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What is the difference between Gleason Score, Gleason Grade Group and Gleason Pattern?

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Posted 1/6/2016 11:15 PM (GMT -5)
This is very confusing and the reason I bring this up is because I was thinking about our 2nd opinion from JHU and wanted to read it again. Upon further investigation my hubby and I realized there was a very small group of words in parenthesis at the end of one of the positive core findings.

I will write the entire quote from Dr. Epstein for that 1 specimen:
Prostatic Adenocarcinoma, Gleason Score 3+4=7 (Grade Group 2)
involving 20% of one(1) core (10% Gleason Pattern 4).

Here is the original:
Prostatic Adenocarcinoma, Grade Group 2, Gleason score 3+4=7/10;
Tumor quantitation: present in one(1) of 2 cores;
approx. 10% of examined tissue.


We realized we had not read the report clearly and re-read the original Pathology suggesting only 10% of the one(1) core(which is different from Dr. Epstein's report) and
with no mention of a Gleason Pattern 4. Is the 10% mentioned in both summaries the same thing?

Now I'm a bit worried; my hubby thinks I'm crazy to be worried. Is this why they told us to get things going within 3 weeks?
Gosh, how did we overlook this? (Our heads were in the clouds I guess)
Posted 1/7/2016 12:01 AM (GMT -5)
Gleason pattern or grade is a number between 3 and 5 that describes the cell architecture seen by the pathologist.

Gleason scores consist of two Gleason grades or patterns. The first number is the predominant pattern, the second is the highest pattern over 5% of the core (and under 50% of the core). If it's 95% all one pattern, it's repeated (e.g., 3+3). The possible scores in order of increasing riskiness are 3+3, 3+4, 4+3, 4+4, 3+5, 5+3, 4+5, 5+4, 5+5

Gleason grade group is Epstein's latest proposal. Group 1 is the same as 3+3, Group 2 is the same as 3+4, Group 3 is the same as 4+3, Group 4 is the same as 4+4, 3+5 or 5+3, and Group 5 is the same as scores of 9 or 10. (my personal opinion is that I doubt this does anything but cause confusion.)

Epstein is telling you that he found tumor tissue in 20% of that biopsy core. That tumor tissue was 90% pattern 3 and 10% pattern 4.

The original pathologist only found tumor tissue in 10% of that core, so a little less than Epstein. But he also found it to be Gleason 3+4. He didn't break down what percent was pattern 3 and what percent was pattern 4 the way Epstein did.

Both readings are pretty close.

- Allen
Posted 1/7/2016 2:31 AM (GMT -5)
Thank you so very much Tall Allen.
Posted 1/7/2016 6:19 AM (GMT -5)
If you look down to a thread titled "big changes to Gleason scoring system are coming", you'll see an explanation of all this and discussion about it. In essence, Dr. Epstein has proposed to the medical community a simplified PC grading system that gets away from the traditional Gleason method and will grade PC on a 1-5 scale. There is a simply psychological reason for this: a Grade 1 situation 'feels' a lot less scary to the patient than a score of 6.

There have been many, many men treated aggressively who didn't need the treatment. This situation is what they are trying to deal with.
Posted 1/7/2016 1:08 PM (GMT -5)
Epstein has been touting this system for about a year now. I wish Epstein had conducted a very simple clinical trial - randomly assign Grade Group scores or traditional Gleason scores (expressed as X+Y) and see if there was any difference in elected treatments or active surveillance in the two groups. That might prove or disprove his conjecture that smaller numbers will lessen the "cancer panic." If that were his goal, he should have called them Group A, B, etc. - presenting patients with more numbers only adds to their confusion, imho, as is amply demonstrated by the OP's query.

Also, D'Amico has pointed out that the presence of any pattern 5 raises the risk level, so Grade Group 4 is glossing over an important distinction.

Unfortunately, Epstein has enough clout to make this stick in spite of the lack of medical evidence of a benefit.

- Allen
Posted 1/7/2016 1:26 PM (GMT -5)
Tall Allen,

I like your suggestion about using Grade A, B, C, D, E. Almost everyone relates to these Grade scales, as "A" is good, and "D" then "E" is the worse.

