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If I'm missing, or not taking messages sorry – I'm more angry about letting my friends down than YOU will ever be at being let down! Unfortunately that is sometimes a side effect of Cancer! Mea Culpa: may I blame being short fused & grumpy on it too! My first symptoms presented in Nov-1998 – Follow The Trail on >DIARY of CANCER< Immediately Below!

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The Redoubtable #Anna_Raccoon Dying With/of #Cancer Defends The NHS …
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Greg Lance – Watkins
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Hi,

Cancer sufferer urges patients to stop suing NHS

Susanne Cameron-Blackie: ‘the NHS provides all you need without a penny going to lawyers’ALBAN DONOHOE/ALBANPIX

A woman dying of cancer has started a campaign to curb the compensation culture in the NHS despite suffering two cases of medical negligence herself.

Susanne Cameron-Blackie, 68, from Norfolk, has been given three months to live after being diagnosed with leiomyosarcoma, a soft tissue cancer, six years ago. It has spread through her body, leaving her virtually paralysed.

She is determined to spend her final weeks battling to cut the spiralling costs of litigation against the NHS. Last year, settlements and costs took £1.5bn out of the NHS budget.

NHS Resolution (formerly known as the NHS Litigation Authority) estimates that £56bn could be needed to deal with all cases arising from failures and mistakes made up to March 2016.

“That is the equivalent of half the annual budget of the NHS,” said Cameron-Blackie. She suffered in her early twenties when her womb was removed without permission as she was undergoing a dilation and curettage procedure. During recent treatment she was given another patient’s medication, leaving her in agony.

“But I didn’t sue,” Cameron-Blackie said. “The money from the original operation would have made no difference, I just got on with my life. The second time, I would not have got anything — the money would have gone to my husband in a few years’ time. What good would that do?

“Even the valid claims where somebody gets £6m and it’s entirely justified, that money goes into the court of protection and all their needs are met by the NHS.

“It is whether there is a fault that matters. If you can’t prove a fault, then you can have a patient with exactly the same damage, exactly the same needs and they are met in exactly the same way, but there is no payout.”

Cameron-Blackie, who formerly worked for the lord chancellor’s office, has returned home after her latest hospital treatment. The NHS has installed a bed and oxygen in her home on the Norfolk Broads.

“When the chips are down and you are left like this, the NHS provides everything and more that you need without a penny piece going anywhere near lawyers,” she said.

Cameron-Blackie is likely to find widespread support for her campaign.

Rob Hendry, medical director at the Medical Protection Society, which represents healthcare professionals, said: “A package of legal reforms is required to control the spiralling cost of clinical negligence, including a fixed cap on the legal fees that can be charged.”

A spokesman for NHS Resolution said it aimed to settle claims fairly and quickly. “We also have a responsibility to defend unjustified claims robustly. We received 10,965 new clinical negligence claims in 2015-16 [and] resolved 4,935 (46%) of clinical negligence claims without the payment of damages.”

10 comments
 
Ralph Naderbolsinmattu 6 days ago

 
 

The NHS Litigation Authority lost 76% of cases it contested in court, causing distress and pain to thousands of patients damaged by negligence.

 
PlatoSays 9 days ago

 
 

For those who’ve enjoyed the Anna Raccoon blog and twitter account over a decade or more.

A superb lady with a remarkable life story.

 
Kate Catleugh 9 days ago

 
 

There is a toxic chicken and egg situation here. Of course a cash-strapped NHS should not be paying enormous damages that result from expensive legal claims.  As things are now, the NHS very often will try and deny/defend/obfuscate to avoid the legal consequences of its actions. This of course not only escalates the costs but also prevents the lessons which should be learned from such errors to be learned.

If the NHS provides the remedies or reliefs needed as a consequence of it’s actions without charge anyway,  how much more rapidly, cleanly and efficiently this could happen if faults were admitted and rectified, as far as possible.  Where loss of life or hurt feelings are concerned,  surely an honest admission, a lesson truly learned and a prompt and sincere apology is far more appropriate than a long drawn out legal case and punitive financial damages awarded against the organisation least able to afford it without further jeopardising it’s ability to deliver for other patients.

 
Nick Simpson 9 days ago

 
 

My missus is a lawyer who spends her working week suing the NHS.  Go on, hate me.

