Impact of tertiary Gleason pattern 5 on prostate cancer aggressiveness: Lessons from a contemporary single institution radical prostatectomy series

Abstract

ObjectiveTo better evaluate tertiary Gleason pattern reporting and to evaluate the impact of tertiary Gleason pattern 5 (TP5) on prostate cancer pathological features and biochemical recurrence at our large single institution.MethodsWe retrospectively reviewed 1962 patients who underwent radical prostatectomy (RP) for prostate cancer; TP5 was reported in 159 cases (8.1%). Men with Gleason score (GS) 7 and GS 8 disease were divided into subgroups with and without TP5, and histopathological features were compared. Multivariate analyses were conducted to assess the impact on TP5 on biochemical-free survival (BFS).ResultsTumors possessing GS 3 + 4 with TP5 were more likely to exhibit extraprostatic extension (EPE) and had a larger tumor diameter (TD) than GS 3 + 4 alone. GS 3 + 4 with TP5 was also associated with positive surgical margins (SM), seminal vesicle involvement (SVI), and higher pre-operative prostate-specific antigen (PSA) values, but without statistical significance. GS 4 + 3 with TP5 more commonly presented with EPE, positive SM, SVI, and greater TD and pre-operative PSA level than GS 4 + 3 alone. In multivariate analysis, Gleason score, EPE, and TP5 were overall independent risk factors for PSA recurrence in this cohort. Additionally, GS 4 + 3 with TP5 was associated with shorter time to recurrence versus GS 4 + 3 alone.ConclusionOur results emphasize the importance of TP5 and suggest that criteria for tertiary pattern reporting in prostate cancer should be standardized. Further studies are needed to evaluate the role of tertiary patterns in prognostic models.

Optimization of the 2014 Gleason grade grouping in a Canadian cohort of patients with localized prostate cancer

“…Patients in GG2‐3 with tertiary Gleason 5 patterns had an increase in absolute risk of treatment failure of >20% at 6 years as compared to patients in the same group without tertiary Gleason pattern; the relative risk increase was 50% to 100%. In line with our findings, patients with Gleason 7 tumours in several other cohorts had a significantly worse prognosis if they had tertiary Gleason 5 pattern . In a retrospective study, 75 patients in GG2 and GG3 who had tertiary Gleason 5 pattern had similar biochemical recurrence rates to those in GG3 and GG4 without a tertiary pattern, respectively .…”

Independent surgical validation of the new prostate cancer grade‐grouping system

“…In addition, most risk‐stratification schemas classify patients with Gleason scores 8–10 as high‐risk, without discrimination between Gleason score 8 vs 9–10. However, multiple studies have reported significantly worse outcomes in patients with Gleason pattern 5 . Sabolch et al assessed the impact of Gleason pattern 5 in patients treated with dose‐escalated radiation therapy and showed that patients with Gleason pattern 5 had significantly lower freedom from metastasis ( P < 0.002), cause‐specific survival ( P < 0.001), and overall survival ( P < 0.001).…”

“…Patients with Gleason score 7 cancer are deemed intermediate‐risk; however, this is a heterogeneous group with Gleason score 4+3=7 tumours portending a worse prognosis than Gleason 3+4=7 tumours . Similarly, patients with Gleason score 8–10 cancer are deemed high‐risk, but multiple studies have shown that the presence of Gleason pattern 5 disease is associated with worse clinical outcomes . The granularity of what was initially a system consisting of 25 possible combinations of primary and secondary patterns has been largely reduced to three risk groups.…”

Practice Patterns in Reporting Tertiary Grades at Radical Prostatectomy: Survey of a Large Group of Experienced Urologic Pathologists

“…[1][2][3][4][5] While most of so-called tertiary grading reported in the literature refers to a higher grade-typically pattern 5-the term has been used variably regarding extent, ranging from a more limited, minor, or less than 5% highergrade carcinoma component in initial publications 3,4 to a third most common pattern of any percentage. [6][7][8][9][10][11][12][13][14][15][16][17][18] The accepted method for reporting ''tertiary'' patterns also differs between needle biopsy and radical prostatectomy (RP). As codified by the International Society of Urologic Pathology (ISUP) 2005 and 2014 grading conferences, cases with 3 patterns on needle biopsy should be graded by using a ''first plus worst'' (most common þ next highest grade) strategy.…”

“…21,22 For RP specimens bearing 3 grading patterns, since the pathologist may assess the entire tumor, the ''tertiary'' terminology has been recommended. 19 The latter recommendation is based on an array of studies 3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18] showing that cancers with a tertiary higher-grade pattern (TP) are associated with increased stage and/or biochemical recurrence following RP when compared with their closest grading counterpart (eg, 4 þ 3 ¼ 7 with tertiary pattern 5 compared with 4 þ 3 ¼ 7). Paradoxically however, TPs are not routinely incorporated into predictive clinical models.…”