Showing my age now . . . .
Posted 1/7/2016 4:19 PM (GMT -5)
The new Gleason grade groups (GGGs) has the same predictive accuracy as the current classifications according to this fresh European study. So the improvement seems only to be "a simplified, user-friendly nomenclature to aid in patient counseling".
The GGG 4 "hiding" of Gleason 5 seems not to be a problem though.

www.europeanurology.com/article/S0302-2838(15)01207-5/abstract/evaluation-of-the-2015-gleason-grade-groups-in-a-nationwide-population-based-cohort
Posted 1/7/2016 4:29 PM (GMT -5)
Why does it not seem to be a problem given the serioiusness of any amount of 5? Persoally, I dont see what the problem was with the old system. If you looked at prostate grading at all it would be pretty obvious even if 6 is greater than 1.
Posted 1/7/2016 5:01 PM (GMT -5)

Gemlin said...
The GGG 4 "hiding" of Gleason 5 seems not to be a problem though.

Why would you say that? Anthony D'Amico (the man who developed the basis for the current risk stratification system) disagrees with your opinion. On what basis do you disagree?

Gleason Score 3 + 5 or 5 + 3 versus 4 + 4 Prostate Cancer: The Risk of Death

Gleason pattern 5 is particularly virulent and especially capable of metastasizing. The presence of any pattern 5 in a tumor is reported as the second number of the Gleason score because of its danger.

- Allen
Posted 1/7/2016 5:02 PM (GMT -5)
IMO, the basic idea, to me, is psychological for 'average' patients (we're not average, ok?). Particularly if the grading includes treatment recommendations. Telling someone that 'something is going on, it's grade 1, which means we need to keep an eye on it for a while' is a great start. They are already using something similar with Breast Cancer, and it seems to be catching on in that world.
Posted 1/7/2016 6:05 PM (GMT -5)
halbert,

You just illustrated my problem with it when you wrote "Telling someone that 'something is going on, it's grade 1, which means we need to keep an eye on it for a while." You see, it's not grade 1. Grade still means Gleason pattern. Grade Group 1 means the tumor has no higher than Grade 3. This language is very confusing, even for me.

The psychological benefit is a valid and testable hypothesis. I'm surprised that Epstein, who is one of the greatest advocates of evidence-based medicine, didn't simply test his hypothesis, perhaps along with other nomenclatures like A,B,C etc., to see whether it was true, and the degree to which it causes confusion. I know he was going with the WHO standard to get international uniformity, but since this is not really a change in the universal Gleason grading system, I wonder how necessary that international uniformity was.

- Allen
Posted 1/7/2016 6:18 PM (GMT -5)
Grade, group...sheesh. I still say it was not exactly rocket science to begin with...maybe if you have no clue whatsoever about it...but still . For example, if the doc says you are group 1 or even A and you ask for further explanation he will probably say it's grade 3-3...back where you started.
Posted 1/7/2016 6:35 PM (GMT -5)
eventually, I think, Gleason patterns will be kept to the academics and pathologists, and PATIENTS will be told "you're grade X, which means Y" At least that's my hope.
Posted 1/8/2016 5:04 PM (GMT -5)

Tall Allen said...

Gemlin said...
The GGG 4 "hiding" of Gleason 5 seems not to be a problem though.

Why would you say that? Anthony D'Amico (the man who developed the basis for the current risk stratification system) disagrees with your opinion. On what basis do you disagree?

Gleason Score 3 + 5 or 5 + 3 versus 4 + 4 Prostate Cancer: The Risk of Death

Gleason pattern 5 is particularly virulent and especially capable of metastasizing. The presence of any pattern 5 in a tumor is reported as the second number of the Gleason score because of its danger.

- Allen


Tall Allen,

I have asked one ISUP cancer pathology expert in Sweden that participated at the ISUP Consensus Conference 2014 where they decided the new system, why they put 5+3 and 3+5 in group 4. He thought it was an insightful question and the answer was (sorry if translation is not perfect):

"4+4 is by far the most common in that group. We considered at the Chicago summit that it was difficult to evaluate if 3 + 5 and 5 + 3 would be included in the ISUP 4 but in the absence of further information, they get there for the time being. However newer studies have shown that 3 + 5 behaves as 4 + 4 and that 5 + 3 is more similar to GS 9 (ISUP 5). Which is also perceived intuitively."

So this seems to be a shortcoming of the new grouping system and I was wrong. Sorry for that.
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