title: Tertiary Gleason pattern 5 in Gleason 7 prostate cancer predicts pathological stage and biochemical recurrence.
abstract: OBJECTIVE
  Gleason sum 7 prostate cancers are a heterogeneous group with diverse tumor behaviors and disease outcomes. Tertiary Gleason patterns are reported with increasing frequency, particularly in prostatectomy pathology reports. We studied the pathological and biochemical outcome following radical prostatectomy in men with Gleason sum 7 and tertiary Gleason pattern 5.
  
  
  METHODS
  We reviewed 1,110 cases of clinically localized prostate cancer treated with primary radical prostatectomy between January 1998 and August 2006 through a prospectively collected prostate cancer database. Patients who underwent neoadjuvant or adjuvant hormonal deprivation, radiation or systemic chemotherapy were excluded.
  
  
  RESULTS
  Of the 1,110 patients 509 had Gleason sum 7 cancer. Tertiary Gleason pattern was present in 66 of 509 cases (13%) and it was absent in 443 (87%). On multivariate analysis tertiary Gleason pattern 5 was associated with higher pT stage (OR 2.55, 95% CI 1.40-4.65) and biochemical recurrence (HR 1.78, 95% CI 1.00-3.17). On subgroup analysis when patients with Gleason sum 3 + 4 + 5 and 4 + 3 + 5 were compared to their respective referent groups without the tertiary Gleason pattern, the 2 groups showed a trend toward higher pathological stage and prostate specific antigen progression. Patients with Gleason sum 3 + 4 with no tertiary pattern had higher PSA recurrence-free probability than those with Gleason sum 3 + 4 + 5 or 4 + 3 and patients with Gleason sum 4 + 3 + 5 had the lowest PSA recurrence-free probability.
  
  
  CONCLUSIONS
  In patients with Gleason sum 7 prostate cancer tertiary Gleason grade 5 is significantly associated with higher pT stage and biochemical recurrence. Larger studies are needed to assess the predictive value of tertiary grade compared to other established parameters in predicting the long-term oncological outcome after radical prostatectomy.
authors.affiliation: Department of Urology, University of Washington, Seattle, Washington 98195, USA.
authors.forename: Hong Gee
authors.initials: HG
authors.lastname: Sim
authors.forename: Donatello
authors.initials: D
authors.lastname: Telesca
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Culp
authors.forename: William J
authors.initials: WJ
authors.lastname: Ellis
authors.forename: Paul H
authors.initials: PH
authors.lastname: Lange
authors.forename: Lawrence D
authors.initials: LD
authors.lastname: True
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Lin
mesh_terms: D000368:Aged; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D017430:Prostate-Specific Antigen / Q000097:blood*; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology* / Q000601:surgery; D012008:Recurrence
chemical_list: D017430:Prostate-Specific Antigen