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Pathology. 2019 Aug;51(5):463-473. doi: 10.1016/j.pathol.2019.05.001. Epub 2019 Jul 3.

Controversial issues in Gleason and International Society of Urological Pathology (ISUP) prostate cancer grading: proposed recommendations for international implementation.

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Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada. Electronic address:
Department of Pathology and Molecular Medicine, Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand.
Aquesta Uropathology and University of Queensland, Brisbane, Qld, Australia.
Department of Anatomic Pathology, School of Medical Sciences, State University of Campinas (Unicamp) Campinas, SP, Brazil.
Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
TissuPath, Mount Waverley, Vic, Australia.
University Health Network, Laboratory Medicine Program, Toronto General Hospital, Toronto, ON, Canada.
Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences and Cancer Genomics Unit, Clinical Genomics Center, Nagasaki University Hospital, Sakamoto, Nagasaki, Japan.
Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and Central Clinical School, University of Sydney, Sydney, NSW, Australia.
Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.
Department of Pathology and Urology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
University and University Hospital Zurich, Department of Pathology and Molecular Pathology, Zurich, Switzerland.
Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan.
Univ Rennes, CHU Rennes, Inserm, EHESP, Irset, UMR, Rennes, France.
Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Weill Medical College of Cornell University, Houston, TX, USA.
Department of Histopathology, The Christie NHS Foundation Trust, Manchester, UK.
Department of Surgical Pathology, Aichi Medical University, School of Medicine, Nagakute, Japan.
Department of Cellular Pathology, University Hospital of Wales, Cardiff, UK.
Department of Pathology and Laboratory Medicine, Baylor St. Luke's Medical Center and Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.
Department of Medicine, University of Queensland, Wesley Urology Clinic, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.
Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.


The Gleason Grading system has been used for over 50 years to prognosticate and guide the treatment for patients with prostate cancer. At consensus conferences in 2005 and 2014 under the guidance of the International Society of Urological Pathology (ISUP), the system has undergone major modifications to reflect modern diagnostic and therapeutic practices. The 2014 consensus conference yielded recommendations regarding cribriform, mucinous, glomeruloid and intraductal patterns, the most significant of which was the removal of any cribriform pattern from Gleason grade 3. Furthermore, a Gleason score grouping system was endorsed which consisted of five grades where Gleason score 6 (3+3) was classified as grade 1 which better reflected the mostly indolent behaviour of these tumours. Another issue discussed at the meeting and subsequently endorsed was that in Gleason score 7 cases, the percentage pattern 4 should be recorded. This is especially important in situations where modern active surveillance protocols expand to include men with low volume pattern 4. While major progress was made at the conference, several issues were either not resolved or not discussed at all. Most of these items relate to details of assignment of Gleason score and ISUP grade in specific specimen types and grading scenarios. This detailed review looks at the 2014 ISUP conference results and subsequent literature from an international perspective and proposes several recommendations. The specific issues addressed are percentage pattern 4 in Gleason score 7 tumours, percentage patterns 4 and 5 or 4/5 in Gleason score 8-10 disease, minor (≤5%) high grade patterns when either 2 or 3 patterns are present, level of reporting (core, specimen, case), dealing with grade diversity among site (highest and composite scores) and reporting scores in radical prostatectomy specimens with multifocal disease. It is recognised that for many of these issues, a strong evidence base does not exist, and further research studies are required. The proposed recommendations mostly reflect consolidated expert opinion and they are classified as established if there was prior agreement by consensus and provisional if there was no previous agreement or if the item was not discussed at prior consensus conferences. For some items there are reporting options that reflect the local requirements and diverse practice models of the international urological pathology community. The proposed recommendations provide a framework for discussion at future consensus meetings.


Gleason; ISUP grade; International Society of Urological Pathology; Prostate adenocarcinoma; grading

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