Biopsy, Gleason and Your Prostate

"Free" PSA May Reduce Need for Some Prostate Cancer Biopsies May 20 1998 This article explains why follow-up tests should be done after the basic PSA test before a biopsy is undergone.

For Biopsy, Get Second Opinion (article, December 9 1999). This article remains relevant. If you receive news of a positive biopsy, make sure you get the pathology slides re-read by a specialist. No one should make decisions about cancer on the basis of a biopsy read by just one local pathologist. Some men have been over-treated and others under-treated because of poorly interpreted biopsy slides. Contacts for some highly-regarded second-opinion pathology laboratories are listed below.

If You Need a Biopsy

Prostate biopsy and other procedures are often done without pain relief. Some men are not bothered by the sensation of biopsy, some men complain of discomfort. A Scientific American editorial, A Real Pain August 2002, asks why this problem has not been solved.

Ask your doctor about lidocaine gel before the biopsy. Today some urologists offer their patients light sedation for this procedure.

Gleason grading system

This is used to grade how far prostate tissue is from normal, healthy tissue. After the doctor has taken biopsy samples of your prostate tissue, he or she sends them to a pathology lab. The pathologist looks at the samples under a microscope and grades the tissue on a scale of 1 to 5. The low number, 1, is for cells that look almost normal (very slow growing cancer). The high number, 5, is for cells that are least like normal prostate cells. Grades 2 to 4 fall in between.

Prostate cancer tumors often have areas of various grades. The pathologist identifies the two most prevalent grades. These are then added together to make the Gleason score (also called Gleason sum).

A result may look like one of these (not all possible combinations are displayed here):

3 + 2 = 5 or
2 + 3 = 5

3 + 3 = 6

3 + 4 = 7 or
4 + 3 = 7

4 + 4 = 8 or
3 + 5 = 8

4 + 5 = 9 or
5 + 4 = 9

The order of the numbers matters and can affect treatment outcomes.

The 1st number is the predominant grade and must be more than 51% of the sample. The second number is the sceondary grade and must make up more than 5% but less than 50% of the sample

A Gleason score (or sum) of 3 + 4 = 7 is a different grade of cancer than 4 + 3 = 7.

In a grade 7 made up of 3 + 4, most of the cancer found is moderately aggressive (3), with less that is more aggressive (4).

In a grade 7 made up of 4 + 3, the balance has tilted. The patient may need more aggressive treatment.

diagram

The Gleason grading system is named after Dr Donald F Gleason, the doctor who formulated it along with members of the Veterans Administration Cooperative Urological Research Group.

Normal body tissue cells are well-formed and differentiated to fit the functions of the specific body part. As you see in this image above, cells at the far right end (5) are quite shapeless and random compared to the moderately differentiated cells in the middle and the quite regular-looking cells at the left (1).

A small tumor with nearly normal structure (well differentiated) will behave in a more normal biological way. It may grow very slowly, with a doubling time of many years, and might never become a serious threat to health. A tumor that is moderately differentiated or undifferentiated is faster growing and more likely to spread.

High-grade tumor cells, having lost the special structure, or "architecture," that made them work as part of the prostate gland, may not even put out much PSA. This is one reason the Gleason grade and score are such key pieces of information for making treatment decisions.

A second opinion reading of the biopsy slides is highly recommended. Treatment decisions depend heavily on the accuracy of the tumor grade; and reading these slides is a highly-trained skill, or an art.

Pathologists at most leading cancer centers do second opinion prostate biopsy readings. Here are three in the USA (these links are unsolicited, based on the reputations of these labs):

Urologic Pathology Laboratory Johns Hopkins Hospital is a nationally recognized center for prostate biopsy and study of urologic disorders. Vast expertise in the study and diagnosis of the pathology of prostate cancer. Primary consultant, Dr. Jonathan Epstein. Check the web page and call

1-800-997-5475

Bostwick Laboratories (David G. Bostwick, M.D., M.B.A.) is a pathology reference laboratory serving patients as well as physicians and managed care. Services include Primary Biopsy Interpretation; Second Opinion; DNA Ploidy Analysis; Immunohistochemistry (markers include p53, c-myc, and bcl-2 oncogene and tumor suppressor gene products and CD34 angiogenesis marker). Dr. Bostwick is one of the authors of the ACS book Prostate Cancer, What Every Man - and His Family - Needs to Know (1996, 1999, Villard, New York, $14.95).

Memorial Sloan-Kettering Pathology: detailson service and how to download a form if you or your local doctor wants to "send slides or samples to Memorial Sloan-Kettering for consultation."

The Prostate Lab (Dr. Jonathan Oppenheimer)
Second Opinion on Biopsy Slides, Biopsy Evaluation (Primary Opinion), Prognostic Evaluation of Radical Prostatectomy Specimen, Prognostic Testing (Ploidy, BCL2 p53, p27, p21) and other services.

Learn More About Biopsy

Prostate Pathology Tutorial with a tables of prostate cancer staging (American Urological Society Clinical Staging) and a series of large images of biopsy slides showing normal prostate tissue, prostatitis, benign disease (BPH, or benign hyperplasia), high grade PIN, and grades of cancer (adenocarcinoma).
From The Internet Pathology Laboratory, WebPath, at medstat.med.utah

Partin Tables. Use these tables to predict the probability that prostate cancer has spread out of the capsule of your prostate into the lymph nodes. The results are based on your input of your Gleason score, your PSA value, and your clinical stage

Biopsy and Your Prostate

Before You Get a Biopsy

If You Need a Biopsy

Gleason grading system

Learn More About Biopsy

Prostate Cancer Basics