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Re: How common is a post-operative Gleason upgrade from 6 to 8 (almost 9)
As you suggest, a Gleason upgrading of this magnitude is fairly rare, though certainly not out of the realm of possibility. A Gleason 3+3=6 implies that no Gleason pattern 4s (and certainly not 5s) were seen under the microscope on biopsy. Yet, the specimen pathology report found not only "secondary" 4s (i.e., the second number in the sum) but also "primary" 4s (i.e., the first number in the sum). The pattern 5 to which you allude (in the 4+5 scenario) is likely a "tertiary" finding, meaning very small smatterings of the most poorly differentiated type of PCa under the Gleason system.
Two reasons could account for the foregoing: (1) the biopsy needle missed the more aggressive cancer cells; or (2) the pathologist who performed the biopsy grading was inept. The only way to rule out #2 is to seek out a second pathology opinion on the biopsy slides, which many men do. Personally, if I were to do AS, I would insist on a minimum 20-core biopsy (vs. 12), with my slides read by two different pathologists.
Re: How common is a post-operative Gleason upgrade from 6 to 8 (almost 9)
Jack,
I certainly agree with the prior posting. And my strong suspicion is that the urologist who took the biopsy samples missed finding the most dangerous areas of the cancer. As I recall the biopsy sampling is done while the urologist has a view of the prostate via an ultrasound image. That gives him information as to where to sample. And clearly a well experienced urologist would know how to understand what he sees in the image, and take samples accordingly.
After surgery the pathologists get to examine the prostate in its entirety, so they will give the fullest, most accurate picture of what's there.
Of course the pathology lab could be mistaken, but I find that less likely given the huge difference in grading. I'd sure go back to the original urologist (who did the sampling) and discuss with him what has transpired.
