpredictible.
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 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 9/14/2010 12:21 PM (GMT -6)   
Purgatory said...
its any component of the "4" cells that make a Gleason 7 case touchy and unpredictible.
Factor in, however, that many "4" readings were "3" until recently - even though the underlying pathology hasn't changed at all.  Therein lies the rub.
 
Zen9

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 9/14/2010 12:35 PM (GMT -6)   
I hate to say it, but there's something wrong with the way this disease is identified to the patient. There needs to be "norms".

One Uro told me he could not advise me at all on what I should do. "too personal".
Another was happy to answer the "If you were in my shoes" question.

Biopsy comes back and i'm 3+4.
Pathology comes back and it's 4+3.

Pre-op they're convinced it's contained so lets operate.
Post op it's reached the margins, and they say had they known they would not have operated.

Post op they sign me up for radiation.
2nd radiation oncologist agrees with me we should wait and see.

"THEY" all tell me their ethical obligation & measuring stick is my life.
I have to explain to "THEM" that quality of life matters to me more than simply numbers of years.

90% of men have ED after, 90% dont have ED, most have incontinence issues, most dont...

Old Gleason, new Gleason.

On and friggen on and friggen on.

I could start a song....

"Watch and wait, operate, radiatiate, dont hesitate, it's not too late, results are great, dont test fate"
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Listed on patholgy as PT3, but with extraprostatic extension,
microscopic invasion of the bladder neck, PT3A is perhaps the case.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain! Update 7/14/2010: When I tried changing this sig a few days after creating it, system was broken. My new rad oncologist are discussing IMRT.. though he says he can see why waiting a bit and watching the PSA on super sensitive basis might make sense. I am leaning towards IMRT.. thinking is my body is pretty strong now, i'm 51, and if I can rid my body of this while trying to minimize the side effects.. I dunno. No really Good answers. When I said I didnt want radiation to the point of being a veg.. I really meant there is a limit as to where I wish to go in order to realize only a small increase in life expectancy.. and not that I am an unreasonable person. I do, after all, have an obligation to my wife and kids.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 9/14/2010 12:37 PM (GMT -6)   
I get left out of so many of these threads with my Gleason 9, should I be jealous ?
 
I think not, but it does save me a lot of anguish I think.  It's almost like it should come down to a pass/fail system.  Any thing over a 6 or 7 is bad, anything under is probably OK.  It's that darn 7 that is the real tough one.  Is it or isn't it aggressive ?
 
We spend a lot of time on this forum discussing diagnostic tools and techniques, and here we see an example of not using one of the most important predictors of agressiveness in a non-uniform manner.
 
Go figure.

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 9/14/2010 12:42 PM (GMT -6)   
How is it that every uro in the world is not aware of THIS website, of OUR exchanges?
Why is is that WE need to ask US about "is this normal, is penis going to shrink, blood in catheter, etc, etc, etc..."???

Most of the major discussions and information I acquired about MY condition and the disease was through this site, and you folks.

There should be a standard checklist of important (QUALITY OF LIFE) issues that EVERY PCA patient should have to read and sign. No where else could you have a situation where only AFTER the hospital made their $35,000 do they tell you 'oh, by the way'!!
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Listed on patholgy as PT3, but with extraprostatic extension,
microscopic invasion of the bladder neck, PT3A is perhaps the case.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain! Update 7/14/2010: When I tried changing this sig a few days after creating it, system was broken. My new rad oncologist are discussing IMRT.. though he says he can see why waiting a bit and watching the PSA on super sensitive basis might make sense. I am leaning towards IMRT.. thinking is my body is pretty strong now, i'm 51, and if I can rid my body of this while trying to minimize the side effects.. I dunno. No really Good answers. When I said I didnt want radiation to the point of being a veg.. I really meant there is a limit as to where I wish to go in order to realize only a small increase in life expectancy.. and not that I am an unreasonable person. I do, after all, have an obligation to my wife and kids.

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 9/14/2010 2:26 PM (GMT -6)   
Very interesting Tud- didn't know it either, can't say that Bostwick is necessarily, fair to be considered any kind of bad guy, many believe he is one of the premier go to guys. Also, Epstein doesn't believe in ploidy analysis to much and therefore doesn't bother doing them, although there is money in doing the additional little testing. But, these expert pathology guys are the ones whom found (now) 24+ variant types of PCa....add that to mix of the twilight zone effect for patients scenarios and outcomes...my conjecture is average pathologists likely wouldn't know all these nuainces and either miss identify or fail to indentify some of these, which might be critical or important. My guess is someone will publish or mention this 'x' factor of variant prostate cancers that are missed by average pathologists, sooner or later....naturally I will be all ears to read it.(might be my Kreskin debut)-LOL

Have a guy at Yananow whom ended up with 3 pathology reports(to sort it all out), because Epstein and Bostwick had different findings...call it the value of second opinion(s). Yeah, this is a wonderful world of PCa....find me definitives...and I can find you the argument and basis to shoot it down as imperfect...it works on most anything in PCa. More like OutBack Steak House- No Rules Just Right (only here for us patients Just Wrong!)

