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True Gleason score

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Posted 9/6/2015 7:00 PM (GMT 0)
My post RALP pathology report reads:

Histological grade: Gleason's score: 4 + 4 = 8; focal areas of Gleason 5 are also noted.

My Urologist said that this was a "misprint" and that my true Gleason score is 9 (4+5). I found this puzzling that a pathologist, who does these things day in and day out, would make an error like this. Then it occurred to me that perhaps the pathologist is communicating that my cancer is worse than Gleason 8 (4+4) but not quite as bad as 9 (4+5).

Perhaps this is an example of the limitations of the Gleason system and the staging system have in accurately describing our cancers?
Posted 9/6/2015 7:25 PM (GMT 0)
My doctors treat the highest Gleason measurement. Since I had 3s and 4s they treat the 4 and disregard the 3s. In your case, since you had enough 5 to be of concern, it appears your urologist will consider you a 9 not an 8 in developing the treatment plan. Either 8 or 9 will put you in the high risk category and call for aggressive treatment.
Posted 9/6/2015 8:44 PM (GMT 0)
The Gleason score is the sum of the most and second-most dominant (in terms of volume) Gleason grade. If
only one grade is present, the primary grade is doubled. If a grade comprises < 5% of the cancer volume it is
not incorporated in the Gleason score (5% rule).
Could it be that the "focal areas of Gleason 5" < 5% of the volume?
Just my two cents worth of thought.
Posted 9/6/2015 9:19 PM (GMT 0)
In my (not-expert) option, Gemlin has it right in terms of the way Gleason is calculated. So the pathologist is correct in that if you had less than 5% G5, that would typically not be reflected in the "official" Gleason grade. (Sometimes the word "tertiary" is used in this context instead of "focal". In either case it means a trace amount.)

But JNF's point is also right in that the urologist is within generally accepted practice in the decision to treat you "as if" you were a G9, and to be more aggressive given even a trace amount of G5.

The error here is that the urologist should not have characterized the G8 as a "mis-print" unless he knows more than what he has shared. It doesn't seem to be a misprint so much as a disagreement over what the data means.
Posted 9/6/2015 10:20 PM (GMT 0)
Your posts all make perfect sense to me. Thank you for helping me to understand. I do believe my Urologist is technically in error. This does not surprise me. While he is an excellent surgeon he is not a great communicator. I estimate he spent a total of 5 minutes discussing the results of my biopsy, my surgery, and my post surgery pathology report with me. Fortunately, my RO and online sources such as this one helped me to understand and map a strategy for my PCA.
Posted 9/6/2015 10:23 PM (GMT 0)
I would think a GS 8 (4+4) and tertiary 5 would likely be what he meant.
Posted 9/7/2015 7:23 PM (GMT 0)
The 2005 Urologic Pathology Consensus agrees with your pathologist. On a biopsy core, a Gleason 4+4 with tertiary 5 should be reported as Gleason 4+5. The thinking is that on a biopsy core, which is only a random sample, there may well be more of the higher Gleason pattern where that came from, and the risk level should be elevated for use in nomograms, etc. However, on a pathology report after RP, where there is access to the entire tumor, it should be reported as "GS 4+4 with tertiary pattern 5."

What is more important is if there were any positive margins and whether any Gleason pattern 5 were found at the positive margin.

- Allen
Posted 9/7/2015 9:23 PM (GMT 0)
My uro / surgeon would treat you as if a G 4+5. His opinion is that any G5 is too much.

The pathology report seems correct, and if done in a local lab (not specialized), they might use more generic terms. I would think your uro is interpreting as mine would.

Another good lab for a second opinion would be Bostwick Labs.
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