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J I Epstein

Publications and source records attributed to J I Epstein.

At least 19 recordsLinked to original sources
PubMed2001

Interobserver reproducibility of Gleason grading of prostatic carcinoma: urologic pathologists.

Gleason grading is now the most widely used grading system for prostatic carcinoma in the United States. However, there are only a few studies of the interobserver reproducibility of this system, and no extensive study of interobserver reproducibility among a large number of experienced urologic pathologists exists. Forty-six needle biopsies containing prostatic carcinoma were assigned Gleason scores by 10 urologic pathologists. The overall weighted kappa coefficient kappa(w) for Gleason score for each of the urologic pathologists compared with each of the remaining urologic pathologists ranged from 0.56 to 0.70, all but one being at least 0.60 (substantial agreement). The overall kappa coefficient kappa for each pathologist compared with the others for Gleason score groups 2-4, 5-6, 7, and 8-10 ranged from 0.47 to 0.64 (moderate-substantial agreement), only one less than 0.50. At least 70% of the urologic pathologists agreed on the Gleason grade group (2-4, 5-6, 7, 8-10) in 38 ("consensus" cases) of the 46 cases. The 8 "nonconsensus" cases included low-grade tumors, tumors with small cribriform proliferations, and tumors whose histology was on the border between Gleason patterns. Interobserver reproducibility of Gleason grading among urologic pathologists is in an acceptable range.

Humans↗
PubMed2001

Interobserver reproducibility of Gleason grading of prostatic carcinoma: general pathologist.

Only a few large studies of interobserver reproducibility of Gleason grading of prostatic carcinoma exist. Thirty-eight biopsies containing prostate cancer were distributed for Gleason grading to 41 general pathologists in Georgia. These cases had "consensus" Gleason grade groups (2-4, 5-6, 7, and 8-10) that were agreed on by at least 7 of 10 urologic pathologists. The overall kappa (kappa) coefficient for interobserver agreement for these 38 cases was 0.435, barely moderate agreement, with a kappa range from 0.00 to 0.88. There was consistent undergrading of Gleason scores 5-6 (47%), 7 (47%) and, to a lesser extent, 8-10 (25%). In cases with consensus primary patterns, there was consistent undergrading of patterns 2 (32%), 3 (39%), and 5 (30%). Pattern 2 was often (17%) mistaken for pattern 3. Pattern 4 was often undergraded (21%) and also mistaken for pattern 5 (17%). The most significant (P < .005) demographic factor associated with better interobserver agreement was having learned Gleason grading at a meeting or course. We believe that Gleason grading can be learned to a satisfactory level of interobserver reproducibility and have undertaken additional studies that support this belief.

Humans↗
PubMed2001

Atypical cribriform lesions on prostate biopsy.

Atypical cribriform lesions on prostate needle biopsy specimens are rare and difficult to diagnose. Of 574 high-grade prostatic intraepithelial neoplasia (PIN) lesions on needle biopsy seen at our institution over 75 months, we identified 23 consult cases in which the differential diagnosis was cribriform high-grade PIN versus infiltrating cribriform carcinoma. Prebiopsy prostate-specific antigen (PSA) averaged 6.5 ng/mL (range, 0.3 to 37.3). A positive digital rectal examination (DRE) was present in 12 of 22 (55%) patients for whom information was available. Ordinary high-grade PIN was present elsewhere in the biopsy specimens in 32% of cases. The following architectural features of cribriform glands were evaluated: number (mean, 5; range, 1 to 21); largest size (mean, 0.5 mm; range, 0.1 to 1 mm); necrosis (14%); detached cribriform fragments (18%); stromal fibrosis (18%); and bilaterality (22%). Cytologically, there was cellular maturation toward the center of the cribriform glands (45%); identifiable basal cells on hematoxylin and eosin sections (36%); marked nuclear atypia (9%); and mitoses (23%). Nucleoli were not visible in 18% of cases, small in 36%, and prominent in 45%. With a mean follow-up of 13.8 months for those without progression (25.9 months' overall follow-up), a repeat biopsy diagnosis of cancer was seen in 10 of 22 men [by report: Gleason score (Gs) 4 (n = 1); Gs 6 (n = 3); Gs 7 (n = 4); Gs 9 (n = 2); three biopsy specimens showed ductal features]. An additional two men developed bone metastases without biopsy. Overall, 12 of 22 (55%) patients had cancer on follow-up (one patient lost to follow-up). Four clinicopathologic findings predicted carcinoma on follow-up: positive DRE (p = 0.02); positive transrectal ultrasound (p = 0.02); bilateral atypical cribriform glands (p = 0.02); and detached cribriform glands (p = 0.04).

