Gleason Scoring System 2017 JASREMAN DHILLON, MD ASSOCIATE PROFESSOR, DEPARTMENT OF ANATOMIC PATHOLOGY, MOFFITT CANCER CENTER, TAMPA, FLORIDA
Learners Objectives u Latest changes per ISUP 2014 that impact Gleason patterns u Changes in the reporting of PA with inclusion of Grade Groups and % of Grade 4 component in GS 7 u When to report and when not to report GS in post therapy biopsies u Concepts about IDC-P
Gleason Score 1977 2005 2014
Gleason Score 1977 2005
Gleason Score 2-4 is Not Made on Needle Biopsies and Prostatectomies u 1) Poor reproducibility among experts for lower grade tumors. u 2) Correlation with the prostatectomy score for Gleason 2-4 tumors is poor and up to 50% of the corresponding prostatectomies may have extraprostatic extension.
American Journal of Surgical Pathology 2012
u Totally embedded RPs from 1975-2010 reported as GS <6 were identified from the combined RP databases of four large academic centers. Participating institutions were The Johns Hopkins Hospital, Henry Ford Hospital, University of California San Francisco (UCSF), and Baylor College of Medicine. u 19 cases, mostly from the 1990s, diagnosed as GS<6 with a positive LN
Conclusions From Study u Of over 14,000 totally embedded radical prostatectomies from multiple institutions, there was not a single case of a GS 6 tumor with LN metastases. u GS 6 tumors do not appear to metastasize to LNs. u Gleason patterns 4 or 5, as defined by the current ISUP system, is required for metastatic disease. u Cannot rely on grading prior to 2005 as accurate.
Gleason Score 1977 2005
Gleason Pattern 3 Smoothly circumscribed small cribriform nodules of tumor
Epstein et al After ISUP 2005 there were multiple studies showing small foci of smoothly circumscribed cribriform prostate cancers are associated with an adverse prognosis
The American Journal of Surgical Pathology: Volume 40. February 2016, p 244-52
Gleason Score 1977 2005 2014
Gleason Pattern 3 u Individual well-formed discrete glands
Gleason Score 1977 2005 2014
Epstein et al
All Cribriform Cancer Glands are Graded as Gleason Pattern 4
Gleason Grading System u Gleason s original data u GS 2-5 comprised 28% u GP 4 (GS 7, 8, 9) comprised 12% u Danneman et al u GS 2-5 comprised 27% in 1998 u GS 2-5 comprised 1% in 2011 u GS 7 comprised 38% in 2011 u Grade scores 2-5 have disappeared from clinical practice
Variants of Prostate Cancer Foamy Gland Cancer Pseudohyperplastic Cancer Colloid Carcinoma Signet Ring Cell-Like Adenocarcinoma Ductal Adenocarcinoma Are graded by same rules as the usual prostate cancer
Ductal Adenocarcinoma u Ductal adenocarcinomas is graded as Gleason score 4+4=8 u Ductal adenocarcinoma with necrosis grades as Gleason pattern 5. u PIN-Like ductal adenocarcinoma is graded as 3+3=6 as it has excellent prognosis
Small Cell Carcinoma Small cell carcinoma of the prostate is not assigned a Gleason score since it is unique histological, immunohistochemical, and clinical features.
Post-Therapy Prostate Cancer If histologically, usual prostate cancer is seen following hormone therapy, radiation therapy, cryotherapy or HIFU and it resembles nontreated cancer Cancer without significant treatment affect and a Gleason score is assigned. Histologically cancer is seen, and it shows treatment effect no Gleason score is assigned.
Reporting Percent Pattern 4 u 1. Ac&ve surveillance in pa&ents with 7(3+4) u Age u co-morbidity u extent of cancer u MRI findings u pa&ent desire u Can be candidates for AS if the % of pajern 4 is limited u 2. Borderline cases of 7(3+4) or 7(4+3) u Benefit the trea&ng physician in deciding the appropriate therapy for the pa&ent in combina&on with other clinical parameters such as PSA levels, % of tumor present, number of core posi&ve, MRI findings
Grading Groups Five prognos&cally dis&nct Grade Groups based on the modified Gleason score groups Grade Group 1 = Gleason score 6 Grade Group 2 = Gleason score 3 + 4 = 7 Grade Group 3 = Gleason score 4 + 3 = 7 Grade Group 4 = Gleason score 8 Grade Group 5 = Gleason scores 9 and 10
Intraductal Carcinoma of the Prostate (IDC-P) u IDC-P is a malignant lesion u Expansile prolifera&on of malignant prosta&c epithelial cells within prosta&c ducts and acini u significant architectural and cytological atypia u IDC-P associated with u large tumor volume u advanced disease stage - extraprosta&c extension, seminal vesicle invasion, and pelvic lymph node metastases u high Gleason score u increased risk of recurrence
IDC-P is not assigned a Gleason score
IDC-P in Prostate Biopsies u IDC-P, when present in a core needle biopsy, requires a prompt re-biopsy or defini&ve treatment u IDC-P has been reported in about 2.8% of biopsies u The presence of isolated IDC-P without accompanying invasive adenocarcinoma is extremely rare, occurring in < 0.3% of core needle biopsies u IDC-P in prostate biopsies u Early biochemical failure u metasta&c disease following radia&on treatment in pa&ents with intermediate or high-risk prostate cancer.
IDC-P in Radical Prostatectomies u IDC-P in radical prostatectomy specimens u increase in the incidence of biochemical recurrence u 61-84% of IDC-P cases show loss of PTEN u TMPRSS2:ERG gene fusion > 2/3 rd of cases of IDC-P ERG IHC
References u u u u Hillary M. Ross, Oleksandr N. Kryvenko, Janet E. Cowan, Jeffry P. Simko, Thomas M. Wheeler and Jonathan I. Epstein. Do adenocarcinomas of the prostate with gleason score (gs) 6 have the potential to metastasize to lymph nodes? Am J Surg Pathol. 2012 Sep; 36(9): 1346 1352. Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley JR, Humphrey PA; Grading Committee. The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: Definition of Grading Patterns and Proposal for a New Grading System. Am J Surg Pathol. 2016 Feb;40(2):244-52. Mukul K. Divatia and Jae Y. Ro. Intraductal Carcinoma of the Prostate Gland: Recent Advances. Yonsei Med J. 2016 Sep 1; 57(5): 1054 1062. Thomas M Schneider and Adeboye O Osunkoya. ERG expression in intraductal carcinoma of the prostate: comparison with adjacent invasive prostatic adenocarcinoma. Modern Pathology (2014) 27, 1174 1178.
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