gleason numbers

good-morning guys

 i'm curious as to why the lowest gleason score I've seen on this site is 6 when the scale goes from 2-10.

thanks carl

Riverunner, as David pointed out, Gleason 6 is the lowest score that is considered to be cancer...anything below that is not. Here is how the Gleason score is determined: For each biopsy sample, pathologists examine the most common tumor pattern and the second most common pattern. Each is given a grade of 1 to 5. These grades are then combined to create the Gleason score.

So, if the most common tumor pattern is 3 and the second most common is 4, then the patient is a Gleason 7 (3 + 4).

Hope this helps.

Jim

I guess that the main reason is that anything lower than a Gleason 6 is very, very low risk. Such cancers are so slow growing that they are highly unlikely to ever cause any problems.

Tumors of this nature are often found at the center of the prostate near the urethra. Biopsies usually do not reach this particlar area (I think it's called the Transition Zone), so lower Gleason scores are not usually associated with biopsies.

These low risk type of tumors, at the prostate's center area, are usually identificed when a patient is going through a TURP procedure to try and alleviate BPH related urination problems.

Take care,
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Pathology showed Gleason 3 + 3, pT2c, N0, MX, R1
adenocarcinoma of the prostate.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, 9/9/13 PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & VERY slowly getting a bit stronger.

Ralph- good stuff on that I was around back in 2002 when pathology grades counted supposedly as low as (1+1) which we never seemed to see, but there were guys found with (2+2) or (2+3) and it was called PCa and not to be confused with HG PIN or PIN, as those were precursors to supposed PCa.  So, isn't it interesting that the pathology info that stood for many years prior, now gets tweaked and redefined, just like screening changes, psa levels and definitions.  I have seen a lot of redefining things or changes over the years, just shows the precise science of PCa is not as perfect as we were lead to believe (i.e. practicing medicine is still evolving), used to be sold to us that ct and bone scans were considered definitive (which is a very big lie).  If you were around back in 2002 or so, many patients lead to believe that those scans were gold and supposedly bankable. Today we have better marketing (lol), so todays new drugs and new scans although looking better are likely to fall into the same practicing medicine category (but improved upon), later on as higher tech evolves and more real knowledge discovered we can compare again.

This is why my mantra to others on PCa:  question everything and all the time and secondly this is a twilight zone episode we didn't wish to be in....

(I am not without humor  )

It was just a change in how it's reported that was done by consensus in 2005. Gleason scores below 3+3 are possible, though seldom reported anymore.

Technically, Gleason patterns or grades are not "cancer" per se -- they are associated with cancer -- the higher the grade, the more likely it is to be cancerous. They show a quality of the cellular architecture called "dysplasia." Dysplasia is identified by non-uniform cell sizes, abnormal shapes, pigmentation, and more dividing cells. Gleason pattern 5 are highly dysplastic, Gleason pattern 1 is barely dysplastic. Not all dysplastic cells are malignant or cancerous, but prostate cancer cells do exhibit dysplasia.

- Allen

The Gleason grade is the pattern that they are associating with the cancer or the adenocarcinoma. Their 2005 consensus statement begins, "Donald F. Gleason in 1966 created a unique grading system for prostatic carcinoma based solely on the architectural pattern of the tumor." The authors of that statement are accepting the 2005 understanding of what the tumor does, but note that that understanding is evolving:

The 2005 Consensus said...

"It is likely that with immunostaining for basal cells many of Gleason’s original 1 + 1 = 2 adenocarcinomas of the prostate would today be regarded as adenosis (atypical adenomatous hyperplasia). Similarly, many of the cases in 1967 diagnosed as cribriform Gleason pattern 3 carcinoma would probably be currently referred to as cribriform high grade prostatic intraepithelial neoplasia, if labeled with basal cell markers."

It's like an architect saying a Victorian building is residential - "Victorian" describes what the architecture looks like, while "residential" describes how it is used. Like an architect, a pathologist looking at a Gleason grade only describes the architecture of the cells but not what the cells do, or how they behave on a molecular level. Gleason grades are useful because higher grades are correlated with more virulent cancers. Without that association, we wouldn't care what the grade was (as is true in some other cancers).

As our knowledge evolves of the natural history of prostate cancer progression or non-progression (and thankfully it's evolved a lot since 2005), we will better be able to discern (e.g., through genomic tests, etc.) which of the tumors are truly cancerous (i.e., capable of destructive unrestrained growth) and which are not.

The Gleason patterns are only descriptive -- it has been left to researchers to find the correlations with prognosis. Oncologists are now struggling with the use of the word cancer to describe tumors that are insignificant in size, indolent in growth, never progress to higher grade, and are not capable of metastasizing.

- Allen

I wonder what his definition is of the word cancer. Clearly not the same as Dr. Thompson's. It will be interesting to see if a consensus develops on that.