Her typical client is a five year old with brain damage caused by an accident at birth.  By accident I mean a toxic combination of incompetence and stupidity. 

If such children die, compensation is minimal to non-existent.  The kids who really cost the NHS money are the ones that live, because they can live for decades unable to speak, walk, talk, feed themselves or wipe their own backside, let alone go to the shops or earn a living.  Someone has to look after them; and looking after them properly costs a lot of money.

The idea that the NHS treats everyone whose life chances are ruined in this way is absolute rubbish.  It doesn’t.

Legal Aid is no longer available for Clinical Negligence cases.  Lawyers must take such cases on contingency fee arrangements (No Win, No Fee).  That means lawyers like Mrs VoP have to decide very carefully which cases stand a reasonable chance of succeeding at trial.  She turns many down, because the alternative is to do a lot of work for nothing and unfairly raise the hopes of families.  Lawyers who push weak cases swiftly find out the consequences.

Yes, it’s true that Clin Neg lawyers are well paid (although not as well remunerated as doctors, whose average pensions are in the region of £50,000).  But the NHS could save enormous insurance fees by putting its own house in order.  Firstly, it could train its midwives properly (a common cause of negligence is that midwives are slow to grasp that a delivery might be in some way out of the ordinary).  Secondly, it could change the culture of defensiveness whereby doctors lie, cover each other’s backs and even alter medical notes in an attempt to avoid blame.  Thirdly, it could try making an early assessment of each allegation of negligence – Mrs VoP reports that again and again Trusts reject claims until a late stage of the procedure (presumably because to do so costs money and would involve medical staff being confronted with their mistakes), by which time the Claimants lawyers have spent tens of thousands which NHS insurers end up having to pay.

The reality is that, in an era where massive NHS failures are routine news items (a major one only last week), the fear of litigation exerts a powerful pressure on Trusts to raise standards.  Get rid of that if you like.  But don’t complain when clinical standards fall.

And by the way, no-fault insurance for medical accidents has been tried in other countries.  And abandoned as too expensive.

 
CM 9 days ago

 
 

Why in early can’t doctors and nurses be required to purchase their own insurance so insurance companies cover the costs? Do we even require this of our vastly over paid locums? It really is time to get rid of the vast state monolith and move to the perfect competition of multiple private suppliers paid by health insurance to drive up standards. I’d happily spend more on healthcare like they do in France if I knew the money followed the patient instead of creating loads of pointless back office non jobs for labour voters. The NHS is third world healthcare. No one who actually uses it regularly thinks it’s great except our many third world health tourists who really do get it for free, unlike the taxpayer, who pays over the odds for a third world service. I want healthcare as good as France’s or Germany’s. That means choosing and copying one of the several superior continental models. Get on with it.

Bobo08 9 days ago

 
 

@CM Insurance is business model that generates profit from premiums. So if doctors etc had to buy their own cover, then they’d ask for more pay to do so and the cost would actually increase. By self insuring, the NHS is saving money. It is as the article demonstrates, the ‘somebody must pay culture’ that drives these claims. My own wish would be that mistakes are recognised, lessons are learnt and corrections made to the process. 

Bryan Attewell 9 days ago

 
 

This lady deserves great credit for her stance on compensation culture. 

While there are no doubt some deserving cases, people in genuine need of financial support due to an error, too often this is seen as a route to easy money with cynical legal professionals stoking the fire. 

 
stella hollis 9 days ago

 
 

It is the level of damages which is the problem not the nmber of cases. Actual provable loss is no longer the yardstick. Huge damages are awarded for people’s feelings and the like. Future loss is assessed and handed over and not repaid if the recipient dies. And this extends as a problem far beyond the NHS to the military and insurance and everyday purchases. And it is all the time being encouraged by adverts on television .

To view the original article CLICK HERE
As I have known and followed Susanne Cameron-Blackie for a number of years and colluded on certain issues, particularly in her personna of Anna Raccoon, a link to her site can be found on CLICK HERE
I totally endorse her sentiments regarding suing the NHS, having refused to sue for considerable damage done to me during my nephrectomy and subsequently, damage that has given me both disability and pain every day since the operation in Sep-2001!
Every penny piece I might have been paid by way of compensation would have been money denied to other patients for their medical treatment, not to mention the obscene percentage that would have vanished in costs and fees!
I whole heartedly endorse Susanne’s stance and would commend to you her heartfelt and selfless essay on the subject CLICK HERE
Think of Susanne and join with me in wishing her a pain free final journey having fulfilled so many challenges, acting ethically and with courage to the end in a reflection of her style through her lifetime. When the time comes I will miss her humour and the razor sharp ethical manner she always had to cut to the chase – I do so hope she will continue to out live both the odds and predictions, with her usual stoic determination, for a prolongued period until it suits her to avoid the risk of further pain and indignity.
Long before her diagnosis with cancer I never really thanked her for her compassion and encouragement in my battle with cancer, that most penicious and unwelcome visitation on ones body, life and loved ones.

