Can a Gleason 6 spread?

Is it true that a G6 will not spread to other parts of the body?

federal law prohibits G6 from spreading.

Andrew, you always make me smile. :)

Just my uneducated 2 cents. It makes no sense to me that G6 does not spread. I've seen enough people on this site alone that have a high volume G6. So if it does not spread how does it progress to high volume? And does it then just stop at the prostate wall because it can't get through? Seems hard to believe. I know when speaking to a couple of the Docs I saw, while not specifically addressing this question, they mentioned how to them it is somewhat irrelevant your gleason score once the cells escape the prostate. Now while it's true that the higher gleason score is usually more aggressive there seem to be quite a few cases of those with lower gleason that was aggressive for a particular person. So what to believe? I know if I had a high volume 6 I would be very concerned and would not trust someone telling me it does not spread. How did it spread from a little to a lot? What if it is in areas of concern like against the prostate wall in in the seminal vesicle area? Of course those that believe it does not would probably say it was not a true G6 to begin with, but where is the evidence of that?

Anyway, just the ramblings of someone who is not as well read as others on the topic. Just my 2 cents for what it is worth....Jim

I have no studies to back this at all.

My BELIEF is that any so called G6s that spread are possibly un-diagnosed G7s or worse.

The research debate goes something like this, as I understand it:

Do G6 cells modify and become G7, or do G7 cells spring up directly from "normal" cells? A question with huge implications for diagnosis and treatment.

As someone who was diagnosed at G6 and was found to be G7 on post surgery pathology, this is more than an academic issue.

(1) True Gleason 6 has never been found to metastasize. But that is a very different from saying that, if left untreated, it will not progress to something that will metastasize. That's why active surveillance involves constant monitoring to see if it has progressed. In 20 years of f/u, 55% of men on active surveillance never progressed to the point where treatment is needed, but the other 45% did.

(2) The reason I emphasized the word "true" is that we don't know from a single biopsy if it really is only a GS 6. about 30% of the time, higher grades are detected on f/u biopsies,especially mpMRI-targeted or saturation biopsies. That's why active surveillance protocols always call for f/u biopsies.

(3) "Metastasize" is different from "spread." GS 6 can certainly spread locally (i.e., eat into surrounding tissue) without metastasizing. It can potentially do damage just from that (in the same way basal cell skin carcinoma can eventually damage other tissue). However, most of the time, it is "indolent" - meaning it doesn't spread. The only way of knowing is through close monitoring on active surveillance.

There is also a theory that both Gleason pattern 3 and higher grade cells may arise from a single progenitor cell source, sometimes thought to be a prostate cancer stem cell. These are rare and hard to detect. Or today's pattern 3 cell may, due to any of a number of influences, evolve into a higher grade cell. It really doesn't matter much which is true, or if both are true, or it differs by person. There are a few tests now (Prolaris and Oncotype Dx) that determine genetic risk. In the end, the practical implications are the same - close monitoring is warranted.

- Allen

Under 'close monitoring' what would the tipping point that treatment would be warranted?

When my mp3T MRI report indicated a minimal Extraprostatic extension of a lesion at left posterolateral peripheral apex which subsequently Bx = G6, I asked the radiologist about his comment on ECE. Below is his answer

Low grade prostate cancer can extend outside of the prostate, although sometimes this appearance on MRI is a “fake-out” because of technical factors such as involuntary patient motion.

So, the radiologist believes that G6 can spread outside the capsule. I have not had a second opinion on the grading of G6.

I have been on AS since August 2012, but now consider a treatment. My prostate oncologist suggested permanent seed.

halbert said...
The research debate goes something like this, as I understand it:

Do G6 cells modify and become G7, or do G7 cells spring up directly from "normal" cells? A question with huge implications for diagnosis and treatment.

As someone who was diagnosed at G6 and was found to be G7 on post surgery pathology, this is more than an academic issue.

Same for me. G6 at diagnosis. Upgraded to G7 post surgery pathology.

Epstein comments:

Good News for Men with Gleason Score 6

"In other news, Epstein and colleagues recently took a closer look at the behavior of Gleason score 6 prostate cancer; their findings were published in the American Journal of Surgical Pathology. Although Gleason score 6 cancer is considered slow-growing and not aggressive, it has been found – rarely – in studies of prostate specimens after radical prostatectomy, to have spread outside the prostate. Could Gleason 6 cancer ever spread to the pelvic lymph nodes? Good news: The answer is no. "We performed a search of the radical prostatectomy databases at four large academic centers," says Epstein. "In more than 14,000 radical prostatectomies, there was not a single case of a Gleason score 6 tumor ever spreading to lymph nodes." It takes a Gleason score of 7 or higher for prostate cancer to become aggressive enough to spread far beyond the prostate. Under the microscope, Gleason score 6 cells appear uniform, "and they have a more predictable, excellent prognosis," Epstein notes. Gleason score 6 disease has such a good reputation as being "indolent" – slow-growing and wellbehaved, as cancers go – among pathologists that some of them have questioned whether it should still be considered cancer. Yes it should, Epstein says. One important reason why is that the biopsy Gleason score is often adjusted after radical prostatectomy, when the prostate is studied by a pathologist, "because the biopsy often underestimates disease grade and extent." Also, "if men think that Gleason 6 tumors are not cancer, this could result in a missed opportunity for cure."

Newday, which is actually the current long-range goal of all cancer treatment: to get to the point where cancers are treated as long term chronic conditions.

I've always been fascinated by the common working definition of cancer 'cure': still alive 5 years after treatment. That does seem to expanding today to more frequently say (with some cancers): cancer free after 5 years.

Recently our town had the annual relay for life, and there was a huge group in the "20 year survivor lap", which is significant. 20 years ago, except for things like low-grade melanoma, how many doctors held out hope for 20 year survival of ANY cancers?

I've been wanting to contribute to this thread all weekend. Finally, I have some time.

So, in my understanding, cancer cells don't create out of thin air. First, there need to be some abnormal cells from which they will form. Much the same as an egg can produce a male or female, abnormal prostate cells can produce a cancer cell of a type specified. those specified PC cells have reproductive cycles specific to its type, with type 3 being the slowest of types 3, 4, and 5. 4 and 5 are more aggressive (faster to reproduce).

Type 3 reproduces in the range of 375 days. Doing the basic math, it takes quite a bit of time for type 3 to produce a mass that would pose a significant risk to the host, hence the urban label "30 year Cancer".
That is not to say, however, that type 3 doesn't spread given an appropriate amount of time without intervention.

Think of it this way, if a town population is small enough to live in 1 sq mile, and the reproductive rate of the population is such that no further town expansion is needed, (every day there is a new baby, an elder dies off) then expansion "spread' is somewhat doubtful, but in the case of a 2 to 1 or 4 to 1 ratio, then without intervention, expansion (spread) is a foregone conclusion.

Not a perfect analogy given other factrors, but close enough.