Gleason Grading

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Anyone use Epsteins new Gleason grading book. It has an Atlas that shows quite a few 3+3 pictures that may be over called a 4.

 

[yaah]

Anyone use Epsteins new Gleason grading book. It has an Atlas that shows quite a few 3+3 pictures that may be over called a 4.

Another way that could be worded: The atlas shows quite a few pictures of cases that were overcalled as 3+4 when they are better termed as 3+3.

Gleason grading is a wonderful example of the phenomenon of "eminence-based pathology." There is poor concurrence on just what constitutes minimal criteria for pattern 4. Thus, the "correct" answer depends on what the expert who is looking at it says. If the experts disagree, then the higher ranked expert is correct. If both experts are authors in a substantial paper on Gleason grading, then this case is chalked up to "difference of opinion" with the patient left to assume that the pathologist from the more famous institution (in his mind) is correct.

 

[scienceguy19]

probably sooner or later we won't have to worry about gleason 3 or 4.

some molecular assay will churn out the result.

Another way that could be worded: The atlas shows quite a few pictures of cases that were overcalled as 3+4 when they are better termed as 3+3.

Gleason grading is a wonderful example of the phenomenon of "eminence-based pathology." There is poor concurrence on just what constitutes minimal criteria for pattern 4. Thus, the "correct" answer depends on what the expert who is looking at it says. If the experts disagree, then the higher ranked expert is correct. If both experts are authors in a substantial paper on Gleason grading, then this case is chalked up to "difference of opinion" with the patient left to assume that the pathologist from the more famous institution (in his mind) is correct.

 

[coomasie blue]

Another way that could be worded: The atlas shows quite a few pictures of cases that were overcalled as 3+4 when they are better termed as 3+3.

Gleason grading is a wonderful example of the phenomenon of "eminence-based pathology." There is poor concurrence on just what constitutes minimal criteria for pattern 4. Thus, the "correct" answer depends on what the expert who is looking at it says. If the experts disagree, then the higher ranked expert is correct. If both experts are authors in a substantial paper on Gleason grading, then this case is chalked up to "difference of opinion" with the patient left to assume that the pathologist from the more famous institution (in his mind) is correct.

Yaah thanks for the reply. Do you have the book? It seems that using the criteria in the book lots of 3 + 4's, 4 + 4's, and 4 + 3's are being overcalled. The book also seems to place great emphasis on "expert opinion" for grading. Are there other books like by Amin, Humphrey , Bostwick, etc and is there reasonable consensus?

The whole fused gland tangential cut thing can be very subjective. To be truly evidence and not eminence based in pathology, there has to be consensus among the "bright and shining stars" that write our books and bless fellows to carry on the tradition. Does this happen in other fields in medicine? Do cardiologists, surgeons, etc do fellowships with a book writing name or a program with institutional legacy? Our problem in pathology is that every jackass and their grandmother is writing a book. How many GU experts, GI experts, Derm experts, cytology, pulmonary, heme, etc etc do we need writing books. If we can at least get eminence base consensus, pathology may become a pseudo-evidence based specialty.

 

[lipomas]

If Epstein says it's 3+3 then it's 3+3. That's the criteria. Sorry, you're wrong. Even if you're right, you're wrong.

 

[KCShaw]

Large enough studies involving a large enough group of different pathologists should provide a significant evidence based result. Study results are often probability and population based, such that whether 1 individual core biopsy is called 3+3 or 3+4 or whatever really is irrelevant. The problem is that a lot of people conflate the two issues. There is a fallacy that a high volume study depending on morphology but using only one pathologist or one small subspecialty group taught or overseen by one pathologist is somehow a good broadly applicable study. Sure, no-one wants to be "wrong" and lead to a poor outcome or inaccurate prognosis for an individual patient, but this is exactly why neither we nor clinicians base standards of care on a study of one patient. We also can't depend on developing the identical subjective interpretation as a specific "expert" pathologist, on every case, every time. If it's not widely reproducible in a statistically significant way then it's useless -- move on to something else. This kind of problem is all the -more- reason for clinicians to want to demand molecular studies on anything and everything, since our best *****s are arguing with one another (and with the peon pathologists who might consult them) about who is more right or more wrong -- ultimately to the detriment of what clinicians need for their patients and what most pathologists need in order to practice.

 

[lipomas]

You are correct, however, the real world example of this is:

Patient: My original biopsy report said 3 + 3 = 6, but I requested it to be sent to Dr Epstein who the internet said was awesome.
Doctor: He said it was 3 + 4 = 7.
Patient: Well he's obviously right then.

 

[member0007]

does prostate biopsy grade determine treatment?

 

[malchik]

yes

 

[mlw03]

does prostate biopsy grade determine treatment?

Yes is the short answer. The longer answer is, "yes, but some scores get the same treatment." I no longer recall those differences, but I'm pretty sure 5+4=9, 4+5=9, and 5+5=10 are treated similarly. There's also the issue of tertiary scoring. But the GU pathologist at my program was a not a nice person (shout out to DZ), so I've suppressed all but the essential GU. But yeah, Gleason grading definitely affects what the urologist will do for the patient much of the time.

 

[KCShaw]

You are correct, however, the real world example of this is:

Patient: My original biopsy report said 3 + 3 = 6, but I requested it to be sent to Dr Epstein who the internet said was awesome.
Doctor: He said it was 3 + 4 = 7.
Patient: Well he's obviously right then.

Interestingly, 3 + 3 does in fact equal 6, and 3 + 4 does equal 7, to the best of my limited knowledge, making both correct. 😀