title: Clinical significance of prospectively assigned Gleason tertiary pattern 4 in contemporary Gleason score 3+3=6 prostate cancer.
abstract: OBJECTIVE
  To determine the oncologic impact of prospectively assigned tertiary pattern 4 in contemporary Gleason score (GS) 3 + 3 = 6 radical prostatectomy (RP) specimens.
  
  
  METHODS
  Oncologic outcomes were retrospectively reviewed for 720 consecutive patients from a single National Comprehensive Cancer Network (NCCN) center with at least 6 months follow-up after RP for GS3 + 3 = 6 (GS6, N = 222), GS6 with tertiary pattern 4 (GS6t4, N = 62), or GS3 + 4 = 7 (N = 436) prostate cancer, as prospectively graded since 2006 using the 2005 International Society of Urologic Pathologists criteria. Preoperative NCCN risk category, RP pathology, progression-free survival (PFS) and metastasis-free survival (MFS) were compared among the GS6, GS6t4, and GS3 + 4 = 7 groups using χ(2) , Kaplan-Meier, and log-rank analyses.
  
  
  RESULTS
  The incidence of low NCCN preoperative risk classification for GS6t4 patients (63%) was less than that for GS6 patients (77%) while greater than that for GS3 + 4 = 7 patients (30%, P < 0.001). GS6t4 patients had RP pathologic features which were intermediate in risk between that of GS6 and GS3 + 4 = 7 based on extraprostatic extension (27% vs. 6% vs. 31%, respectively, P < 0.001) and mean percentage of prostate gland involvement (13% vs. 10% vs. 16%, respectively, P < 0.001). With a mean overall follow-up of 42 months, PFS for GS6t4 patients (5-year 85%) was intermediate between that of GS6 (5-year 93%) and GS3 + 4 = 7 (5-year 76%) patients (P < 0.001). The 5-year MFS rate was 100% for GS6 and GS6t4 patients compared to 97% for GS3 + 4 = 7 patients (P = 0.07).
  
  
  CONCLUSIONS
  This study provides the longest follow-up to date for RP patients with prospectively assigned GS6t4 and supports a risk for adverse RP pathology and postoperative disease progression that is intermediate between GS6 and GS3 + 4 = 7. Whether a tertiary pattern 4 in GS6 disease increases the risk of metastasis is uncertain and requires longer term study. Given favorable oncologic outcomes, less stringent postoperative surveillance for both GS6 and GS6t4 patients may be warranted.
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Chirag
authors.initials: C
authors.lastname: Doshi
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Michael
authors.initials: M
authors.lastname: Vacchio
authors.affiliation: Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Kristopher
authors.initials: K
authors.lastname: Attwood
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Christine
authors.initials: C
authors.lastname: Murekeyisoni
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Diana C
authors.initials: DC
authors.lastname: Mehedint
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Shervin
authors.initials: S
authors.lastname: Badkhshan
authors.affiliation: Department of Pathology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Gissou
authors.initials: G
authors.lastname: Azabdaftari
authors.affiliation: Department of Pathology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Norbert
authors.initials: N
authors.lastname: Sule
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.|Department of Urology, University of Buffalo, Buffalo, New York.
authors.forename: Khurshid A
authors.initials: KA
authors.lastname: Guru
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.|Department of Urology, University of Buffalo, Buffalo, New York.
authors.forename: James L
authors.initials: JL
authors.lastname: Mohler
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.|Department of Urology, University of Buffalo, Buffalo, New York.|Department of Cancer Genetics, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Eric C
authors.initials: EC
authors.lastname: Kauffman
mesh_terms: D000368:Aged; D016208:Databases, Factual; D018450:Disease Progression; D018572:Disease-Free Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D011379:Prognosis; D011467:Prostate / Q000473:pathology*; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D012189:Retrospective Studies; D015996:Survival Rate
keywords: biochemical failure; prostate cancer; radical prostatectomy; tertiary Gleason pattern