The Gleason grading system has been incorporated into the WHO classification of prostate cancer, the AJCC/UICC staging system, and the NCCN guidelines as . Prostate cancer as incidental finding in transurethral resection biopsias previas negativas y 1 con PSA bajo y tumor agresivo (Gleason 4+3). Advertisement. Prostate Prostatic carcinoma. Grading (Gleason) Author: Kenneth A. Iczkowski, M.D.. Revised: 6 November , last major update June
The Gleason grading system for prostate adenocarcinoma has evolved from its original scheme escwla in the s—s, to a significantly modified system after two major consensus meetings conducted by the International Society of Urologic Pathology ISUP in andrespectively. Both pathologists and clinicians need to fully understand the principles and practice of this grading system.
The Gleason grading system for prostate adenocarcinoma originated in the s—s from a pioneering randomized, well-controlled, prospective study initiated by the Veterans Administration of the USA, in which over 2, patients were included.
Donald Gleason detailed and summarized the histological growth patterns grades of prostate adenocarcinoma, and the correlation with clinical data such as escalx and prognosis were analyzed.
ESCALA GLEASON CANCER PROSTATA DOWNLOAD
The eponymous Gleason patterns have since been well-known, although a number of other grading systems have also been proposed or used over the last few decades.
The classical Gleason system defines five histological growth patterns grades. Gleason 1 represents the best differentiated and is correlated with the most favorable prognosis, whereas Gleason 5 the least differentiated and correlated with poor prognosis.
As many prostate adenocarcinomas harbored two or more Gleason patterns, the Gleason score was developed, which was shown to correlate with the biological behavior of prostate adenocarcinoma even better. The sum of the primary e. In those cases with just one pattern, e.
In the original system, Gleason pattern 1 is characterized by a well-circumscribed, nodular lesion composed of roughly uniform, closely compacted, discrete, well-differentiated glands of moderate size. Gleason in his original study may be mimicking lesions [such as adenosis or atypical adenomatous hyperplasia AAH ] rather than bona fide prostate cancer.
In contrast, Gleason pattern 2 may show variations in sizes of the neoplastic glands, slightly increased stroma between the glands, and even slight irregularity at the periphery of the nodule.
This pattern is currently also considered to be very rare.
Gleason pattern 3 has been seen in many series as the most common pattern, comprised of individual, discrete and distinct neoplastic glands, typically small, but often of variable sizes and infiltrating into the stroma in between the benign glands. Gleason pattern 4 features fused glands, which are no longer individual or distinct, resulting in broad, irregular fused glandular or cribriform patterns. A variant is the hypernephroid pattern with sheets of cells with abundant clear cytoplasm.
Comedo type necrosis in the context of these structures leads to upgrading to pattern 5, which also includes solid or cordlike growth or infiltration by individual tumor cells, without any trace of gland formation 6.
Many changes since the s—s have called for updating of the original Gleason system. For example, new growth patterns or variants of prostate adenocarcinoma have been recognized, which need to be incorporated into the system. Modified needle biopsy protocols and modern surgical approaches in combination with increased screening by serum PSA and other modalities yielded samples which required pathologists to address many issues such as grading multiple core biopsies from different sites or multiple nodules in radical prostatectomies RP.
These also raised such issues as how to interpret and score biopsies with tertiary in addition to the primary and secondary patterns, and how to differentiate between cribriform patterns in well-defined spaces from high grade PIN, which have been better appreciated with the availability of basal cell immunohistochemical markers. The most important advance in this regard is the ISUP consensus published inwhich represented the culmination of years of attempts by pathologists to address controversial issues and to reach consensus in the Gleason grading system.
Some of the most important updates in the consensus are highlighted below 7 – This basically eliminates Gleason 1 pattern. Similar to the original Gleason 1, the edge of the so-called Gleason 2 nodule can hardly be properly assessed on needle biopsies.