Adenocarcinoma↗
PubMed2001

Isolated local recurrence is rare after radical prostatectomy in men with Gleason 7 prostate cancer and positive surgical margins: therapeutic implications.

PURPOSE: We determined whether the high biochemical failure rate in men with Gleason score 7 disease and positive surgical margins after radical retropubic prostatectomy is secondary to distant metastasis or to local tumor recurrence that could be eliminated by immediate adjuvant radiation therapy. MATERIALS AND METHODS: Between 1982 and 1997, 112 men with Gleason score 7 disease and positive surgical margins but no seminal vesicle or lymph node involvement underwent radical retropubic prostatectomy without immediate adjuvant radiation or hormonal therapy. Median followup was 8 years (range 1 to 16) and 45 men (40%) were followed 10 years or more. Kaplan-Meier actuarial survival estimates were used to determine the actuarial 5 and 10-year post-prostatectomy, and 5-year post-radiation recurrence rates. RESULTS: The actuarial 5 and 10-year post-prostatectomy biochemical, local and distant recurrence rates were 40% and 52%, 6% and 6%, and 7% and 16%, respectively. For 20 men who received radiation therapy for isolated prostate specific antigen elevation actuarial 5-year post-radiation biochemical recurrence-free rate was 34%. For 5 men who received radiation therapy for local recurrence actuarial 5-year post-radiation biochemical recurrence-free rate was 20%. CONCLUSIONS: Isolated clinical local recurrence is rare during long-term followup of men with Gleason score 7 disease and positive surgical margins at radical prostatectomy. Radiation therapy given at prostate specific antigen elevation poorly controlled the disease. Because patients with biochemical failure rarely had local recurrence at long-term followup, they most likely harbored subclinical distant metastasis. These data suggest that immediate adjuvant radiation therapy will not have a major impact on outcome because most men with Gleason score 7 disease and positive surgical margins in whom treatment fails most likely had distant metastasis at surgery. To improve the outcome in cases of Gleason score 7 disease and positive surgical margins a systemic approach to adjuvant therapy is necessary.

Aged↗
PubMed2000

A neural network predicts progression for men with gleason score 3+4 versus 4+3 tumors after radical prostatectomy.

OBJECTIVES: To determine the significance of Gleason scores 3+4 (GS3+4) versus 4+3 (GS4+3) with respect to biochemical recurrence in a retrospective review of a series of men with clinically localized prostate cancer who underwent radical retropubic prostatectomy (RRP) and to develop and test an artificial neural network (ANN) to predict the biochemical recurrence after surgery for this group of men using the pathologic and clinical data. METHODS: From 1982 to 1998, 600 men had pathologic Gleason score 7 disease without lymph node or seminal vesicle involvement. We analyzed the freedom from biochemical (prostate-specific antigen) progression after RRP on 564 of these men on the basis of their GS3+4 versus GS4+3 (Gleason 7) status. The Cox proportional hazards model was used to determine the importance of Gleason 7 status as an independent predictor of progression. In addition, an ANN was developed using randomly selected training and validation sets for predicting biochemical recurrence at 3 or 5 years. Different input variable subsets, with or without Gleason 7 status, were compared for the ability of the ANN to maximize the prediction of progression. Standard logistic regression was used concurrently on the same random patient population sets to calculate progression risk. RESULTS: A significant recurrence-free survival advantage was found in men who underwent RRP for GS3+4 compared with those with GS4+3 disease (P <0.0001). The ANN, logistic regression, and proportion hazard models demonstrated the importance of Gleason 7 status in predicting patient outcome. The ANN was better than logistic regression in predicting patient outcome, in terms of prostate-specific antigen progression, at 3 and 5 years. CONCLUSIONS: A simple modification of the Gleason scoring system for men with Gleason 7 disease revealed a difference in the patient outcome after RRP. ANN models can be developed and used to better predict patient outcome when pathologic and clinical features are known.

Disease Progression↗
PubMed2000

Molecular and immunohistochemical staging of men with seminal vesicle invasion and negative pelvic lymph nodes at radical prostatectomy.

