Pinthus Jehonathan H, Witkos Maciej, Fleshner N E, Sweet Joan, Evans Andrew, Jewett M A, Krahn Murray, Alibhai Shabir, Trachtenberg John
Prostate Cancer Center, Princess Margaret Hospital, 620 University Avenue, Toronto, Ontario M5G 2M9, Canada.
J Urol. 2006 Sep;176(3):979-84; discussion 984. doi: 10.1016/j.juro.2006.04.102.
Differentiation between Gleason score 6 and 7 in prostate biopsy is important for treatment decision making. Nevertheless, under grading errors compared with the actual pathological grade at radical prostatectomy are common. We compared the characteristics and outcomes of tumors that were scored 6 on prostate biopsy but were 7 on subsequent radical prostatectomy pathological evaluation to those in tumors with a consistent rating of Gleason score 6 or 7 at biopsy and surgery.
We performed a retrospective database analysis from our referral center (1989 to 2004). We compared pre-prostatectomy characteristics, radical prostatectomy pathological features and the post-radical prostatectomy prostate specific antigen failure rate, defined as any 2 consecutive detectable prostate specific antigen measurements, in 3 subgroups of patients, including 156 with matched Gleason score 6 in the prostate biopsy and radical prostatectomy, 205 with upgraded Gleason score 6/7, that is prostate biopsy Gleason score 6 and radical prostatectomy Gleason score 7, and 412 with matched Gleason score 7 in the prostate biopsy and radical prostatectomy.
Radical prostatectomy Gleason score matched the prostate biopsy score in 38.2% of biopsy Gleason score 6 and 81.4% of biopsy Gleason score 7 cases. Higher prostate specific antigen was associated and an increased percent of cancer in the prostate biopsy was predictive of discordance between the prostate biopsy and radical prostatectomy Gleason scores (p <0.001). Margin (p = 0.0075) or seminal vesicle involvement (p = 0.0002), cancer volume (p <0.001) and the prostate specific antigen failures rate (p = 0.014) were significantly higher in under graded Gleason score 7 cancer compared to those in matched Gleason score 6 cases. However, they were comparable to those with a matched Gleason score 7 tumor grade (p = 0.66).
Almost half of tumors graded Gleason score 6 at biopsy are Gleason score 7 at surgery. Upgraded Gleason score 6 to 7 tumors have outcomes similar to those of genuine Gleason score 7 cancer. For prostate biopsy Gleason score 6 tumors clinicians should consider the overall likelihood of tumor upgrading as well as specific patient characteristics, such as prostate specific antigen and the percent of tumor in the prostate biopsy, when contemplating treatments that are optimized for low grade tumors, including watchful waiting or brachytherapy.
在前列腺活检中区分Gleason评分6分和7分对于治疗决策至关重要。然而，与根治性前列腺切除术后的实际病理分级相比，分级错误很常见。我们比较了前列腺活检时评分为6分但在随后的根治性前列腺切除病理评估中为7分的肿瘤与活检和手术时Gleason评分均为6分或7分且保持一致的肿瘤的特征和结果。
我们对我们的转诊中心（1989年至2004年）进行了回顾性数据库分析。我们比较了三组患者前列腺切除术前的特征、根治性前列腺切除的病理特征以及根治性前列腺切除术后前列腺特异性抗原失败率（定义为任何连续两次可检测到的前列腺特异性抗原测量值），这三组患者包括156例前列腺活检和根治性前列腺切除时Gleason评分匹配为6分的患者、205例Gleason评分升级为6/7分的患者（即前列腺活检Gleason评分为6分而根治性前列腺切除Gleason评分为7分）以及412例前列腺活检和根治性前列腺切除时Gleason评分匹配为7分的患者。
在活检Gleason评分为6分的病例中，38.2%的根治性前列腺切除Gleason评分与活检评分匹配；在活检Gleason评分为7分的病例中，81.4%的根治性前列腺切除Gleason评分与活检评分匹配。较高的前列腺特异性抗原与之相关，且前列腺活检中癌症比例增加可预测前列腺活检和根治性前列腺切除Gleason评分之间的不一致（p<0.001）。与Gleason评分匹配为6分的病例相比，Gleason评分7分的低分级癌症的切缘（p = 0.0075）或精囊受累情况（p = 0.0002）、癌体积（p<0.001）和前列腺特异性抗原失败率（p = 0.014）显著更高。然而，它们与Gleason评分匹配为7分的肿瘤分级的情况相当（p = 0.66）。
活检时Gleason评分为6分的肿瘤中，几乎一半在手术时为Gleason评分7分。Gleason评分从6分升级到7分的肿瘤的结果与真正的Gleason评分为7分的癌症相似。对于前列腺活检Gleason评分为6分的肿瘤，临床医生在考虑针对低级别肿瘤优化的治疗方法（包括密切观察或近距离放射治疗）时，应考虑肿瘤升级的总体可能性以及特定的患者特征，如前列腺特异性抗原和前列腺活检中肿瘤的比例。