Regards,
Greg_L-W.

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CAVEAT:

This is a VERY long and detailed article which in full runs to over 10,000 words – with, at the end, LINKS to almost 2,000 other articles related to The Prostate!

Prostate Cancer: Stages and Grades

Approved by the Cancer.Net Editorial Board, 01/2017

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as what the cancer cells look like under a microscope. This is called the stage and grade. To see other pages, use the menu.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Staging for prostate cancer also involves looking at test results to find out if the cancer has spread from the prostate to other parts of the body. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

There are 2 types of staging for prostate cancer:

  • The clinical stage is based on the results of tests done before surgery, which includes DRE, biopsy, x-rays, CT and/or MRI scans, and bone scans. X-rays, bone scans, CT scans, and MRI scans may not always be needed. They are recommended based on the PSA level; the size of the cancer, which includes its grade and volume; and the clinical stage of the cancer.
  • The pathologic stage is based on information found during surgery, plus the laboratory results, referred to as pathology, of the prostate tissue removed during surgery. The surgery often includes the removal of the entire prostate and some lymph nodes.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?
  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?
  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details about each part of the TNM system for prostate cancer.

Tumor (T)

Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of a tumor in the prostate.

T1: The tumor cannot be felt during a DRE and is not seen during imaging tests. It may be found when surgery is done for another reason, usually for BPH or an abnormal growth of noncancerous prostate cells.

  • T1a: The tumor is in 5% or less of the prostate tissue removed during surgery.
  • T1b: The tumor is in more than 5% of the prostate tissue removed during surgery.
  • T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level.

T2: The tumor is found only in the prostate, not other parts of the body. It is large enough to be felt during a DRE.

  • T2a: The tumor involves one-half of 1 lobe (part or side) of the prostate.
  • T2b: The tumor involves more than one-half of 1 lobe of the prostate but not both lobes.
  • T2c: The tumor has grown into both lobes of the prostate.

T3: The tumor has grown through the prostate capsule on 1 side and into the tissue just outside the prostate.

  • T3a: The tumor has grown through the prostate capsule either on 1 side or on both sides of the prostate, or it has spread to the neck of the bladder. This is also known as an extraprostatic extension (EPE).
  • T3b: The tumor has grown into the seminal vesicle(s), the tube(s) that carry semen.

T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter, the part of the muscle layer that helps to control urination; the rectum; levator muscles; or the pelvic wall.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These tiny, bean-shaped organs help fight infection. Lymph nodes near the prostate in the pelvic region are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional (pelvic) lymph node(s).

Metastasis (M)

The “M” in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones. This is called distant metastasis.

MX: Distant metastasis cannot be evaluated.

M0 (M plus zero): The disease has not metastasized.

M1: There is distant metastasis.

  • M1a: The cancer has spread to nonregional, or distant, lymph node(s).
  • M1b: The cancer has spread to the bones.
  • M1c: The cancer has spread to another part of the body, with or without spread to the bone.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classification. See the table below the stage descriptions for all of the TNM combinations for each stage.

Stage I: Cancer is found in the prostate only, usually during another medical procedure. It cannot be felt during the DRE or seen on imaging tests. A stage I cancer is usually made up of cells that look more like healthy cells and is usually slow growing. 

Stage I Prostate Cancer

Stage IIA and IIB: This stage describes a tumor that is too small to be felt or seen on imaging tests. Or, it describes a slightly larger tumor that can be felt during a DRE. The cancer has not spread outside of the prostate gland, but the cells are usually more abnormal and may tend to grow more quickly. A stage II cancer has not spread to lymph nodes or distant organs. 

Stage IIA Prostate Cancer

Stage IIB Prostate Cancer

Stage III: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles. 