BACKGROUND: Patients with seminal vesicle invasion (SVI) at radical retropubic prostatectomy (RRP) have a poor prognosis. Routine microscopic examination of pelvic lymph nodes (LNs) can miss small metastases and, thereby, confuse tumor staging and clinical decision-making. The authors used immunohistochemical and molecular methods to examine archival paraffin-embedded LNs of men who had undergone RRP for clinically localized prostate carcinoma and who had tumors demonstrating SVI and negative LNs at surgery. METHODS: Between June 1982 and June 1997, 2151 consecutive men underwent RRP for clinically localized prostate carcinoma. Of these, 109 (5.1%) tumors had SVI with negative LNs. The actuarial likelihood of having a tumor that was undetectable by testing prostate-specific antigen (PSA) 5 and 10 years after surgery was 45% and 29%, respectively, for men with isolated SVI. Archival LN specimens were available for 102 men who had isolated SVI. Reverse transcription polymerase chain reaction (RT-PCR) was performed for PSA and prostate-specific membrane antigen (PSMA). All specimens were examined concurrently by immunohistochemistry (IHC). RESULTS: Careful reevaluation of pelvic LNs demonstrated metastases in 9 (8.8%) men originally classified as metastasis-free. Reevaluation by hematoxylin and eosin (H&E) staining identified three previously unrecognized cases of LN metastases. IHC identified six cases, three of which were missed by H&E. RT-PCR identified four cases, three of which were not revealed by other methods. CONCLUSIONS: The poor prognosis of patients with SVI does not seem due to occult LN metastases. The low yield of unsuspected foci of prostate carcinoma in the LNs of men with SVI and negative LNs by routine staging does not justify IHC or molecular examination to find occult carcinoma.

Adult↗
PubMed2000

Papillary urothelial hyperplasia is a clonal precursor to papillary transitional cell bladder cancer.

Papilloma and papillary hyperplasia (PH) have been proposed to be the putative precursor lesions of papillary transitional-cell carcinoma of the urinary bladder. We examined 15 PH lesions and 4 papillomas for loss of heterozygosity (LOH) at 17 microsatellite markers on 9 chromosomal arms. Eight of 15 (53%) PHs were clonal, demonstrating LOH of at least 1 microsatellite marker. In contrast, none of the papillomas showed any genetic changes among the markers tested. In PH, chromosomal arm 9q was the most frequently lost (4/15), followed by 9p and 18q (n = 2) and, less frequently, 8p, 10q, 11p and 17p (n = 1). Furthermore, 2 hyperplastic lesions demonstrated LOH at 9q only, confirming the notion that allelic loss on chromosomal arm 9q is among the earliest events in bladder-cancer progression. In 1 patient, identical LOH patterns were observed between PH and a recurrent transitional-cell carcinoma. Our molecular data demonstrate that at least a proportion of PHs represent pre-cancerous lesions of the bladder that subsequently progress to papillary bladder cancer. Moreover, chromosomal arm 9q may harbor a tumor-suppressor gene(s) inactivated in the earliest stages of human bladder tumorigenesis.

Carcinoma, Transitional Cell↗
PubMed2000

Prognostic significance of Gleason score 3+4 versus Gleason score 4+3 tumor at radical prostatectomy.

OBJECTIVES: To determine the clinical significance of Gleason score 3+4 versus 4+3 on radical prostatectomy. METHODS: Of 2390 men who underwent radical prostatectomy by a single surgeon, 570 had Gleason score 7 tumors without lymph node metastasis, seminal vesicle invasion, or tertiary Gleason pattern 5. Patients were evaluated for biochemical recurrence (prostate-specific antigen progression) and distant metastases. RESULTS: Eighty percent of patients had Gleason score 3+4, 20% had 4+3. The rate of established extraprostatic extension at radical prostatectomy for Gleason score 3+4 and 4+3 tumors was 38.2% and 52.7%, respectively (P = 0.008). With a mean follow-up of 4.6 years for men without progression, Gleason score 4+3 tumors had an increased risk of progression independent of stage and margin status (P <0.0001). The 5-year actuarial risk of progression was 15% and 40% for Gleason score 3+4 and 4+3 tumors, respectively. The mean time to progression was 4.4 years for Gleason score 3+4 tumors and 3.2 years for Gleason score 4+3 tumors. We stratified the patients into four prognostic groups on the basis of organ-confined status, margin status, and Gleason score (3+4 versus 4+3). The 5-year actuarial risk of progression was 10%, 35%, 45%, and 61%, with 10-year progression rates of 29%, 42%, 69%, and 84%, for the four groups. 3.9% of patients with Gleason score 3+4 and 10. 5% with Gleason score 4+3 tumors developed metastatic disease within a mean of 5.7 and 5.6 years, respectively. A Gleason score of 4+3 versus 3+4 was predictive of metastatic disease (P = 0.002) but not local recurrence. CONCLUSIONS: Gleason score 7 tumors are heterogeneous in their biologic behavior. The differences in prognosis for patients with Gleason scores 3+4 and 4+3 tumors at radical prostatectomy are significant. Although the assessment of the percentage of pattern 4 at radical prostatectomy is not likely to be reproducible, the distinction between Gleason score 3+4 and 4+3 should be easier for pathologists to perform.

