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Gleason Grading Explaination

I haven't seen Gleason Grading explained this way before so I thought I'd post it in case others felt it was useful to see. I'll put what I'm talking about in BOLD.

I don't know how knowledgeable the writer is but I thought the explanation of how cancer cells looked was interesting. If anyone has more information on how cancer cells look please chip in your knowledge.

The Stranger

QUOTE:

Not all prostate cancer is equal. One type of tumor may lie dormant for years while another is virulent and deadly. Deciding whether to wait or act can be difficult because physicians often can't judge conclusively which tumors might spread. Size can give some indication. Another gauge, the Gleason system, identifies a tumor's growth potential based on its appearance under the microscope. The system distinguishes progressive grades of prostate cancer on a scale of 2 to 10. Clumped-together cancer cells with well-defined edges are less likely to grow rapidly and are given a low Gleason number. Cells distributed randomly with uneven edges are more apt to spread and receive a high Gleason number.

Article Link

Re: Gleason Grading Explaination

That’s an old study - 15 years old!! I see it refers to the ‘ new’ PSA tests. One of the interesting aspects of those old articles is how far out their estimates always were. This one says The American Cancer Society says prostate cancer will strike 334,500 U.S. men in 1997, twice the number of male lung cancer cases. Some 41,800 will die. Those figures were not reached in 1997 and in fact the numbers never got that high

For a visual of how cancer cells may look go along to DIAGNOSIS and click on the relvant link that will take you to PROSTATE LAB At the bottom of that page there is a link to PROSTATE GALLERY which has pictures that I have never been able to interpret

Time and again newly diagnosed men are urged to get a second opinion on their biopsy results from an expert pathologist before making a firm decision on their choice of treatment ( some of these experts are listed here RECOGNISED EXPERT PATHOLOGISTS )

The reason for this is that the Gleason score is a critical item in the diagnostic process because it may indicate the aggressiveness of the disease. It is used as a variable in virtually every prognostic and treatment algorithm and thus is used as a guide to what may potentially be the best choice of treatment. But the allocation of grades to tumours is subjective – one well known pathologist was quoted as saying “Tell me what Gleason Score you want and I’ll tell you which pathologist to approach.”

It is often said that Gleason Scores following the dissection of a prostate gland after surgery are inevitably higher than those obtained through needle biopsy. It is indeed true that this is the case in some instances, but, as many studies show, there are often equal numbers of instances where the Gleason Score post surgery is in fact lower and, regrettably a small number of cases where it is found that the biopsy report was incorrect and no cancer cells are found after the surgical removal of the gland.

Two stories published on my website in the past year underline the importance of getting expert opinions on pathology reports. The first, told by DAVE MARTINEZ He was fortunate in that the institution he chose for his laparoscopic surgery checked path slides before commencing any procedure and a week before he was due to have his surgery he was told that he did not have prostate cancer, a diagnosis confirmed by a fourth pathologist after a second biopsy.

The second story is still in development; it is that of DAVID MILLER David duly sent his slides to an expert pathology lab and the initial diagnosis was confirmed. However when a third lab reviewed the slides they were of the opinion that there was no cancer. David too had a second biopsy, which was also said to be negative – he is now, somewhat bemusedly waiting for the new slides to be reviewed.

I am not certain that this information will give much comfort to the newly diagnosed, but I believe that they should be made aware of the issue and take appropriate action.

Re: Re: Gleason Grading Explaination

Terry,

Thanks for all the information. I seen the diagnosis page shortly after I found your site and it's filled with useful information. I think everyone should read it when they find yananow.

I've never been able to make anything from the pictures of prostate tissue either and looking at them definitely makes me understand why an EXPERT pathologist is necessary to get a good reading. In fact as you've shown, a second and third opinion is necessary. And that's a scary thing, imagine getting your post op report of NO CANCER.

I found that article while I was looking for something else but clicked on the link to see what was there. The only thing I took from the article is how the person said cancer cells looked and I wanted to share that part. Looking back at it this morning after reading your post I realize it's very old like you pointed out.