Stage I Prostate Cancer

Stage IV: This stage describes any tumor that has spread to other parts of the body, such as the bladder, rectum, bone, liver, lungs, or lymph nodes. 

Stage IV Prostate Cancer

Recurrent: Recurrent prostate cancer is cancer that has come back after treatment. It may come back in the prostate area again or in other parts of the body. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Stage Grouping Chart

Stage

T

N

M

I

T1a, T1b, or T1c

N0

M0

T2a

N0

M0

Any T1 or T2a

N0

M0

 

 

 

 

IIA

T1a, T1b, or T1c

N0

M0

T1a, T1b, or T1c

N0

M0

 

T2a

N0

M0

 

T2b

N0

M0

 

T2b

N0

M0

 

 

 

 

IIB

T2c

N0

M0

 

Any T1 or T2

N0

M0

 

Any T1 or T2

N0

M0

 

 

 

 

III

T3a or T3b

N0

M0

 

 

 

 

 

 

 

IV

T4

N0

M0

Any T

N1

M0

 

Any T

Any N

M1

Used with permission of the AJCC, Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition, published by Springer-Verlag New York, www.cancerstaging.org

Gleason score for grading prostate cancer

Prostate cancer is also given a grade called a Gleason score. This score is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less aggressive tumors generally look more like healthy tissue. Tumors that are more aggressive are likely to grow and spread to other parts of the body. They look less like healthy tissue.

The Gleason scoring system is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 1 to 5. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score. To assign the numbers, the doctor determines the main pattern of cell growth, which is the area where the cancer is most obvious; looks for any other less common pattern of growth; and gives each 1 a score. The scores are added together to come up with an overall score between 2 and 10.

The interpretation of the Gleason score by doctors has changed recently. Originally, doctors used a wide range of scores. Today, doctors no longer use Gleason scores of 5 or lower for cancer found with a biopsy. The lowest score used is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.

Doctors look at the Gleason score in addition to stage to help plan treatment. For example, active surveillance, described in the Treatment Options section, may be an option for a patient with a small tumor, low PSA level, and a Gleason score of 6. Patients with high Gleason score may need treatment that is more intensive, even if it does not appear that the cancer has spread.

Gleason X: The Gleason score cannot be determined.

Gleason 6 or lower: The cells are well differentiated, meaning they look similar to healthy cells.

Gleason 7: The cells are moderately differentiated, meaning they look somewhat similar to healthy cells.

Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated, meaning they look very different from healthy cells.

Recently, pathologists have begun to adopt a new Gleason grouping system that arranges the scores into simplified groups that are translated as follows:

  • Gleason Group I = Former Gleason 6
  • Gleason Group II = Former Gleason 3 + 4 = 7
  • Gleason Group III = Former Gleason 4 + 3 = 7
  • Gleason Group IV = Former Gleason 8
  • Gleason Group V = Former Gleason 9 or 10

Prostate Cancer Risk Groups

In addition to stage, doctors use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Two such risk assessment methods come from the National Comprehensive Cancer Network (NCCN) and the University of California, San Francisco (UCSF).

NCCN

The NCCN developed 4 risk-group categories based on PSA level, prostate size, needle biopsy findings, and the stage of cancer. The lower your risk, the lower the chance that the prostate cancer will grow and spread.

  • Very low risk. The tumor cannot be felt during a DRE and is not seen during imaging tests but was found during a needle biopsy (T1c). PSA is less than 10 ng/mL. The Gleason score is 6 or less. Cancer was found in fewer than 3 samples taken during a core biopsy. The cancer was found in half or less of any core.
  • Low risk. The tumor is classified as T1a, T1b, T1c, or T2a (see above). PSA is less than 10 ng/mL. The Gleason score is 6 or less.
  • Intermediate risk. The tumor has 2 or more of these characteristics:
    • Classified as T2b or T2c (see above)
    • PSA is between 10 and 20 ng/mL
    • Gleason score of 7
  • High risk. The tumor has 2 or more of these characteristics:
    • Classified as T3a (see above)
    • PSA level is higher than 20 ng/mL
    • Gleason score is between 8 and 10
  • Very high risk. The tumor is classified as T3b or T4 (see above). The histologic grade is 5 for the main pattern of cell growth, or more than 4 biopsy cores have Gleason scores between 8 and 10.

Source: Risk group information is adapted from the NCCN.