Ralph,

Defining what we mean by the word cancer would seem to be a good first step in arriving at a consensus. How about "a mass of cells or lesion characterized by destructive unrestrained growth," which is similar to my dictionary definition. By that definition, a lesion that remains indolent and insignificant would not be labeled as cancer. They still bear watching because they may be pre-cancerous. I also left off any mention of metastatic potential -- there are some cancers (e.g. basal cell carcinoma) that are never metastatic yet can become locally destructive.

For example, I have several actinic keratoses (AK) on my face from sun damage. AK is characterized by disordered cellular architecture of the skin's keratinocytes, including less mature cells, wider spaces, overgrowth and bigger nucleii (much as Gleason patterns are characterized). Yet no one calls them cancerous and they are widely regarded as pre-cancerous, and just something to watch, or to remove if I so choose. Although they are growths, their growth is not totally unrestrained (they only grow bigger indolently) are they are not destroying other tissue.

Properly defining what we mean by cancer will help eliminate the suffering caused by unnecessary treatment, while maintaining the treatments that are truly life-preserving. What we now know about its natural history is that many men will get what we are calling prostate cancer and will never be killed by it.

- Allen

Ralph, perhaps you misunderstood or I mis-communicated Dr. Bostwick's position. He does indeed believe that the lower grade Gleason scores ( 1 and 2) are cancer. Of course, he is expressing his personal and professional opinion on this. I have no idea whether or not he would support a change in the name to pre-cancerous - though that makes some sense to me.

The further point that I was trying to make is that, for all intents and purposes, it is a moot point as to whether or not the Gleason 1 and 2 cells are called cancer or not. It's an interesting academic discussion but, since pathologists almost never report any pathology from a prostate biopsy that is less than G 3 + 3 then that is the only time men will be diagnosed as having cancer.

Of course there is another school of thought that says even some Gleason 6 scores should not be called cancer but that's another debate...

Jim

TA,
You are right...got carried away. Corrected. Thanks.

Yes, in the support group environment I always tried to reassure men with low risk disease that if the Gleason Score is verified their prognosis is good and they should consider AS if they qualify.

That said, I would not tell them that their diagnosis is not cancer and that it will never progress. I just provide information and recognize that it is the individual's preference to decide what they want to do. Many ask what would I do in their shoes. I have always refused to answer that question as MY preference could be very different.

RalphV

hi guys,

 i'm really learning a lot from the question I posted but have to ask another question after reading the responses. isn't the definition of cancer uncontrolled growth of abnormal cells? and while I know that my gleason 6 is much better than having a higher number, that cancer by it's nature going to grow maybe slower but grow none the less. it had to be growing for my psa to go from 1.9 in 2011 to 5.85 this aug. at any rate my uro went to great lengths to inform me of the benefits of  as (I knew he was thinking it was my best option) but when he went over the path report with me he said it was a good decision to remove it because of the location, even though it was a small amount it was as close as it could be to the margins without being in the in the margins on the left side. he also told me that this was unusual in his experience.

thanks carl    

Carl,

You may have noticed several discussions on this board about the question of Gleason 6s. They have never been known to metastasize outside of the prostate/seminal vesicles, although they can grow into the prostate bed or surrounding tissue(extra-prostatic extension). Sometimes Gleason 6s are upgraded when the post-surgery path report comes out - but that was not true in your case. It seems that Gleason 6s probably do not become Gleason 7s, 8s, 9s or 10s -- it now seems more likely that the higher grade cells emerge from the same source, possibly a cancer stem cell. It is not inevitable that Gleason 6s will grow - some remain indolent and insignificant for the entire life of the man -- we know this is true from cadaver studies where incidental PC was found in the prostates of men who died of something else. We also have seen that many men do not progress while on Active Surveillance for over 10 years.

A cancer isn't just the uncontrolled growth of abnormal cells -- it must be destructive as well, otherwise the tumor is deemed benign rather than malignant. Benign tumors can sometimes grow quite large and can interfere with other physiological processes, but they are not usually referred to as cancerous. Sometimes such abnormal cell overgrowths don't grow that large, like the AKs I mentioned or a mole. It is not inevitable that they are destined to become malignant.

There are many reasons that your PSA could increase, including prostatitis and BPH on top of the PCa. Some doctors advocate use of Proscar or Avodart to get a purer reading on PSA and possibly prevent, slow, stop or reverse any GS6 growth. Given your low % cancer involvement and the up-and-down PSA, it is possible that you also had some prostatitis going on. Dr. Klotz now believes that PSA doubling time is not a great indicator for a trigger of when to come off of Active Surveillance. At minimum, he believes that the presence of predominant Gleason pattern 4 (i.e., GS4+3) ought to be a trigger.

No one has a crystal ball that predicts what would have happened in your case without surgery. What is important is that you made the best decision you could given the facts you had at your disposal.

- Allen