The Stranger

Re: Gleason Grading Explaination

I carry in mind that the aggressiveness of the cancer is indicated by the Gleason score yet we also read of the PSA doubling time being an indicator of aggressiveness. Surely the two go hand in hand to some extent, but still they are different. I've never seen any comprehensive explanation which encompasses both these factors.

Re: Re: Gleason Grading Explaination

Bill,

As I understand it, the standard theory goes along these lines:

1. Normal cells are well differentiated and should not ‘leak’ PSA into the bloodstream

2. Tumour cells are not well differentiated (just how badly they are de-differentiated is what the Gleason Grading system tries to define) and as their structure collapses, more PSA enters the bloodstream

3. A high Gleason Score is allocated to the tumour cells that are the least well defined – and therefore which leak most PSA

4. Cells with a high Gleason Score multiply more rapidly – and are therefore designated as being aggressive – than those with a low Gleason Score and therefore

5. As the number of tumour cells multiplies and multiplies the PSA generated by these cells increases more and more rapidly

So, on the basis of this theory, it will be seen that high Gleason Scores are often (but not always) associated with short doubling times and vice versa – rapid doubling times are often (but not always) indicative of a more aggressive tumour.

As ever with prostate cancer, there are however many, many exceptions, the most dangerous of which (in a business that depends so much on PSA numbers for decision making) is the very aggressive tumour – Gleason Score 8 and above usually – which generates very little PSA. These tumours will initially generate so little PSA that they will only be discovered by DRE (Digital Rectal Examination), which is one of the reasons that a good directive on PCa diagnosis will emphasise annual DRE plus PSA.

The usual explanation given as to what appears to me to be a logical inconsistency here is that a high grade tumour generating a low volume of PSA is that these cells have degenerated so far that they are no longer capable of creating PSA. To which I have always said…..”Hmmmmmm. Maybe.”

Anyway, that’s my understanding of the issues in a nutshell. My personal view is that the discrepancies in outcomes are more likely to be accounted for by different strains of the disease we now call ‘prostate cancer.’ There is already a suggestion that two genetic structures associated with breast cancer may also be indicative of a greater proclivity towards prostate cancer in men. This newspaper article gives a general overview Gene Mutations Increase Risk For Aggressive Prostate Cancer but there are studies that define the issues more accurately. And when you read up the mouse experiments you will often find reference to different strains of cancer – which unsurprisingly, behave in different ways. Yet the prostate industry continues to treat most cancers the same way without trying to establish any kind of differentiation, which is why Dr Strum despairs and Dr Myers says As a physician, I am painfully aware that most of the decisions we make with regard to prostate cancer are made with inadequate data

I have seen small movements over the past twelve years towards a better diagnosis, towards a slwoing of the all too rapid dash to treatment that is such a feature of current diagnosis and treatment, but the progress is painfully slow. To quote another well known doctor – Dr Stamey “I believe that when the final chapter of this disease is written, which is unlikely to be in my lifetime, never in the history of oncology will so many men have been so overtreated for one disease.

I guess, having reviewed this bit, it may seem that I am a bit down today – and I am. It is as hot as…..here for the third day in succession (Yesterday it hit 43C / 110F and even last night only dropped to 34C/92F ) and the medication for my heart condition makes it extremely difficult for me to deal with extreme changes. But that’s not the main reason. I have been in correspondence with a young lady who mailed me for help. Her father is in his 70s, he has a diagnosis that indicates an insignificant tumour if there ever was one, they haven’t read a darn thing I sent them and he is having surgery – unwarranted in my opinion – in less than four weeks of being diagnosed.

I have said time and again that we must each make the decision that suits us, but that decision should be based on gathering appropriate information, not being stampeded into treatment that is likely to do more harm than good.

Apologies for the rant – but I just have to get these things off my chest from time to time :- )

All the best

Terry in Australia

Re: Gleason Grading Explaination

I have experienced this Gleason subjectivity directly.

