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Does your Gleason score usually remain the same?

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User

Posted 15 May 2024 at 10:07

I've become quite decent at researching reputable information on prostate cancer, but have not been able to establish whether your initial Gleason score can progress to a more aggressive one or usually remains the same.

Our initial Gleason score is calculated from biopsies. Of course biopsies are not an exact science and may miss more aggressive cancer cells. Apparently even examining and grading biopsy samples is open to a degree of opinion.

As far as I'm aware the only true histology is after surgery, when the prostate is examined.

However, if we were in perfect world and our intial biopsies were a 100% accurate and the grading was spot on. Would that initial Gleason score ever change, could the cancer become more aggressive?

If anyone can conclusively answer this question would they please include a link to support it.

Cheers.

User

Posted 15 May 2024 at 10:48

Here are a couple of attempts to answer that difficult question, both of which seem to say that it is probably unusual for the grade to change because it is set by genetics.

A. A short answer in one of Dr Scholz's videos- see the question at 2.36 in this video.

https://www.youtube.com/watch?v=pPqlVc93Raw

B. A very technical statistical study which seems to support the conclusion that a change in Gleason score is unusual

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775342/

User

Posted 28 Jun 2024 at 12:29

Originally Posted by: Online Community Member

Histology after surgery still only examines a very tiny proportion of the prostate volume, typically about 5 surfaces cut through the prostate, depending on size. Positive margins are only identified if they line up with one of these slices.

Only in research you might microtome (thinly slice) a large volume of the prostate to construct a detailed 3D model of the cancer.

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User

Posted 15 May 2024 at 10:48

Here are a couple of attempts to answer that difficult question, both of which seem to say that it is probably unusual for the grade to change because it is set by genetics.

A. A short answer in one of Dr Scholz's videos- see the question at 2.36 in this video.

https://www.youtube.com/watch?v=pPqlVc93Raw

B. A very technical statistical study which seems to support the conclusion that a change in Gleason score is unusual

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775342/

User

Posted 15 May 2024 at 11:11

Originally Posted by: Online Community Member

Here are a couple of attempts to answer that difficult question

Cheers Kevin, the two links are very informative. Thank you very much for posting them.

User

Posted 15 May 2024 at 12:12

Good question Adrian and good answer Kevin. For most of the reasons Adrian stated about biopsy inaccuracies I thought that it would be impossible to get a definitive answer. Dr Sholtz gives an intuitive answer but doesn't quote any research.

Kevin's second link is a very elegant way of researching the problem. Repeated biopsies over a time period on individual patients are fraught with difficulties from a research point of view. The increase at population level in biopsies, at lower PSAs over the last 30 years has effectively created two sets of biopsy results, one from late diagnosed cancers (pre PSA 'screening') and another from early diagnosed cancers (post PSA screening). The two sets of data have roughly the same distribution of Gleason scores, which implies young cancers and old cancers start and end with the same Gleason score (or some become a higher G score, but an equal amount become a lower G score. Very unlikely).

I was not expecting to find studies like the above so I tried to research the opposite to Adrian's hypothesis i.e. do cancers get more aggressive? The general rule seems to be yes. The main reason is simple Darwinian evolution. If a cancer cell splits in to two, and for some reason (mutation) one daughter cell is more aggressive than the other then that cells daughters will eventually swamp out the less aggressive daughters cancer cells. Prostate cancer being a slow growing cancer, results in slower evolution towards aggressiveness. So Gleason would get worse but at such a slow rate we would probably die before it became noticeable.

Dave

User

Posted 15 May 2024 at 17:40

It seems to me that with PCa you can make generalisations but there are few if any certainties. As regards the aspect under review here, I can say that when diagnosed in 2007 my TRUS biopsy resulted in a grading of 3+4=7. A Template biopsy in 2015 was also assessed at 3+4=7. However by 2021 a further less extensive template biopsy resulted in a revised grading of 4+3=7. So the more advanced cancer component had gone from the minority to the majority. Butt this was based on what was seen in the cores taken at the time, which does not show definitively all the cancer within the Prostate. Had the biopsy been more extensive it might well have been possible that more 3 graded component could in reality be present so a 3+4 would in reality still have more correct. Another possibility is that RT plus my first HIFU had dealt more successfully with the 3 graded cells but some of the more advanced 4 graded cells had been more resilient to treatment and had persisted. So it does not necessarily mean cancer cells have become more aggressive but only as seen in cores taken which may not be extensive or wholly representative and does not prove the cancer has become more aggressive even if a cursory look at the revised Gleason score may lead to that conclusion.