PCa superlative description words: Jungle, Twilight Zone, Limbo Land, Bizzaro Land. Makes fiction look like reality t.v., makes infinity look calculable, makes doctors look like voo-doo artists and machinery to treat us now looks like star wars & cybernetics and all this while we live watching our psa scores, like it is level Defcon 5. Maybe I over discribed it-LOL!

BobCape- we need English Alf to write up another list, like he did on surgery posted at top of home page...that should be a document on disclosure at docs offices, I don't think he missed any details. That needs expanding to include other treatments and issues in gaining better assessments on disease levels, which Dr. Strum has harped on for years...this is why we listen to him, he is found correct very often.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35 normal, ct and bone scans appearing clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off for 1 yr., controlled so well, resumed, using intermittently, pleased with results

riverbend
Regular Member


Date Joined Mar 2009
Total Posts : 39
   Posted 9/14/2010 3:45 PM (GMT -6)   
hey BobC...was that INXS you just referenced on the prostate board? If so, I thought at least one person should appreciate your effort.

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 9/14/2010 4:22 PM (GMT -6)   

The previously referenced Gleason grade migration/inflation has been well documented.  If you would like more background on migration, see the excellent August 2006 PCRI article here.  This article has an excellent graph showing the decrease over time (through 2005) of the G6 scores and the corresponding increase over time of G7 scores.

 

Of general interest, one of the explanations in the PCRI article for Gleason migration/inflation is the “learned experience” of pathologists over time.  Many studies have shown that biopsy scores are frequently upgraded after RP, most likely as the result of sampling error (only a small portion is analyzed by biopsy).  Over the years, the discrepancy has “pressured” pathologists (according to the “learned experience” hypothesis), in the case of borderline or questionable cases, to up-grade cancers knowing that in a significant number of cases the patient most likely has a higher grade of cancer lurking in his prostate.  Interesting perspective on one element of the variation of Gleason scoring.

 

The PCRI article also describes (from a 2006 context) the changes, and impact of the changes, from the consensus agreements from the 2005 International Society of Urological Pathology (ISUP).

 

The purpose of this posting is to provide a link to (what I deem as) a more interesting article published this year in the journal Nature with a 2010 contextual perspective of the 2005 ISUP changes.

 

The Nature article is an interesting read…

 

 

Of additional possible interest, please also see the posting I made this morning about a study published yesterday on Gleason upgrading in the thread titled "Active surveillance and upgrading.

 

 


Added later as an edit:

* The 2006 PCRI article URL:  http://www.prostatecancerwatchfulwaiting.co.za/Migration.pdf

* The 2010 Nature article URL:  http://www.nature.com/nrurol/journal/v7/n3/pdf/nrurol.2010.9.pdf

 

Post Edited (Casey59) : 9/14/2010 6:10:04 PM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4237
   Posted 9/14/2010 4:47 PM (GMT -6)   
Casey,
Couldn't get your link to work.
From what I understand in 2005 there were a few changes to Gleason grading. It used to be that the 1st score reflected the type of cells that were most prevelent and the 2nd score reflected the 2nd most type of cells. This was changed, and the 2nd score now reflects the highest gleason grade found regardless of the amount or % found. Before a G3+3 meant that G3s were the most prevelent type of cells found. Now if even a small amount of G4 cells are found then it's a Gleason 7. This could be the major reason that the amount of upgrades after surgery has drastically increased. It also appears that many labs are still using the old standards and this is also a reason for discrepancies on 2nd opinion and after surgery pathology.

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


a777
Regular Member


Date Joined Aug 2010
Total Posts : 22
   Posted 9/14/2010 4:51 PM (GMT -6)   
we are still in the dark ages.
Age-65
PSA- 9.9
G7 (3+4)
6 of 10 positive (two were 2% at 3+3 so nothing to worry about)
The part to worry about-
left base (conventional type seen in 2/2 cores, involving 50% of submitted tissue, G7 (3+4-pattern 4 accounting for 40% of tumor)
left mid (conventional type seen in 2/2 cores, involving 50% of submitted tissue, G7 (3+4-pattern 4 accounting for 40% of tumor)

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 9/14/2010 7:10 PM (GMT -6)   
John T said...
Casey,
Couldn't get your link to work.

