Tertiary gleason grade

Sandra's clip gives a great explanation of what the pathologist should do when undertaking a Histology report from a biopsy. It also explains the criteria for each Gleason grading, the wikipedia explanation is much the same. What they don't explain is what to actually make of it all.

From what I have gleaned in my recent education this is how I see it.

The cores are examined and graded according to the size and spread of the cells the smaller and denser packed the lower the score.

Think of the sample being reported in a pie chart the biggest slice will be the primary gleason score , the next biggest slice (which also has to represent more than 5% of cells in the sample) is the secondary Gleason score. If asked to report to a Tertiary or third level then this would be the next biggest slice of cells but could actually be as little as less than 5 % of the total.

However here comes the confusing bit, If a tertiary gleason score is given and it is a higher score than either the primary or the secondary then it automatically becomes the second figure.

so primary = 4

secondary =3 but tertiary = 5 becomes a 4+5 = 9 This is because even though the tertiary is only a small representation in terms of cell volume, it is more aggressive so should be taken into account.

If the tertiary gleason is lower than either or both of the primary and secondary it does not reduce the overall figure. I believe that in high grade and aggressive cancer this would be an extremely rare thing to happen.

I think what a lower tertiary score might signify to an Oncologist as on the ball as yours, is that although the cancer is aggressive there is still some that is not. This may have some impact on the treatment given. There has to have been something other than pure instinct that made Jamie look at your treatment differently and opt for immediate chemo long before that was a recognised gold standard with your diagnosis. I wonder if that very unusual incidence of a lower tertiary than primary or secondary influenced him? Maybe a question you can ask him in January or sooner if curiosity gets the better of you!!

Of course it could mean absolutley nothing and be of no clinical significance at all. I am sure someone with far more suss than me will reply soon.

xxxxxxx

Mo

edited for my usual typos and grotty grammar!!

Edited by member 13 Nov 2015 at 14:32  | Reason: Not specified

Any help ? I've copied and pasted it in case the link doesn't work

http://surgpathcriteria.stanford.edu/prostate/adenocarcinoma/grading.html

Prostatic Adenocarcinoma Grading

The Gleason grading system is intended to be applied primarily at low power
Don’t go down on high power looking for one or two fused glands
The Score is the sum of the two most prevalent patterns subject to the following:
For needle biopsies
The predominant pattern is given first
The second most predominant pattern is given second, e.g. Gleason score 3+4 as long as the second score applies to >5% of the carcinoma
If the tertiary pattern is higher than both of the first two, it becomes the second pattern, regardless of its prevalence, e.g. 3+4 with tertiary 5 becomes 3+5
For prostatectomies
As for needle biopsies except that a high tertiary pattern is reported simply as a tertiary pattern e.g. Gleason score 3+4 with tertiary 5
Gleason grading criteria (based on 2005 ISUP modified system) (Epstein 2005, Egevad 2012)

Pattern 1
Circumscribed nodule of closely packed uniform glands
Described only in transition zone
Most if not all cases of Gleason 1+1 are really adenosis
We do not make this diagnosis, even as a secondary pattern

Pattern 2
Circumscribed nodule of loosely packed slightly variable glands
Described only in transition zone
Many/most cases of Gleason 2+2 are really adenosis
The entire lesion must be examined
IPOX for basal cells must be completely negative
We do not make the diagnosis of 2+2 or 2+3 on needle biopsies
Transition zone is rarely sampled and the entire lesion is rarely encompassed by the core
If the lesion is considered to be carcinoma it should be graded at least 3+3

Pattern 3
Single glands of variable size and density, with an infiltrative pattern, each separated by at least a strand of stroma
Critical distinctions from higher grade carcinomas are the widespread presence of well formed lumens and the lack of fused glands

This is the common pattern of low grade carcinoma
If no higher grade pattern is present, diagnose as Gleason 3+3
Resist the urge to imagine a component of pattern 2, even if the focus is small
Classical Gleason grading included sharply circumscribed cribriform in pattern 3
We consider this pattern 4, or in some cases high grade PIN

Pattern 4
Ragged infiltration with poorly formed glands or sheets and cords of fused glands
Poorly formed glands includes small nests of cells with only a rudimentary formed lumenal space (almost rosette like)
Intracytoplasmic lumens do not count as pattern 3, they are 4 or 5
Fused glands are recognized as back to back glands without intervening stroma
May produce a cribriform pattern
Glomeruloid bodies are pattern 4 by definition
Clear cell hypernephroid is pattern 4 by definition

Pattern 5
Ragged infiltrative single cells, cords or sheets without gland formation, or any pattern with comedonecrosis
Occasional cells with these features can be seen in pattern 4, especially peripherally
Signet ring carcinoma is by definition pattern 5
Special considerations for grading
The proper score for a very small focus that is just barely diagnostic of carcinoma is 3+3=6, not 2+2 or 3+2
Even very small foci should get two patterns to avoid confusion (single number in a report may appear to be a sum of two patterns)
The most critical clinical distinctions occur with the recognition of pattern 4
Some urologists want to know what percentage of the cancer is pattern 4, if yours do, then report it
A recent large study suggests that carcinomas of Gleason 3+3 or lower do not have the ability to metastasize to nodes (Ross 2012)
Scores should be given for each individual core, if they are received separately labeled
Treated carcinoma cannot be graded
If treated with radiation, we typically report that it cannot be graded but that it shows features of Gleason pattern 3 or 4 etc. if possible
Hormonally treated carcinoma cannot be graded at all
The rare variant of p63 positive adenocarcinoma should not be graded (Giannico)
Stanford Medicine » School of Medicine » Departments » Surgical Pathology Criteria » Prostatic Adenocarcinoma