Actuarial Analysis↗
PubMed2000

A web-based tutorial improves practicing pathologists' Gleason grading of images of prostate carcinoma specimens obtained by needle biopsy: validation of a new medical education paradigm.

BACKGROUND: The Internet, although it is in widespread use in medicine, to the authors' knowledge has not been tested rigorously as an educational tool. The authors investigated, as a model to validate web-based education for physicians, the Gleason grading of images of prostate carcinoma tissue specimens that were obtained by needle biopsy, which provides critical information for patient management. METHODS: A free, web-based program (available at www. pathology.jhu.edu/prostate) was developed. It consisted of 20 pretutorial quiz images of prostate carcinoma specimens that were obtained by needle biopsy for grading, followed by 24 tutorial images with text describing the Gleason grading system. Subsequently, pathologists took a posttutorial quiz, which consisted of the same 20 images that were used in the pretutorial quiz. RESULTS: In 16 months, there were 2021 visits with 916 participants completing the entire web site; 643 participants (70.2%) were practicing pathologists and formed the basis of the current study. Only the location of practice within the United States compared with outside the United States (P < 0.0001) and < 5 years in practice (P = 0.003) were correlated independently with a higher pretutorial quiz score. Overall, the web-based tutorial significantly improved grading in 15 of 20 images. Of these, on average, there was an 11.9% increase (range, 6-25.3%) in assigning the correct Gleason score. Improvements were noted in images of tumors with the following grades: Gleason score, 2-4 (0 of 1 images); Gleason score, 5-6 (5 of 7 images); Gleason score, 7 (4 of 6 images); and Gleason score, 8-10 (6 of 6 images). Greater improvement after taking the tutorial was correlated with lower pretutorial scores (P < 0.0001). CONCLUSIONS: A web-based tutorial improves the accuracy of Gleason grading of practicing pathologists. To the authors' knowledge the current study is the first large scale, international study that has evaluated and validated the use of a web-based program to educate a population of widely dispersed physicians.

Biopsy, Needle↗
PubMed2000

Adenocarcinoma of the prostate invading the seminal vesicle: prognostic stratification based on pathologic parameters.

OBJECTIVES: To stratify the prognosis of lymph node-negative, seminal vesicle-positive tumors in men with prostate cancer after radical retropubic prostatectomy. METHODS: Sixty cases were analyzed for multiple parameters and correlated with postoperative biochemical (prostate-specific antigen) progression. Variables included Gleason score, primary Gleason pattern, percentage of Gleason pattern 4, any presence of Gleason pattern 5, method of seminal vesicle invasion (SVI), margin positivity, SVI extent, SVI bilaterality, vascular invasion, extent of extraprostatic extension, length of tumor extending along the seminal vesicles, presence of intraductal carcinoma within the prostate, bladder neck margin positivity, and tumor volume. RESULTS: We were able to stratify the prognosis based on the combination of a variation of the Gleason score and margin status and vascular invasion status. Using this stratification, a few patients had an excellent long-term prognosis, with most patients split into two groups, one experiencing rapid and the other slower progression. CONCLUSIONS: SVI is not associated with a uniformly poor prognosis. Rather, tumors can be substratified by pathologic parameters into groups with differing prognoses based on routine histologic examination.

Adenocarcinoma↗
PubMed2000

Molecularly confirmed primary prostatic synovial sarcoma.