UCSF Cancer of the Prostate Risk Assessment (UCSF-CAPRA) score

The UCSF-CAPRA score predicts a man’s chances of having the cancer spread and of dying. This score can be used to help make decisions about the treatment plan. Points are assigned according to a person’s age at diagnosis, PSA at diagnosis, Gleason score of the biopsy, T classification from the TNM system, and the percentage of biopsy cores involved with cancer. These categories are then used to assign a score between 0 and 10.

  • CAPRA score 0 to 2 indicates low risk.
  • CAPRA score 3 to 5 indicates intermediate risk.
  • CAPRA score 6 to 10 indicates high risk.   

Information about the cancer’s stage and other prognostic factors will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu to choose another section to continue reading this guide.

To view the original of this article CLICK HERE
BELOW:
is another, even more detailed article, on Gleason Grading or Staging

Gleason grading system

Links

- Susan J. Maygarden and Raj Pruthi. Gleason Grading and Volume Estimation in Prostate Needle Biopsy Specimens Am J Clin Pathol Pathology Patterns Reviews 2005 123:S58-S66; doi : PDF)

- Grading of prostatic adenocarcinoma: current state and prognostic implications
Jennifer Gordetsky and Jonathan Epstein. Diagnostic Pathology 2016; 11:25. doi : 10 1186/s13000-016-0478-2 (Free)

Historical background

In the 1960s and 1970s, Donald F. Gleason and collaborators characterized various architectural patterns of prostatic cancer and grouped them into five grades or patterns, thus establishing the Gleason grading system.

More than four decades since its introduction, the Gleason system still remains the key prognostic factor in patients with prostatic cancer.

The Gleason system was derived largely from observations in larger specimens, such as prostatectomy and transurethral prostatic resection specimens.

Donald F. Gleason in 1966 created a unique grading system for prostatic carcinoma based solely on the architectural pattern of the tumor.

Another innovative aspect of this system was, rather than assigning the worst grade as the grade of the carcinoma, the grade was defined as the sum of the two most common grade patterns and reported as the Gleason score. The original description of this system was based on a study of 270 patients from the Minneapolis Veterans Administration Hospital.

Initially, Gleason intended to classify carcinomas into four Gleason patterns (GPs), but a small group of distinctive tumors (clear cell) was observed and they were placed in a separate 5th category (pattern 4).

Certain aspects of the original Gleason system would be interpreted differently in today’s practice. The cribriform pattern described, as a component of Gleason’s original pattern 2 and 3 would today typically be considered higher grade.

Individual cells listed under Gleason’s original pattern 3 would also be currently assigned a higher grade.

Pattern 4 has become significantly expanded beyond Gleason’s original description of tumors with clear cytoplasm that resembled renal cell carcinoma.

By 1974, Gleason and the Veterans Administration Cooperative Urological Research Group expanded their study to 1,032 men.

Gleason pattern 4 was described in a figure legend, as “raggedly infiltrating, fused-glandular tumor, frequently with pale cells, may resemble hypernephroma of kidney.”

The Gleason system was further refined by Mellinger in 1977 when the papillary and cribriform tumor under Gleason pattern 3 was described as having a “smooth and usually rounded edge”.

In describing the breakdown of Gleason patterns amongst 2,911 cases, Gleason pattern 1 was seen in 3.5%; pattern 2 in 24.4%; pattern 3 in 87.7%; pattern 4 in 12.1%; and pattern 5 in 22.6%.

These percentages added up to approximately 150% since 50% of the tumors showed at least two different patterns.

In 1977, Gleason provided additional comments concerning the application of the Gleason system. “Grading is performed under low magnification (40-100x).” He also stated “an occasional small area of fused glands did not change a pattern 3 tumor to pattern 4. A small focus of disorganized cells did not change a pattern 3 or 4 tumor to pattern 5.”

The only comment relating to tertiary patterns was “occasionally, small areas of a third pattern were observed.”

Synopsis Gleason Grade or Gleason Pattern Identification

The Gleason Grade is also known as the Gleason Pattern and ranges from 1 to 5:

- Gleason Grade 1 – Here, cancerous tissue is well differentiated and looks like normal prostate tissue. Glands are well packed and formed.
- Gleason Grade 2 – Here, well-formed large glands have more tissue between them.
- Gleason Grade 3 – Glands begin to look darker and show signs of randomness. They seem to be breaking away from monotony of their existence and invading surrounding tissue.
- Gleason Grade 4 – Majority of glands appear to be interspersed with surrounding tissue. A few recognizable glands are still present though.
- Gleason Grade 5 – There are no recognizable glands. Cells with distinct nuclei appear in sheets within surrounding tissue.

