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J Urol. 2017 Dec;198(6):1309-1315. doi: 10.1016/j.juro.2017.07.009. Epub 2017 Jul 11.

Biopsy Detected Gleason Pattern 5 is Associated with Recurrence, Metastasis and Mortality in a Cohort of Men with High Risk Prostate Cancer.

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Department of Urology, Naval Medical Center San Diego, San Diego, California; Department of Urology, University of California-San Diego, San Diego, California. Electronic address:
Department of Urology, Mayo Clinic, Rochester, Minnesota.
Duke University Medical Center and Durham Veterans Affairs Medical Center, Durham, North Carolina.
Department of Urology, Naval Medical Center San Diego, San Diego, California.
Augusta Veterans Affairs Medical Center, Augusta, Georgia.
West Los Angeles Veterans Affairs Medical Center, West Los Angeles, California; University of California-Los Angeles School of Medicine, Los Angeles, California.
San Francisco Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, California.
Oregon Health and Sciences University, Portland, Oregon.
Department of Urology, University of California-San Diego, San Diego, California; San Diego Veterans Affairs Medical Center, San Diego, California.
Cedars Sinai Medical Center, Los Angeles, California.



We evaluated the relative risk of biochemical recurrence, metastasis and death from prostate cancer contributed by biopsy Gleason pattern 5 among men at high risk with Gleason 8-10 disease in the SEARCH (Shared Equal Access Regional Cancer Hospital) cohort.


Men with biopsy Gleason sum 8-10 prostate cancer treated with radical prostatectomy were evaluated. The cohort was divided into men with Gleason 4 + 4 vs those with any pattern 5 (ie Gleason 3 + 5, 5 + 3, 4 + 5, 5 + 4 or 5 + 5). Predictors of biochemical recurrence, metastases, and prostate cancer specific and overall survival were analyzed using Kaplan-Meier, log rank test and Cox proportional hazards models.


We identified 634 men at high risk in the SEARCH database, of whom 394 (62%) had Gleason 4 + 4 and 240 (38%) had Gleason pattern 5 on biopsy. Baseline characteristics did not significantly differ between the groups. On multivariable analysis relative to Gleason 4 + 4 men at high risk with Gleason pattern 5 showed no difference in the risk of biochemical recurrence (HR 1.26, 95% CI 0.99-1.61, p = 0.065). However, they were at significantly greater risk for metastasis (HR 2.55, 95% CI 1.50-4.35, p = 0.001), prostate cancer specific mortality (HR 2.67, 95% CI 0.1.26-5.66, p = 0.010) and overall mortality (HR 1.60, 95% CI 1.09-2.34, p = 0.016).


Preoperative subclassification of high risk prostate cancer by biopsy Gleason grade (4 + 4 vs any Gleason pattern 5) identified men at highest risk for progression. Any Gleason 5 on biopsy is associated with a greater risk of metastasis, and prostate cancer specific and overall mortality. Grouping all Gleason 8-10 tumors together as high risk lesions may fail to fully stratify men at highest risk for poor outcomes.


local; mortality; neoplasm recurrence; neoplasm grading; prostatectomy; prostatic neoplasms


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