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The Author: Dr. Raphael Nyarkotey Obu

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I was very happy when a woman called me concerning her husband’s prostate cancer. She happens to know everything about his prostate cancer including Gleason score and I was amazed. She was very proactive and so much concerned about her husband’s condition.  This is what women should be doing. So, if you or a loved one has been diagnosed with prostate cancer, you may already be familiar with the Gleason scale. The Gleason scale, developed by physician Donald Gleason in the 1960s, provides a score that helps predict the aggressiveness of prostate cancer.

A pathologist begins by examining tissue samples from a prostate biopsy under a microscope. To determine the Gleason score, the pathologist compares the cancer tissue pattern with normal tissue.

According to the National Cancer Institute (NCI), cancer tissue that looks most like normal tissue is grade 1. If the cancer tissue has spread through the prostate and deviates widely from the features of normal cells, it is grade 5.

The pathologist assigns two separate grades to the two predominant cancer cell patterns in the prostate tissue samples.  The first number, called the primary grade, is determined by observing the area where the prostate cancer cells are most prominent. The second number, or secondary grade, considers the area where the cells are almost as prominent.

These two numbers added together produce the total Gleason score or sum. This is a number between 2 and 10. A higher score means the cancer is more likely to spread

When you discuss your Gleason sum with your doctor, ask about both the primary and secondary grade numbers.  A Gleason score of 7 can be derived from differing primary and secondary grades, for example 3 and 4, or 4 and 3. This can be significant because a primary grade of 3 indicates that the predominant cancer area is less aggressive than the secondary area.  The reverse is true if the score results from a primary grade of 4 and secondary grade of 3.

The Gleason score is only one consideration in establishing your risk of advancing cancer and in weighing treatment options. Your doctor will consider your age and overall health, as well as additional tests to determine the cancer stage and risk group. These tests include digital rectal exam (DRE), bone scan, MRI or CT scan.
Your doctor will also consider your level of prostate-specific antigen (PSA), a protein produced by cells in the prostate gland. PSA is measured in nanograms per milliliter of blood (ng/ml). PSA level is another important factor in assessing the risk of advancing cancer.

According to the NCI, a Gleason score of 6 or lower, a PSA level of 10-20 ng/ml, and an early tumor stage places you in the low-risk category. Together, these factors mean that the prostate cancer is unlikely to grow or spread to other tissues or organs for many years.

Some men in this risk category monitor their prostate cancer with active surveillance. They have frequent checkups that may include DREs, PSA tests, ultrasound or other imaging, and additional biopsies.

A Gleason score of 7, a PSA between 10 and 20 ng/ml, and a medium tumor stage indicates medium risk. This means that the prostate cancer is unlikely to grow or spread for several years. You and your doctor will consider your age and overall health when weighing treatment options, which may include surgery, radiation, medication, or a combination of these.

A Gleason score of 8 or higher, accompanied by PSA level higher than 20 ng/ml and a more advanced tumor stage, signifies a high risk of advancing cancer. In high-risk cases, the prostate cancer tissue looks very different from normal tissue. These cancerous cells are sometimes described as being “poorly differentiated.” This point is still considered early-stage prostate cancer because the cancer has not spread. High risk means the cancer is likely to grow or spread within a few years.

While a higher Gleason score generally predicts that prostate cancer will grow more quickly, remember that the score alone does not predict your prognosis. When you evaluate treatment risks and benefits with your doctor, be sure that you also understand the cancer stage and your PSA level. This knowledge will help you decide whether active surveillance is appropriate or guide you in selecting treatment that best suits your condition.

Here is a look at what the numbers mean, how to interpret your results, and where the scale fits in with the outcomes of other tests.

Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread.

The lowest Gleason score of a cancer found on a prostate biopsy is 6. These cancers may be called well-differentiated or low-grade and are likely to be less aggressive – they tend to grow and spread slowly. Cancers with Gleason scores of 8 to 10 may be called poorly differentiated or high grade.



Number of cores

An ideal report also specifies how many samples, or cores, were removed during the biopsy. The standard number of cores used to be six: three from the right side of the prostate and three from the left. However, this limited sampling meant that cancerous portions of the prostate, if there were any, might be missed. As a result, as many as one in four patients eventually diagnosed with prostate cancer was told, on the basis of the initial biopsy, that he did not have cancer — meaning that the test provided a false-negative finding.

