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Do Adenocarcinomas of the Prostate With Gleason Score (GS)6 Have the Potential to Metastasize to Lymph Nodes?

Ross, Hillary M.*; Kryvenko, Oleksandr N.; Cowan, Janet E.; Simko, Jeffry P.‡,§; Wheeler, Thomas M.; Epstein, Jonathan I. MD*,¶,#

American Journal of Surgical Pathology: September 2012 - Volume 36 - Issue 9 - p 1346–1352
doi: 10.1097/PAS.0b013e3182556dcd
Original Articles

Although rare, there are cases within reported series of men with Gleason score (GS)≤6 on radical prostatectomies that show pelvic lymph node (LN) metastases. However, there are no studies on whether pelvic LN metastases occur in tumors with GS≤6 using the International Society of Urological Pathology (ISUP) updated GS system. We performed a search of the radical prostatectomy databases at 4 large academic centers for cases of GS≤6. Only prostatectomies submitted and embedded in entirety with pelvic LN dissections were included. A combined total of 14,123 cases were identified, of which 22 cases had a positive LN. Histopathologic review of 19 cases (3 cases unavailable for review) showed higher grade than originally reported by the pathologists in all cases. Of the 17 pre-ISUP reviewed cases, 2 were upgraded to 4+3=7 with both cribriform and poorly formed glands. One case was upgraded to 4+3=7 with tertiary pattern 5 displaying cribriform glands, poorly formed glands, and cords of single cells. Eleven cases were upgraded to 3+4=7 with glomeruloid structures and small to large cribriform glands (1 of these also had features of ductal adenocarcinoma). Two cases had tertiary pattern 4 with small cribriform glands. One case had a prominent colloid component that would currently be graded as 4+5=9 because of large cribriform glands and solid sheets of cells within the mucin. Of the 2 post-ISUP cases, 1 demonstrated tertiary pattern 4, and the other showed GS 3+4=7 with irregular cribriform glands. Undergrading is the primary reason for LN positivity with GS≤6, which has decreased significantly since the adoption of the ISUP grading system in 2005. Of over 14,000 totally embedded radical prostatectomies from multiple institutions, there was not a single case of a GS≤6 tumor with LN metastases. In contrast to prevailing assumptions, GS≤6 tumors do not appear to metastasize to LNs. Rather, Gleason pattern 4 or 5, as better defined by the current ISUP updated grading system, is required for metastatic disease.

Departments of *Pathology

Urology

#Oncology, Johns Hopkins Hospital, Baltimore, MD

Department of Pathology, Henry Ford Hospital, Detroit, MI

Departments of Urology

§Anatomic Pathology, University of California San Francisco, San Francisco, CA

Department of Pathology, Baylor College of Medicine, Houston, TX

Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Jonathan I. Epstein, MD, Department of Pathology, The Johns Hopkins Hospital, Weinberg Building, Room 2242, 401N Broadway, Baltimore, MD 21231-2410 (e-mail: jepstein@jhmi.edu).

© 2012 Lippincott Williams & Wilkins, Inc.