The original Gleason pattern 3 actually included diverse patterns, ranging from the classical individual, distinct glands of variable sizes most characteristic of this pattern, to cribriform growths, and even to individual cells. The consensus addressed the issue of the controversial cribriform Gleason pattern 3, and unanimously agreed to remove individual cells, as well as to move large cribriform growths into pattern 4, but still allowed diagnosis of cribriform pattern 3 in well-circumscribed, smooth and rounded glands the size of normal glands.
Some urologic pathologists required other features to diagnose cribriform pattern 3, such as evenly spaced lumina and even thickness of inter-connecting bridges. Thus, based on the consensus, most cribriform patterns would have been placed into Gleason pattern 4, but allowance for rare cribriform pattern 3 was still made However, additional data, experiences accumulated in larger centers, and discussions by urological pathologists post-ISUP consensus conference further led to the proposal that all cribriform glands should be considered Gleason pattern 4 The most recent AFIP fascicle on tumors of the prostate gland now published by the ARP press 17 and other monographs 18 promoted such modifications, which have been adopted by most practicing urologic pathologists.
A cluster of such glands should be classified as Gleason pattern 4, as it is unlikely to represent tangential sections of Gleason pattern 3 glands, which need to be ruled out. However, very small but distinct glands still should be assigned Gleason pattern 3. Comedo necrosis in solid nests or cribriform background formations, represents Gleason pattern 5, and it was emphasized that stringent criteria should be applied for comedo necrosis, which include intraluminal necrotic cells and karyorrhexis.
The consensus also addressed the issues related to grading other structural features as well as variants of prostate adenocarcinoma. One of these was adenocarcinoma with vacuoles.
As vacuoles can be observed not only in Gleason pattern 4 more commonly but gleasin in Gleason pattern 5 and Gleason pattern 3 tumors rarelyit was proposed that vacuoles should be ignored and esscala the grading should be based escaa on the underlying structural patterns. Similarly, focal mucinous extravasation as well as mucinous fibroplasia collagenous micronodules should be ignored and the grading should be based on the underlying gland structures.
At the consensus, the opinions regarding the grading of glomeruloid structures were divided, but later discussions led to their inclusion in pattern 4. For grading foamy gland carcinomas, the foamy cytoplasm is to be ignored and the grading should be based on the underlying structures.
However, the opinions regarding the grading of colloid carcinomas were divided grade as Gleason score 8, or ignore the extracellular mucin and grade according to underlying structures. In summary, modified Gleason system based on the consensus prosata later developments basically eliminated Gleason grade 1, and put very stringent limits on Gleason pattern 2. Gleason 3 would thus be the lowest grade assigned if no higher grade patterns are identified. Many changes were made to Gleason pattern 3, particularly the moving of most original Gleason pattern 3 cribriform structures as well as clusters of poorly formed glands into Gleason 4 7.
The most direct impact of the modified Gleason system is a shift toward higher Gleason score being reported.
In another series of thin core biopsies, re-grading by the ISUP criteria resulted in increase of score 7 tumors from These changes resulted in increase of high-risk-category tumors, from There are data showing that the overall agreement between grading of needle cacner and radical prostatectomy specimens increased e.
However, other studies appeared to show no significant change in level of agreement between scores of escals biopsies and subsequent radical prostatectomy specimens Most studies addressing the issue whether the modified system correlated with clinical stage and patient outcome better than the original scheme have reached positive conclusions, despite occasional dissent 23 For example, the modified system, particularly relocation of original Gleason pattern 3 cribriform growth into Gleason pattern 4, has shown to be valuable in predicting biochemical recurrence after radical prostatectomy 2125 – Interestingly, the latter two groups also showed significant differences.
An important aspect for any grading system to canceg clinically useful is its gleasin and inter-observe reproducibility.