We report the second molecularly-confirmed primary prostatic synovial sarcoma. The diagnosis was particularly elusive at the light microscopic level in that the tumor failed to show epithelial differentiation, but it did show combined spindle-cell and poorly differentiated (round-cell) morphologies. The immunohistochemical staining profile was nonspecific and potentially misleading. Only by demonstration of the characteristic SYT-SSX gene fusion of synovial sarcoma by reverse transcriptase polymerase chain reaction (RT-PCR) analysis of RNA extracted from archival material could the diagnosis be confirmed. This case further illustrates the use of this technique in diagnostic pathology.

Adult↗
PubMed2000

Needle biopsy of recurrent adenocarcinoma of the prostate after radical prostatectomy.

The objective of this study was to evaluate needle biopsy of recurrent prostate cancer after radical prostatectomy. We evaluated 37 cases of recurrent prostate cancer after radical prostatectomy that were diagnosed by needle biopsy between March 1984 and July 1998. Fifteen were from consultations in which contributors were uncertain of the diagnosis, and 22 were from men who had come to The Johns Hopkins Hospital for treatment. The median interval from radical prostatectomy to biopsy showing recurrent tumor was 40 months. There was no correlation between the interval to recurrence and either pathologic features of the biopsy and radical prostatectomy or various clinical features. The mean extent of adenocarcinoma in the biopsies was 3.2 mm (range, 0.1 to 18 mm; median, 2 mm). The length of recurrent cancer on biopsy correlated with an abnormal rectal examination (P = .001). The mean Gleason score for the recurrent tumors was 6.5, which correlated with the grade of the radical prostatectomy cancer (P = .005). The cancers often lacked overt histologic features of malignancy. Benign prostatic acini were seen in five cases (14%), usually separate from the cancer. In 5 (33%) of the consultation cases, we would not have been able to diagnose cancer if not for the fact that atypical prostate glands should not be present after radical prostatectomy. In well-sampled radical prostatectomies, margins were almost always positive, as was extraprostatic extension. In cases with less sampling, there was a higher incidence of organ-confined disease and margin-negative disease implying suboptimal processing of the radical prostatectomy. After radical prostatectomy, recurrent cancer on needle biopsies may be focal and difficult to diagnose and must be assessed differently than in patients who have not had surgery.

Adenocarcinoma↗
PubMed2000

Pathology residents' use of a Web-based tutorial to improve Gleason grading of prostate carcinoma on needle biopsies.

Little is known about pathology residents' ability to Gleason grade or their ability to learn surgical pathology using Internet-based technology. A free Web-based program (available at www.pathology. jhu.edu/prostate) was developed that consisted of 20 pretutorial images for grading, 24 tutorial images, and the same 20 posttutorial images for Gleason grading. The grading images were selected from cases that had a consensus Gleason grade from 10 uropathology experts. In 2.5 months, 255 residents visited the website, and 151 (59%) completed it. Of those who completed the website, their year in training was known in 85 (56%): 1st year, 25.8%; 2nd year, 20%; 3rd year, 22.3%; 4th year, 14.1%; 5th year, 15.3%; and 6th year, 2.4%. Eighty percent learned Gleason grading in residency versus being self-taught, and 66% were male. In a multivariate analysis, higher pretutorial scores were associated with both their year in training (P = .001) and their hospital size (P = .003). Improvements in grading posttutorial were not related to the residents' year in training. Overall, the website significantly improved grading in 11 of 20 images and had no effect in 9 of 20 images. Improvements were noted in 1 of 1 Gleason score 4; 2 of 7 Gleason score 5 to 6; 2 of 6 Gleason score 7; and 6 of 6 Gleason score above 7 tumors. In summary, a Web-based tutorial improved Gleason grading accuracy by pathology residents to an equal extent regardless of their year in training. It is more difficult to teach residents to grade Gleason scores 5 to 7 tumors, and additional training should be concentrated in this area.

Biopsy, Needle↗
PubMed2000

Efficacy of restaining prostate needle biopsies with high-molecular weight cytokeratin.