I was initially diagnosed in August 2008 with 3 biopsy cores positive

The first lab saw my cancer as:

mid apex 3+4 80%
left apex 3+4 30%
right mid 3+4 20%

Then I sent my biopsy slides to a second prestigious pathologist in New York. The results were:

mid apex 4+4 75%
left apex 4+3 30%
right mid 4+3 15%

My PSA is 2.1 but based upon the upgraded Gleason score I was designated "high risk" and chose HT/Brachytherapy/EBRT as my treatment.

I am still "twisted" by the difference in interpretation. One week I'm 3+4 then 3 weeks later I'm (4+3 & 4+4) and on a whole new and urgent treatment path...

Anyway - the first 90 days of HT (Trelstar & Casodex) have gone well as I've had little side effects and I'm scheduled for brachytherapy Tuesday Feb 3rd.

Had I not gotten the second opinion on my biopsy I would be moving much more slowly and trying watchful waiting. The Gleason 8 scared me however and I felt I had to act immediately.

Re: Gleason Grading Explaination

Terry,
Thanks for the very thoughtful recounting of your take on my question of gleason score and PSA doubling time. Not much rant in there at all.

In my case the PSA went rather smoothly from 3 to 7 over five years, so that's a rather slow doubling. But my Gleason at biopsy (at the end) was a nasty 4+3. And I have sure seen others on this site whose PSA rose more rapidly yet they had a more favorable Gleason. My sense of the missing factor is the environment of the host, meaning ourselves. Our physical health, what we eat and such.

I could suggest that the cancer will mutate at a rather steady rate and thus the Gleason will increase accordingly. But the body chemistry will be good or bad at slowing the expansion of the tumor size. Thinking the tumor size will directly relate to PSA numbers. (More volume of the same thing will correspondingly increase the PSA production.) On that thought basis maybe the younger men who get diagnosed with higher gleason grades yet low PSA's might be a reflection of their very good overall health. The tumor evolves yet isn't able to gain the upper hand against the body's defenses, hence its volume remains low. This is only a proposition, without evidence.

But maybe body chemistry also affects the rate of mutation, the rate of increase in Gleason score? Seems like there should be some info out there about such things. Or some theories getting tested.

Like you it is unconvincing to me that highest grade Gleason tumours would have trouble generating PSA. Just look at the very high PSA numbers that regularly come with advanced cancer.

PS. Watching the live TV coverage of the Australian Open at night here alerts me to the tremendous heat in Melbourne. That seems surprising and distressing.

Re: Re: Gleason Grading Explaination

Yes, it has been very hot here – we usually have these very hot spells in January and February, but they don’t normally last as long as this one – or hit quite the same high temperatures. Of course everyone is pointing to global warming, while us old sceptics, who lived through the ‘global freezing’ scares of the sixties (which was then said to be caused by greenhouse gases!) point out that the last time we hit these temperatures was in 1939, when it was slightly hotter, and in 1908 when it lasted slightly longer – must have been all those Model T Fords, I guess.

It may sound off the subject to bring in a contentious subject like global warming, but to me it illustrates how theories come and go in the scientific world; theories that often overlook some pretty basic information – in the case of global warming the historical cycles of warming and cooling that have no more to do with man’s activities than the tides do – as poor King Canute tried to demonstrate all those years ago – a wise man he was.

The way I look at the issue of PCa in its broadest terms is that it is a natural occurrence and in nature, there is either progression or regression – there is no stasis. At times an occurrence might appear to be static, but that is only because the movement forwards or backwards is so slow that it cannot be identified in the short term. Progression and regression can vary and alternate, depending on the factors that are involved in such movements.

So I agree with you wholeheartedly that the progression of PCa can depend on any number of issues within the host body – which is why I believe so emphatically in maintaining the body and the immune system in the best condition possible – eating well, exercising appropriately, avoiding or dealing with stress etc etc.

