Harnden Patricia, Shelley Mike D, Coles Bernadette, Staffurth John, Mason Malcom D
Cancer Research UK Clinical Centre, St James's University Hospital, Leeds, UK.
Lancet Oncol. 2007 May;8(5):411-9. doi: 10.1016/S1470-2045(07)70136-5.
The Gleason system for grading prostate cancer assigns a score on the basis of the most prevalent and second most prevalent grade. Several studies have investigated the clinical significance of a tertiary grade in radical prostatectomy samples. A systematic search of the published work identified seven studies that reported the prognostic value of a tertiary Gleason grade. Three studies correlated the presence of a tertiary grade with pathological stage, and six with prostate-specific antigen recurrence or clinical progression. In the small number of studies available, the frequency of a tertiary grade was consistently higher in samples characterised with pathological variables of poor outcome, such as extra-prostatic extension and positive surgical margins, but not lymph-node metastases. In five studies the presence of a tertiary grade increased the risk of prostate-specific antigen recurrence after radical prostatectomy by a factor of 2.5. However, modification of the Gleason score to include a tertiary grade in Gleason 4+3 tumours might overestimate the risk of seminal-vesicle or lymph-node invasion. This systematic review has established the association of a tertiary grade with poorer outcome than that associated with no tertiary grade. A tertiary grade should, therefore, be included in the pathological reporting of prostate cancer and be considered in the interpretation and design of clinical trials. However, all studies assessed for this review were retrospective, potentially affected by selection bias, and based on radical prostatectomy samples or transurethral resections rather than biopsy samples. Therefore, more evidence is needed to warrant the adaptation of the Gleason system to account for the presence of a tertiary grade, especially when scoring prostatic biopsies and applying predictive algorithms.
用于前列腺癌分级的格里森系统根据最常见和第二常见的分级来给出分数。多项研究调查了根治性前列腺切除术样本中三级分级的临床意义。对已发表文献的系统检索发现了七项报告三级格里森分级预后价值的研究。三项研究将三级分级的存在与病理分期相关联，六项研究将其与前列腺特异性抗原复发或临床进展相关联。在现有的少数研究中，在以预后不良的病理变量（如前列腺外侵犯和手术切缘阳性）为特征的样本中，三级分级的频率一直较高，但与淋巴结转移无关。在五项研究中，三级分级的存在使根治性前列腺切除术后前列腺特异性抗原复发的风险增加了2.5倍。然而，在格里森4+3肿瘤中修改格里森评分以纳入三级分级可能会高估精囊或淋巴结侵犯的风险。这项系统评价已证实三级分级与无三级分级相比预后较差之间的关联。因此，在前列腺癌的病理报告中应纳入三级分级，并在临床试验的解读和设计中予以考虑。然而，本次评价所评估的所有研究均为回顾性研究，可能受到选择偏倚的影响，且基于根治性前列腺切除术样本或经尿道切除术样本而非活检样本。因此，需要更多证据来支持调整格里森系统以考虑三级分级的存在，尤其是在对前列腺活检进行评分和应用预测算法时。
