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The continuing importance of primary Gleason pattern 4 in Gleason 7 prostate cancer

Posted Jan 06 2011 12:00am

It has long been understood that men with a Gleason score (GS) of 7 could be divided into two groups: those with Gleason 4 + 3 disease (in which Gleason pattern 4 was more common or “dominant”) and those with Gleason 3 + 4 disease (in which Gleason pattern 3 was dominant).

It was first suggested many years ago that Gleason 4 + 3 = 7 disease was associated with a higher risk of progression over time than Gleason 3 + 4 = 7 disease, and clinicians have been taking account of this factor in their prognostic and management decisions ever since. However, it is gratifying to see that this trend continues to be true even in a much more modern series of patients.

Alenda et al. have reported data on the impact of the primary Gleason pattern on biochemical progression-free survival (bPFS) after radical prostatectomy (RP) in a series 2,239 patients all treated for localized prostate cancer at a single center in France between 1998 and 2008. Biochemical recurrence in these patients was defined as a PSA level > 0.2 ng/ml at any time after surgery.

The results of their study show that:

  • 1,248/2,239 patients had an actual GS of 7 based on their post-surgical pathology.
  • Median postoperative follow-up was 23.4 months.
  • 721/1,248 patients (57.8 percent) had a final GS of 3 + 4
  • 527/1,248 patients (42.2 percent) had a final GS of 4 + 3.
  • Patients with GS 4 + 3 had a significantly higher risk of biochemical progression than those with GS 3 + 4 (P < 0.001).
  • The 3- and 5-year bPFS for patients with GS 3 + 4 cancers were 84.6 and 76.4 percent, respectively
  • The 3- and 5-year bPFS for patients with GS 4 + 3 cancers were 69.9 and 61.1 percent, respectively.
  • When analysis was stratified by both pathologic stage and margin status

The authors conclude that in their modern series of patients, a primary Gleason pattern of 4 after radical prostatectomy remains a significant predictor for biochemical progression within 2 years of their surgery, compared to a primary Gleason pattern of 3 in men with GS 7 disease.

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