 

Thanks for letting me know.  I've gone back to the original posting (above) and added the URLs.  You will find the Nature article very informative.  There were other more detailed changes...I found it too difficult and detailed to easily summarized.  Let me know what you think.

Post Edited (Casey59) : 9/14/2010 6:20:03 PM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4237
   Posted 9/14/2010 7:29 PM (GMT -6)   
Casey,
Can't get the Nature article. Did read the PCRI article and it was very informing. I didn't realize that the Partin tables and nomograms are based on the old Gleason grading system and not the modern one. Also something like 55% of old biopsy samples that were reviewed today were 1 point higher than the original samples. This puts a lot of studies that had data from pre 2005 very suspect. Also we have been led to believe that today's treatments are much more effective than 10 years ago. With the large Gleason grade migrations it would appear that there has been no increase in the effectiveness of the treatments only a raising of the risk catagories. This should be a major concern to all of us.
Tud, you opened a can of worms.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 9/14/2010 7:42 PM (GMT -6)   
Hmmm. Sorry, I don't understand why the URL doesn't work.

Try Googling the article's title: "Clinical implications of changing definitions within the Gleason grading system"

Should be the first thing that pops up. Epstein is co-author of the article, and he was the lead author of the 2005 ISUP consensus conference on the Gleason changes.  I think you'll find the level of detail interesting.

Post Edited (Casey59) : 9/14/2010 6:56:32 PM (GMT-6)


An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1149
   Posted 9/14/2010 11:37 PM (GMT -6)   
Tud,
 
Very very interesting ... good pickup.
I checked my husbands path reports and it said 2005. I think I am going to put this on my husbands signature as my original assumption that everyone elses would be the same is no longer true.
 
John T, you said:
From what I understand in 2005 there were a few changes to Gleason grading. It used to be that the 1st score reflected the type of cells that were most prevelent and the 2nd score reflected the 2nd most type of cells. This was changed, and the 2nd score now reflects the highest gleason grade found regardless of the amount or % found. Before a G3+3 meant that G3s were the most prevelent type of cells found. Now if even a small amount of G4 cells are found then it's a Gleason 7. This could be the major reason that the amount of upgrades after surgery has drastically increased.
 

There is actually way more than this that's causing the Gleason scores to change. The actual pathology (large cribform patterns) which would previously considered as Gleason 3 now (post ISUP 2005) is considered to be intermediate risk and Gleason 4.

http://www.europeanurology.com/article/S0302-2838(10)00422-7/fulltext

see table 4.

I think its just sad that the pathologist cannot agree on the same language, Bostwick and Epstien, two very respected labs are providing information that is just not consistant and the worst thing is that until Tud pointed it out now, no one knew!

I think we all need to change our signatures after looking at our pathology reports and when a new person comes on board it would need to be a standard question that we ask.

An


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/15/2010 12:24 AM (GMT -6)   
Another great discussion,
Thank you Tud for the post.

I have some interesting food for thought that somewhat relates to this post. This is me thinking outside of the box...

I was 3+4=7 at biopsy, and I was 4+3=7 after surgery. And we have been learning that 3+3=6 is likely less dangerous and does not always require treatment unless the tumor is large or outside the prostate. OK

It is my theory that maybe the Gleason Sum system is not as important as the highest Gleason grade and the size of that grade in the tumor.

Here are my hypothetical patients:
All are after RP...
In patient A he has a ten gram tumor that is 70% grade 3 and 30% grade 4. He would be a 3+4=7.

In patient B he has the opposite. A ten gram tumor that is 70% grade 4 and 30% grade 3. He is 4+3=7.

In patient C he has only a 3 gram tumor that is all grade 4. He is 4+4=8.

Here's my trivia:
Why aren't patient's A and B also Gleason Sum of 8? Both have just as much Gleason grade 4 cells as patient C. The grade 3 cells are likely not going to be the problem. Patient B has far greater grade 4 tumor cells than both A and C combined. Yet he is still Gleason Sum of 7. If I used common sense, Patient A and C are the same risk according to tumor size, and patient B has the highest risk...In fact Patient A should have even higher risk than patient C because he also has additional cancer (let's call it a tertiary grade 3).

It is my contention that not just the way we view slides to define aggressiveness is very suspect, but also we are missing the key component of exactly how much of each grade is present.

This one has bugged me since day 1 of my journey...In 4 years I still don't have an acceptable answer...

Just a thought...

I would think that patient C will do the best here, followed by patient A, and patient B has the highest risk.

Tony

Post Edited (TC-LasVegas) : 9/14/2010 11:57:06 PM (GMT-6)

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