Barry

User

Posted 28 Jun 2024 at 12:29

Originally Posted by: Online Community Member

Only in research you might microtome (thinly slice) a large volume of the prostate to construct a detailed 3D model of the cancer.

User

Posted 30 Jun 2024 at 21:08

My dh was given a Gleason of 3+3 after biopsy. He was recommended AS. But went with brachytherapy. PSA was 0.01 for 5 years before creeping up. Roll on 9 years after brachy and we find out that the brachy worked on his prostate as there is no cancer there. However, he does have spread to several lymph nodes high up in abdomen and in his chest, meaning it was there all along. Everything I read says a Gleason 6 doesn’t spread. So I’d like to know…did the Gleason 6 upgrade while it was sitting in lymph nodes? Or was the original diagnosis wrong and it was a higher Gleason. Or did the G6 spread anyway? We will never know the answer to those questions.

User

Posted 01 Jul 2024 at 02:31

That the cancer has spread outside the Prostate means that staging is now different to Prostate confined. It does not necessarily mean that the Gleason has changed, although this is possible. It could be that some cancer cells had already left the prostate by the time Brachy was administered or received insufficient dose to adequately damage them. I believe you are correct in saying it is unlikely to learn when the lymph nodes became affected. With a Gleason of 3+3=6 a number of Consultants don't even regard this as cancer, so well treatment was done in your husband's case and now the affected lymph nodes need treating either individually or systemically as considered appropriate.

Barry

User

Posted 01 Jul 2024 at 06:31

Thanks Barry, the fact that there is no cancer in dh’s prostate and nothing in the local nodes (he has a psma scan) I think can only mean the spread must’ve happened before the original treatment.
The consultant just said it must’ve been in the nodes for years. But how long for or why it didn’t put any psa out all those years we will never know. The only treatment offered is HT and second gen HT (enza) I don’t know where we’d be if DH had taken the AS route that the urologist and the oncologist both suggested.

User

Posted 01 Jul 2024 at 11:28

At one tiime UCLH believed I had an infected Iliac Lymph Node from assessing a Choline Pet scan they did. But I sent the scan to 3 other hospitals that I had been involved with and from the size and shape of the node they were unconvinced by the apparant take up of Choline and suggested I get a 68 Gallium PSMA scan privately 'cos nobody would do it for me on the NHS at the time. This did not show an uptake of PSMA so UCLH eventually did a HIFU on an infected part of the Prostate. So sometimes hospitals can get it wrong. However, prior to getting the result I asked if they could surgically remove the node in question and I was told they would look into the possibility (as Dr Eugene Kwon said they did in a case in the USA), but they never got back to me on this and the negative result of the PSMA came through so no need to pursue There is obviously a limit to how many nodes and their location that could be emoved but sometimes during a Prostatectomythey remove quite a number of lymph nodes. I wonder why they could not do this in your husband's case especially as his cancer free Prostate would not need to be removed making the operation simpler. Maybe worth asking the question?

Barry

User

Posted 01 Jul 2024 at 20:23

Thanks Barry. I think there are too many nodes involved. Up to 27 nodes. Removing them wasn’t mentioned. This is what the consultant wrote…
Multiple highly avid nodes in left sidewall (maximum of 11) a few more at the aortic bifurcation and infrarenal paraaortic regions (SUV up to 7)

Additional avid lymph nodes in posterior mediastinum at the level of carina (SUV up to 9)

User

Posted 02 Jul 2024 at 01:24

Ahh sorry looks like too many and well spread in your husband's case so let's hope systemic treatment works for a long time.

Barry

User

Posted 02 Jul 2024 at 05:01

Thanks. Psa went down to 1 after 4 weeks on the tablets and 2 weeks on zoladex. A month later it was 0.01 where it stayed. Hopefully will remain there a few years.

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