Today, most doctors agree that an initial biopsy should include at least 10 to 12 core samples. In certain situations, some doctors recommend doing a saturation biopsy, which typically removes 12 to 14 cores — and sometimes as many as 20 or more — but less agreement exists about this practice.

Anatomic location
Ideally, the pathologist who prepares your report will have separated and labeled the core samples according to what part of the prostate they came from. This labeling will tell you and your doctors whether the cells came from the right or left side and whether they were drawn from the apex (counterintuitively, at the bottom), mid zone (middle), or base (top) of the prostate. In a saturation biopsy you may see even more detailed labels, such as RMA and RMB to differentiate between the right mid zone near the apex and the right mid zone closer to the base. Similarly, the report may refer to three zones: the peripheral, central, and transition zones (see Figure 2). All of this information can be invaluable in helping to determine the general location of the tumor, which helps guide treatment decisions.

Zones of the prostate
To help your doctor more precisely determine the location of prostate cancer or another condition, such as high-grade PIN, your pathology report may name specific areas. For example, it may refer to the apex, located at the bottom of the prostate; the base, at the top; or the mid zone, the area between the apex and base. Alternatively, it may note three zones: the peripheral zone (1), the central zone (2), and the transition zone (3). Seventy percent of prostate cancers arise in the peripheral zone. Few arise in the anterior prostate.

Example of An ideal pathology report
Men’s Health Hospital
Department of Pathology


Patient Name: John Doe

Medical Record #: 01020304

Date of Birth: 04/01/26 (Age: 81) Sex: Male

Procedure performed by: Dr. Yen

Specimen #: S00-9999

Procedure date: 07/15/07

Report date: 07/16/07
Gross description by: Dr.  Cock


Prostate needle biopsies: 21

A) R5A: Fibromuscular tissue only; no prostatic epithelium seen.

B) R5MA: Atypical glandular focus suspicious for adenocarcinoma.

C) R5M: No malignancy identified.

D) R5MB: No malignancy identified.

E) R5B: No malignancy identified; focal chronic inflammation.

F) R4A: No malignancy identified.

G) R4MA: No malignancy identified; focal chronic inflammation.

H) R4M: No malignancy identified.

I) R4MB: No malignancy identified.

J) R4B: No malignancy identified; focal chronic inflammation.

K) L5A: Fibromuscular tissue and colonic mucosa; no prostatic epithelium seen.

L) L5MA: Adenocarcinoma, Gleason score 7 (3 + 4), involving 50% of core.

M) L5M: Adenocarcinoma, Gleason score 8 (4 + 4), involving 70% of core.

N) L5MB: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

O) L5B: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

P) L4A: No malignancy identified.

Q) L4MA: Adenocarcinoma, Gleason score 7 (4 + 3), involving 80% of core.

R) L4M: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

S) L4MB: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

T) L4B: Adenocarcinoma, Gleason score 8 (4 + 4), involving 70% of core.

U) L seminal vesicle: Seminal vesicle, no malignancy identified.

Note: Perineural invasion is seen. Focally, a tertiary Gleason 5 pattern is noted.

Clinical Data: None given.
Gross Description: Received in 21 formalin containers labeled with the patient’s name, “John Doe,” the medical record number, and additionally labeled “R5 apex,” “R5 mid-apex,” “R5 mid,” “R5 mid base,” “R5 base,” “R4 apex,” “R4 mid apex,” “R4 mid,” “R4 mid base,” “R4 base,” “L5 apex,” “L5 mid apex,” “L5 mid,” “L5 mid base,” “L5 base,” “L4 apex,” “L4 mid apex,” “L4 mid,” “L4 mid base,” “L4 base,” and “left seminal vesicle” are multiple prostate cores measuring up to 2.5 cm, entirely submitted in cassettes A–U respectively.

If you are confused talk to me

Dr. Raphael Nyarkotey Obu is a Research Professor of Prostate Cancer and Holistic Medicine at Da Vinci College of Holistic Medicine, Cyprus. His clinic can be located at Dodowa-Akoto House. Consultation Hours: Monday-Friday @ 9am-5pm

Understanding Prostate Cancer: The Gleason Scale - Healthline www.healthline.com › Prostate Cancer › Home
Sep 6, 2013 - 
Peter A Humphrey (2004) Gleason grading and prognostic factors in carcinoma of the prostate. Modern Pathology



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