There are very few discussions on these issues in the accepted scientific journals although, of course, they are widely discussed in arenas that ‘true scientists’ look down on They are all very difficult to prove, but by searching around it is possible to find material that seems to fit this approach. For example:

Yakovlev A; Boucher K; DiSario J. Modeling insight into spontaneous regression of tumors. Mathematical Biosciences, 1999 Jan 1, 155(1):45-60.

The abstract opens by saying The phenomenon of spontaneous regression of benign and malignant tumors is well documented in the literature and is commonly attributed to the induction of apoptosis or activation of the immune system. We attempt
at evaluating the role of random effects in this phenomenon. To this end, we consider a stochastic model of tumor growth which is descriptive of the fact that tumors are inherently prone to spontaneous regression due to the random nature of their development.



At one stage I used to try to get discussions going on spontaneous regression. They never went very far but it was always interesting to see the classic denial arguments coming to the fore: the initial reaction was that this did not happen – that all cancers progress unstoppably (unless there is direct intervention by accepted scientific procedures, usually physical removal, radiation or chemotherapy ). My response to this was that there were studies that demonstrated that there were recorded cases of cancers regressing spontaneously, and quoting some of them.

The response to that was along the lines that while some cancers (including very dangerous ones like melanoma) might regress spontaneously, PCa didn’t. Again I would quote relevant studies – and point out that with most PCa being treated within a median time of six weeks, the tumour didn’t have much time to regress even if it wanted to. That usually ended the discussion, with no response from the other side.

The problem of course is that it is very difficult to explain how spontaneous remission occurs – and even more dangerously for the medical profession, it undermines their entire raisin d’etre – if people get better without doctors, what would they do?

Here’s another relevant study – sorry they are all so old, but they were current when I was investigating this phenomenon:


Papac RJ.: Spontaneous regression of cancer: possible mechanisms. In Vivo, 1998 Nov-Dec, 12(6):571-8.

Abstract: Spontaneous regression of cancer is reported in virtually all types of human cancer, although the greatest number of cases are reported in patients with neuroblastoma, renal cell carcinoma, malignant melanoma and lymphomas/ leukemias. Study of patients with these diseases has provided most of the data regarding mechanisms of spontaneous regression. Mechanisms proposed for spontaneous regression of human cancer include: immune mediation, tumor inhibition by growth factors and/or cytokines, induction of differentiation, hormonal mediation, elimination of a carcinogen, tumor necrosis and/or angiogenesis inhibition, psychologic factors, apoptosis and epigenetic mechanisms. Clinical observations and laboratory studies
support these concepts to a variable extent. The induction of spontaneous regression may involve multiple mechanisms in some cases although the end result is likely to be either differentiation or cell death. Elucidation of the process of spontaneous regression offers the possibility of improved methods of treating and preventing cancer.



Isn’t it interesting to see that one of the mechanisms proposed for spontaneous regression is “psychologic factors” Hmmm! Can that means that since you can ‘think’ yourself sick, you can ‘think’ yourself well?

All the best

Terry in Australia

Re: Gleason Grading Explaination

Excellent info Terry I might just throw out this spare change (pennies) another parameter on PCa:

There are atleast 18 different variants of PCa's and a few of those are the worst ever, like 'small cell' and others. The prognosis on some of those, rarer PCa's is so ominious that you feel better about yours in comparison (not kidding).

Do you think you uro-doc knows what the heck you got??? He does not until he reads the pathology report and hopefully it was reviewed by the experts whom already have identified that these 18 types exist. The average patho-doc probably could miss on this one big time, it is an art and not pure science.

'PCa-combination of the jungle and Twilight Zone' We need to know how to navigate and get street smart if possible and we can, but it take work and effort to be envolved in your own case as a warrior.

Re: Gleason Grading Explaination

Another thing to throw in the mix: some of the most aggressive PCa's do not give off psa's to measure...i.e. you could have a low psa and be found with highly aggressive PCa, it is a rarer thing to see than normal cases...they exist...usually the pathology will show a huge Gleason score or a bizzare variant type of PCa, not the norm type usually found in the majority of PCa patients.

PCa- full of inconsistencies and land of the bizzare

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