title: Should we replace the Gleason score with the amount of high-grade prostate cancer?
abstract: OBJECTIVE
  The stage and grade shift of currently diagnosed prostate cancer has led to a diminished prognostic power of the Gleason score system. We investigated the predictive value of the amount of high-grade cancer (Gleason growth patterns 4/5) in the biopsy for prostate-specific antigen (PSA) and clinical relapse after radical prostatectomy.
  
  
  METHODS
  PSA-tested participants (N=281) of the European Randomized Study of Screening for Prostate Cancer (ERSPC) who underwent radical prostatectomy were analyzed. Besides clinical features, and serum-PSA, histopathologic features as determined in the diagnostic biopsy and matching radical prostatectomy specimen were related to patient outcome.
  
  
  RESULTS
  At a median follow-up of 7 yr, 39 (13.9%), 24 (8.5%), and 12 (4.3%) patients had PSA >/=0.1 ng/ml, PSA >/=1.0 ng/ml, and clinical relapse after radical prostatectomy, respectively. Using Cox proportional hazards, PSA level (p=0.002), length of tumour (p=0.040), and length of high-grade cancer (p=0.006) in the biopsy, but not Gleason score, were independent prognostic factors for biochemical relapse (PSA >/=0.1 ng/ml) when assessed as continuous variables. In radical prostatectomies, the proportion of high-grade cancer (p<0.001) was most predictive of relapse (PSA >/=0.1 ng/ml). For PSA >/=1.0 ng/ml and clinical relapse, the amount of high-grade cancer, both in the biopsy specimen (p=0.016 and p=0.004, respectively) and radical prostatectomy specimen (p=0.002 and p=0.005, respectively), but not Gleason score, was an independent predictor.
  
  
  CONCLUSIONS
  In biopsy and radical prostatectomy specimens of surgically treated prostate cancer, the amount of high-grade cancer is superior to the Gleason grading system in predicting patient outcome. We propose that, in addition to the Gleason score, the amount of Gleason growth patterns 4/5 in the biopsy (whether absolute length or proportion) should be mentioned in the pathology report.
authors.affiliation: Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands. a.vis@erasmusmc.nl
authors.forename: André N
authors.initials: AN
authors.lastname: Vis
authors.forename: Stijn
authors.initials: S
authors.lastname: Roemeling
authors.forename: Ries
authors.initials: R
authors.lastname: Kranse
authors.forename: Fritz H
authors.initials: FH
authors.lastname: Schröder
authors.forename: Theo H
authors.initials: TH
authors.lastname: van der Kwast
mesh_terms: D000368:Aged; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000097:blood / Q000453:epidemiology; D011379:Prognosis; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology* / Q000601:surgery*
chemical_list: D017430:Prostate-Specific Antigen