Part 2: Gleason Score is how much subjective and how much objective

This post is an update to my post on 11/27/2011 with the title: “Gleason Score is how much subjective and how much objective.” While there is background information in my 11/27/2011 post and very good responses, I changed the direction of the discussion away from Gleason scores. This is my attempt to continue the discussion on Gleason scores.

Note: In my 11/27/2011 post I used the name “Clinic X” which is actually the University of Minnesota Prostate Clinic.

The short version of this update:

How unusual is it for a biopsy results summary report to state 5% of a specimen (labeled Specimen D in this case) is malignant with Gleason 6 = 3 +3 and a couple of months later a second look at the same biopsy slides at the same laboratory now report the same Specimen D is actually 50% malignant with Gleason 7 =3 +4?

A biopsy procedure at the University of Minnesota (U of M) resulted in a summary report (2 of 14 specimens positive: specimen A and specimen D) showing Gleason 6 = 3 +3. The slides were sent to the Mayo Clinic and they created their own report agreeing with the U of M’s data (i.e. the percents values for total surface area involved were the same) in the report but the Gleason score was upgraded to Gleason 7 = 3 +4. The slides were then returned to the U of M where they created an addendum to their original report in which they agreed with the Mayo Gleason 7 = 3 +4 upgrade but disagreed with the Mayo’s and their own original report in the percent of a specimen’s total surface area that was malignant. The U of M upgraded one specimen’s total surface area involved from 5% in their original report to 50% in their addendum report.

The much longer version of this update with more data included.

It starts at the University of Minnesota (U of M) where I had a biopsy procedure. The results report identifies Specimen D as Adenocarcinoma (Gleason 6 = 3 +3) with total surface area involved 5% on 09/28/2011.

The slides are then sent to the Mayo Clinic and they created their own report which was different than the U of M’s report. The Mayo report identifies Specimen D as Adenocarcinoma (Gleason 7 = 3 +4) with total surface area involved 5% on 11/23/2011.
Lastly, the slides are returned to the U of M and they took a second look at the slides used to create their first report. The U of M creates an addendum report identifying Specimen D as Adenocarcinoma (Gleason 7 = 3 +4) with total surface area involved 50% on 12/01/2011.

The upgrade from Gleason 6 to Gleason 7 is very bad news to me. I also wonder how accurate malignant surface area can be measured or even estimated when it is reported as 5% at one viewing and then changed to 50% after a second viewing of the slides at the same laboratory. While the Mayo clinic disagreed with the Gleason 6 and upgraded it to Gleason 7, the Mayo did agree Specimen D malignant total surface area was correct at 5%. The U of M disagreed with itself and with Mayo when it changed the Specimen D malignant total surface from 5% to 50% on 12/01/2011.

The actual slides of my second biopsy have been evaluated 3 times with differing results each time.

I. First slide evaluation at University of Minnesota (U of M) dated 09/28/2011.

This biopsy was taken at the U of M on 09/28/2011 and analyzed in house.

The U of M looked at the biopsy slides and created report showing 2 of 14 cancerous specimens.

The U of M report for specimens A and D were:

A. Prostate biopsy, left base:
Prostatic (acinar) adenocarcinoma, combined Gleason score 6 = 3+3 Total surface area involved: 20% , number of needle biopsy cores involved: 2 of 2; Perineural invasion: Absent, Angiolymphatic invasion: Absent; No extraprostatic extension identified.

D. Prostate biopsy, right base:
Prostatic (acinar) adenocarcinoma, combined Gleason score 6 = 3+3, Total surface area involved: 5%, Number of needle biopsy cores involved: 1 of 2, Perineural invasion: Absent, Angiolymphatic invasion: Absent; No extraprostatic extension identified.

II. Second evaluation of the same slides at the Mayo Clinic dated 11/23/2011.

The slides were sent to the Mayo Clinic for their own evaluation on 11/23/2011. The Mayo report agreed with the U of M report except the Mayo’s Gleason scores were upgraded to Gleason 7 = 3 +4.

The Mayo report for specimens A and D were:

A. Left base - Adenocarcinoma (Gleason 3 + 4) involving 20% of the specimen. No perineural invasion or extraprostatic extension.

D. Right base - Adenocarcinoma (Gleason 3 + 4) involving 5% of the specimen. No perineural invasion or extraprostatic extension.

The area involved percentages for both specimens A and D were exactly the same at both the U of M and the Mayo: Specimen A surface area involved 20%. and Specimen D surface area involved 5%.

While the U of M said both specimens were Gleason 6 = 3 + 3, the Mayo labeled both specimens Gleason 7 = 3 + 4

III. Third evaluation of the same slides for the second time back at the U of M dated 12/01/2011.

I called the U of M and told them the Mayo had upgraded their 09/28/2011 biopsy report from a Gleason 6 = 3 + 3 to a Gleason 7 = 3+4.

The U of M then evaluated the slides for a second time and created an addendum to the original 09/28/2011 report with a new date of 12/01/2011. The U of M addendum report for specimens A and D now looked almost like the Mayo report except for the Specimen D total surface area involved.

Looking at their own slides created on 09/28/2011 in which the Specimen D total surface area involved was 5%, the new U of M addendum report on 12/01/2011 gave Specimen D total surface area involved 50%.

The U of M addendum report of 12/01/2011 for Specimens A and D:

A. Prostate biopsy, left base:
Adenocarcinoma, combined Gleason score 3 + 4 (combined score 7). Total surface area involved: 20% , number of cores involved: 2 of 2; Perineural invasion: Absent, Extraprostatic extension: Absent.

