Gleason Scoring

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)

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.

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.

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 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

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.

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"

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'!!

hey BobC...was that INXS you just referenced on the prostate board? If so, I thought at least one person should appreciate your effort.

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.

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)

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)

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)