Prostate tissue and lesions obtained by needle biopsy may be scant and not survive cutting into the block; this study examined the efficacy of destaining hematoxylin and eosin-stained sections and restaining the slides using immunohistochemistry with high-molecular weight cytokeratin (high-molecular weight cytokeratin). We identified 105 prostate needle biopsies referred to Johns Hopkins Hospital in an 18-month period (January 1997-June 1998) that had been destained and restained for high molecular weight cytokeratin. The slides were reviewed for the Johns Hopkins Hospital diagnosis (benign, malignant, or equivocal), which had factored in the immunohistochemistry results, and for immunohistochemistry staining quality (optimal, suboptimal, stain failed, or lesion fell off). We obtained data on 96 cases from the referring institutions about the fixative and glass slides used for processing the needle biopsy. In 58% of cases, destaining and restaining with high-molecular weight cytokeratin allowed a definitive benign or malignant diagnosis to be made; in 79% of these cases, the staining was optimal. In only 13% of cases the diagnosis remained equivocal; of these, the stain worked optimally in only 36%. In 19% of cases, the stain failed. In 9% of cases, the lesion fell off; in all 7 cases with available data the tissue had been cut on non-charged slides. All but 3 cases were received in 10% neutral buffered formalin. There was no correlation between the use of charged (plus or lysine coated) or non-charged slides and the staining quality. Furthermore, in 12 instances, we received more than 1 specimen from the same referring institution, and in 6 of these instances there was variable staining in the different cases from the same institution. Destaining hematoxylin and eosin-stained slides and restaining for high-molecular weight cytokeratin is a useful technique that in the majority of cases enables a definitive diagnosis to be made. Tissue may survive the procedure better if originally cut on charged slides, but staining quality is no different for charged or non-charged slides.

Adenocarcinoma↗
PubMed2000

Foamy gland high-grade prostatic intraepithelial neoplasia.

A 60-year-old man underwent radical prostatectomy for biopsy-proved adenocarcinoma of the prostate. Histologic examination of the entirely embedded prostatectomy specimen revealed extensive ordinary adenocarcinoma, Gleason's grade 3 + 3 = 6, involving both sides of the gland, and extending into extraprostatic soft tissue at the left base. Adjacent to the carcinoma, and separately, extensive high-grade prostatic intraepithelial neoplasia (PIN) was identified, much of which showed bland nuclei and abundant xanthomatous cytoplasm, identical morphologically to that seen in foamy gland prostate carcinoma. However, unlike foamy gland carcinoma, the foamy glands in the current patient were large, showed papillary infolding, and were associated with a discontinuous layer of basal cells, demonstrated by immunostaining for high-molecular weight cytokeratin. No invasive foamy gland carcinoma was identified in the prostatectomy specimen. Immunostains for Ki-67 showed an increased proliferation rate in foamy high-grade PIN glands when compared with adjacent benign glands. Review of additional outside biopsy material revealed foamy gland high-grade PIN on four of seven needle cores, two of which showed no carcinoma. This patient demonstrates a new subtype of high-grade PIN that is difficult to recognize on needle biopsy. It is important to distinguish foamy gland high-grade PIN from its infiltrating counterpart, and it is critical to recognize because of the association of high-grade PIN with prostate carcinoma.

Adenocarcinoma↗
PubMed2000

The prognostic significance of tertiary Gleason patterns of higher grade in radical prostatectomy specimens: a proposal to modify the Gleason grading system.

The Gleason grading system of prostatic adenocarcinoma does not account for the existence of a tertiary (third most prevalent) pattern, and there are no studies concerning the latter's prognostic influence. The authors analyzed 114 radical prostatectomies with small tertiary components, which mostly occupied less than 5% of whole tumors. These specimens were compared with a prostatectomy database comprised of 2,276 cases without a tertiary component. The pathologic stages of "typical" Gleason score 5 to 6 tumors (Gleason scores 2 + 3 = 5, 3 + 2 = 5, 3 + 3 = 6), which contained tertiary patterns 4 or 5, were significantly higher than those of "typical" Gleason score 5 to 6 tumors without pattern 4 (p = 0.018) but lower than those of "typical" Gleason score 7 tumors (p = 0.021; Gleason scores, 3 + 4 = 7, 4 + 3 = 7). Typical Gleason score 7 tumors with a tertiary pattern 5 showed significantly worse pathologic stages than typical Gleason score 7 tumors (p = 0.008) without pattern 5 and were not different statistically from typical Gleason score 8 (Gleason score, 4 + 4 = 8) tumors. Both typical Gleason score 5 to 6 and 7 tumors with tertiary components revealed significantly higher progression rates than typical Gleason score 5 to 6 tumors (p <0.0001) and Gleason score 7 tumors (p = 0.003) without tertiary components, and progressed like typical Gleason score 7 and 8 tumors respectively. Tertiary high-grade components have an adverse impact on biologic behavior. The authors propose that the Gleason system for radical prostatectomy specimens be modified to take into account small volumes of patterns 4 and 5, which are important prognostically.

Adenocarcinoma↗