Gleason score 7 prostate cancer on needle biopsy: relation of primary pattern 3 or 4 to pathological stage and progression after radical prostatectomy

Abstract

Purpose: There have been only a few contradictory publications assessing whether Gleason score 4 + 3 = 7 has a worse prognosis than 3 + 4 = 7 on biopsy material in predicting pathological stage and biochemical recurrence. Older studies predated the use of the modified Gleason grading system established in 2005. Materials and Methods: We retrospectively studied 1,791 cases of Gleason score 7 on prostatic biopsy to determine whether the breakdown of Gleason score 7 into 3 + 4 vs 4 + 3 has prognostic significance in the modern era. Results: There was no difference in patient age, preoperative serum prostate specific antigen, maximum tumor percent per core or the number of positive cores between Gleason score 3 + 4 = 7 and Gleason score 4 + 3 = 7. Gleason score 4 + 3 = 7 showed an overall correlation with pathological stage (organ confined, focal extraprostatic extension, nonfocal extraprostatic extension, seminal vesicle invasion/lymph node metastases, p = 0.005). On multivariate analysis Gleason score 4 + 3 = 7 (p = 0.03), number of positive cores (p = 0.002), maximum percent of cancer per core (p = 0.006) and preoperative serum prostate specific antigen (p = 0.03) all correlated with pathological stage. Gleason score 4 + 3 = 7 on biopsy was also associated with an increased risk of biochemical progression after radical prostatectomy (p = 0.0001). On multivariate analysis Gleason score 4 + 3 = 7 (p = 0.001), maximum percent of cancer per core (p < 0.0001) and preoperative serum prostate specific antigen (p < 0.0001) but not number of positive cores correlated with the risk of biochemical progression after radical prostatectomy. Conclusions: Our study further demonstrates that Gleason score 7 should not be considered a homogenous group for the purposes of disease management and prognosis.

Earlier prostate-specific antigen testing in African American men—Clinical support for the recommendation

“…A difference in tumor biology has been suggested in patients with intermediate-grade (Gleason 7) prostate cancer depending on the predominant pattern (4 or 3). Prior studies have shown that subcategorization of prostate cancer into patterns 4 þ 3 vs. 3 þ 4 is associated with differences in rates of margin positivity, biochemical recurrence rates, and prostate cancer-specific mortality rates [24][25][26]. An unexpected finding among veterans with intermediate-grade (Gleason 7) cancer was that WVs were more likely to have Gleason 4 þ 3 disease than AAVs were, a difference that only reached significance in the older age group (Table 2, P o 0.0001).…”

Primary Gleason pattern in biopsy Gleason score 7 is predictive of adverse histopathological features and biochemical failure following radical prostatectomy

“…Other studies that predate the Gleason modification have found higher risk of biochemical failure in patients with RP GS 4 +3 who had primary Gleason pattern 4 on biopsies compared to primary Gleason pattern 3 [12], and that biopsy GS 4+3 had a similar risk of biochemical failure to biopsy GS 4+4 [20]. Using the ISUP 2005 guidelines in the aforementioned study by Amin et al, the authors demonstrated that biopsy GS 4+3 was associated with a higher risk of biochemical failure [10]. In the current study, biopsy GS 4+3 more than doubled the risk of biochemical failure compared to biopsy GS 3+4.…”

“…Amin et al compared 1267 patients with biopsy GS 3+4 to 524 patients with biopsy GS 4+3 and found by multivariate analysis that primary Gleason pattern 4 was associated with increased pathological stage (from organ-confined to focal EPE, non-focal EPE and SVI/lymph-node metastases, p = 0.03) and risk of positive surgical margins following RP (p = 0.001) [10].…”

“…In the current study, biopsy GS 4+3 more than doubled the risk of biochemical failure compared to biopsy GS 3+4. In part, the conflicting results regarding the prognostic difference between GS 3+4 and 4+3 on biopsies may reflect sampling error during biopsy procedures [10][11][12]20,21,[25][26][27][28].…”

“…Only a few studies have assessed the association between the primary Gleason pattern in biopsy GS 7 and the RP specimen histopathology and risk of biochemical failure [10][11][12][13]. Results from these studies are conflicting, and most studies were conducted before the modified Gleason grading system established in 2005 by the International Society of Urological Pathology (ISUP) [14].…”