It is essential to recognize the basic rules of the modified Gleason system, as well as the differences in reporting on different types of samples. escaala
For needle biopsies, identifiable high-grade component of any quantity should always be included in the Gleason score, as it indicates high probability of finding significant high-grade tumor in the prostate. In addition to the basic operation of summing up the primary and the secondary patterns to yield the Gleason score, one must remember that when tertiary component i.
It differs from reporting needle biopsies in that tertiary, highest grade should be reported separately, preferably with an accompanying note, rather than incorporated into the Gleason score. Also separate Gleason score should be assigned to each dominant tumor nodule in cases of multiple nodules with different grades.
Rarely, a nondominant nodule may show a higher score, and the grade for this nodule should be reported separately, because it likely will drive the biologic behaviour of the cancer. An international consensus meeting to update Gleason grading convened in Chicago US in latewhich represented not only experts in pathology, but also urologists, radiation and medical oncologists 37 – The meeting was conducted by the ISUP in response to the need to address issues not resolved or not covered in the consensus, as well as new research data and challenges from clinicians to the current grading system.
The meeting reached consensus on several major issues, including that cribriform and glomeruloid glands should be graded as Gleason 4, irrespective of morphology, and that mucinous colloid carcinoma of the prostate should be graded on the basis of underlying growth patterns rather than all as pattern 4. The consensus emphasized that intraductal carcinoma of the prostate in the absence of invasive component should not be graded but should be commented on in the report to alert clinicians of its consistent association with aggressive cancer.
The meeting reached consensus on many issues regarding various morphologies within Gleason patterns 3, 4, and 5. The most important development of the meeting is the proposal of a new prognostic grade grouping system, which may have major impact on practicing pathologists and clinicians.
This is basically a new grading system, although it is based on Gleason patterns, together with which it is to be used for the time being. The current Gleason grading system with typical Gleason patterns and the new Group Grade system are illustrated in Figure 1. Typical Gleason patterns of the modern Gleason grading system and the corresponding new Grade Group system. The authors have no conflicts of interest to declare. National Center for Biotechnology InformationU.
Chin J Cancer Res. Ni Chen and Qiao Zhou. Author information Article notes Copyright and License information Disclaimer. Received Apr 19; Accepted Jan Copyright Chinese Journal of Cancer Research.
This article has been cited by other articles in PMC. Abstract The Gleason grading system for prostate adenocarcinoma has evolved from its original scheme established in the s—s, to a significantly modified system after two major consensus meetings conducted cancdr the International Society of Urologic Pathology ISUP in andrespectively. Historical overview of the Gleason grading system The Gleason grading system for prostate adenocarcinoma czncer in the s—s from a pioneering randomized, well-controlled, prospective study initiated by the Veterans Administration of the USA, in which over 2, patients were included.
The modified Esxala system based on the International Society of Urologic Pathology ISUP Consensus and later developments Many changes since the s—s have called for updating of the original Gleason system. Impact and clinicopathological correlations of the modified Gleason grading system The most direct impact of the modified Gleason system is a shift toward higher Gleason score being reported.
Gleason grading system
Future directions and developments An international consensus meeting to update Gleason grading convened in Chicago US in latewhich represented not only experts in pathology, but also urologists, radiation and medical oncologists 37 – glfason Open in a separate window.
Footnotes Conflicts of Interest: Histologic grading and clinical staging of prostate carcinoma. Surgical pathology of the prostate. World Health Organization Classification of Tumours. Pathology and genetics of the urinary system and male genital organs. Gleason grading and prognostic factors ee carcinoma of the prostate. Mod Pathol ; Gleason grading of prostate cancer.
The evolving Gleason grading system
Caner perspectives on the Gleason grading of prostate cancer. Arch Pathol Lab Med ; Update on prostate pathology. Clinical implications of changing definitions within the Gleason grading system. Nat Rev Urol ; 7: Helpap B, Egevad L. Histol Histopathol ; Update on the Gleason grading system for prostate cancer:
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