D. Prostate biopsy, right base:
Adenocarcinoma Gleason grade 3 + 4 (combined score 7). Total surface area involved: 50% , number of cores involved: 1 of 2; Perineural invasion: Absent, Extraprostatic extension: Absent.

GLTA, Terry

This is where Tarzan-ProstatePathologist would be most welcome to drop in and shed extremely large light on the whole subject matter and what goes on in pathology, that we lay people would seldom or never know. We are all hung up on what the biopsies slide show us, which is good and understandable, now add to the mix you have many missed biopsies and areas within that huge gland (comparitively to small samplings done), they could harbor different Gleason grades, more PNI or HG PIN, PIN and the (tarzan) pathologist could confirm this...I believe it is possible to harbor more than one type of PCa going on within the gland and have seen such written about concerning some signet ring variant along with acinar the common PCa. So.........ask yourself how perfect is all my pathology, lousy scannings, psa history and everything....then the rush to treat anyone and cut, freeze, zap, microwave or seed it, etc. Some have tigers and some have ***** cats....alot of imperfection right now in knowing exactly what one has to deal with. Easy one size fits all thinking by many of the treatments, the disease is unique to each person is more the reality and how you will fair individually when compared has plenty of unknowns. So, when your doc says 'we got it all', acts like they know it all or can handle it all....start questioning it. The over all definitivity of PCa looks surely questionable to me, and that is my opinion and will look at most everything, so far has not swayed me much from thinking differently. Good hunting in your Twilight Zone episode of this, it is bizzare as to what has happened.

Hopkins does second opinions and their main pathologist is noteworthy. I was told by multiple sources to "trust Hopkins' pathology." I'm early in, but the biopsy and post have matched. It's an art as much as a science--- imo.

Imtis, you find the best people you can, you make your decision and you never look back, ever...You play the cards in your hand at the moment. You may not like the cards...Too bad...Those are the ones you have to play...This is a journey with no guarantees...

imtls said...
Thanks for your responses to this situation. I am going to the U of M and talk to my Urologist on Wednesday, December 14. I will ask for his analysis of what happened with the varying reports.

If you can think of any questions I should ask him, please let me know (reply to this post) and I will bring them up when I see him.

Thanks again and GLTA, Terry

I can understand disagreeing between a G3+3 and G3+4 but from 5% to 50%? Could very well be a typo.

Here is a possible answer. Imtis, you could find a friendly local pathologist and pay him to examine the slides you have from your biopsy. Tell him about the changes in earlier readings and ask him to allow you to look through the microscope yourself. He should be able to give you a teaching moment and perhaps to project the specimen onto a larger screen for close examination without looking directly into an eyepiece. This will allow you an amateur opinion as well as his (her) professional opinion and give you something to answer the big boys with. After this kind of examination there should be less confusion in your mind, at least.

Final update on this issue (I think). The 50% was an error and the correct surface area percent is 5%.

Thanks for all of your responses and input.

I had an appointment with my urologist at the U of M and I asked him about the percent change in Specimen D from 5% to 50%. I mentioned online comments also thought a leap from 5% to 50% was quite a jump and should be investigated.

The urologist told me he would have a pathologist investigate this discrepancy and call me if the newly reported 50% was a mistake.

I did receive a call this morning and the affected surface area was NOT 50% but was 5%. The U of M apologized for the mistake and the call was over.

Thanks again for your help and don’t be afraid to ask and ask again until YOU understand what your doctors are telling you or (as in this case) giving you.

GLTA, Terry

Hello again with another update (so much for my previous “final” update).

My biopsy at the U of M was analyzed in-house as Gleason 3+3=6 at U of M.

A second biopsy analysis was Gleason 3+4=7 at Mayo Clinic. I just called the Mayo Clinic today and asked if their pathologist had the U of M analysis report as background information. The answer was NO; the Mayo pathologist only looked at the slides sent to him and did not look at the report created by the U of M.

When I went back to the U of M and told them of the Mayo upgrade from Gleason 6 to Gleason 7, they then came back with their own upgrade from a Gleason 6 to a Gleason 7 (agreeing with the Mayo).

I am thinking that if I had not told the U of M of the Mayo upgrade but just asked the U of M to verify their original Gleason 3+3=6, I would expect the U of M to confirm their own analysis and not upgrade to a Gleason 7.

Because of this thinking I decided to get another opinion of the slides at Bostwick and see their Gleason Score without the benefit of the U of M and Mayo reports. I wanted a completely independent analysis and report of the data shown on the slides.

I expected Bostwick to act like the Mayo Clinic and not ask for any previous written report but just give the slides to a pathologist to create a report using the information found on the slides.

I was wrong. Bostwick wanted both the slides and the previously created pathological report. I specifically did not want Bostwick to know the story how two different clinics came up with two different results and then one clinic (U of M) agreed the other clinic (some minor clinic called the Mayo) was correct. In my opinion the Bostwick pathologist would be under some needless pressure to conform with the consensus of two other major clinics. I don’t see the benefit of reading and studying previous analysis and reports of data if the object is to create and independent report from the data on the slides.

I then looked on-line at Johns Hopkins and they also want both the slides and any report in order to create their own second opinion report.

I agree with the Mayo when it comes to creating an “independent” second opinion. I also wonder how much of a biopsy analysis is art and how much is science. What do you think?

Do you have any recommendations of a quality laboratory that analyzes biopsy slides without looking at previous reports?

GLTA, Terry