Description

Numerous grading systems have been designed for histopathological grading of prostate cancer. The main controversies have been whether grading should be based on glandular differentiation alone or a combination of glandular differentiation and nuclear atypia, and also whether prostate cancer should be graded according to its least differentiated or dominant pattern.

The Gleason grading system named after Donald F. Gleason is now the predominant grading system, and in 1993, it was recommended by a WHO consensus conference.

As described by Gleason, the initial grading of prostate carcinoma should be performed at low magnification using a 4x or 10x lens.

After one assesses the case at scanning magnification, one may proceed to use the 20x lens to verify the grade. For example, at low magnification one may have the impression of fused glands or necrosis but may require higher magnification at 20x to confirm its presence.

However, one should not initially use the 20x or 40x objectives to look for rare fused glands or a few individual cells seen only at higher power which would lead to an overdiagnosis of Gleason pattern 4 or 5, respectively.

The Gleason grading system is based on glandular architecture; nuclear atypia is not evaluated. Nuclear atypia as adopted in some grading systems, correlates with prognosis of prostate cancer but there is no convincing evidence that it adds independent prognostic information to that obtained by grading glandular differentiation alone.

The Gleason grading system defines five histological patterns or grades with decreasing differentiation.

- Normal prostate epithelial cells are arranged around a lumen.
- In Gleason patterns 1 to 3, there is retained epithelial polarity with luminal differentiation in virtually all glands.
- In pattern 4, there is partial loss of normal polarity.
- In pattern 5, there is an almost total loss of polarity with only
occasional luminal differentiation.

Prostate cancer has a pronounced morphological heterogeneity and usually more than one histological pattern is present.

The primary and secondary pattern, i.e. the most prevalent and the second most prevalent pattern are added to obtain a Gleason score or sum.

It is recommended that the primary and secondary pattern as well as the score be reported, e.g. Gleason score 3+4=7.

If the tumour only has one pattern, Gleason score is obtained by doubling that pattern, e.g. Gleason score 3+3=6.

Gleason scores 2 and 3 are only exceptionally assigned, because Gleason pattern 1 is unusual.

Gleason score 4 is also relatively uncommon because pattern 2 is usually mixed with some pattern 3 resulting in a Gleason score 5.

Gleason score 2-4 tumour may be seen in TURP material sampling the transitional zone.

With the introduction of the needle core biopsy technique, the Gleason system evolved to accommodate needle biopsy practice, in which the grading was done on limited biopsy core tissue.

In needle biopsy material, it has been proposed that a Gleason score of 2-4 should not be assigned. Gleason scores 6 and 7 are the most common scores and include the majority of tumours in most studies.

Gleason pattern 1

Gleason pattern 1 is composed of a very well circumscribed nodule of separate, closely packed glands, which do not infiltrate into adjacent benign prostatic tissue. The glands are of intermediate size and approximately equal in size and shape. This pattern is usually seen in transition zone cancers. Gleason pattern 1 is exceedingly rare. When present, it is usually only a minor component of the tumour and not included in the Gleason score.

Gleason pattern 2

Gleason pattern 2 is composed of round or oval glands with smooth ends. The glands are more loosely arranged and not quite as uniform in size and shape as those of Gleason pattern 1. There may
be minimal invasion by neoplastic glands into the surrounding non-neoplastic prostatic tissue. The glands are of intermediate size and larger than in Gleason pattern 3. The variation in glandular size and separation between glands is less than that seen in pattern 3. Although not evaluated in Gleason grading, the cytoplasm of Gleason pattern 1 and 2 cancers is abundant and pale-staining. Gleason pattern 2 is usually seen in transition zone cancers but may occasionally be found in the peripheral zone.

Gleason pattern 3

Gleason pattern 3 is the most common pattern. The glands are more infiltrative and the distance between them is more variable than in patterns 1 and 2. Malignant glands often infiltrate between adjacent non-neoplastic glands. The glands of pattern 3 vary in size and shape and are often angular. Small glands are typical for pattern 3, but there may also be large, irregular glands. Each gland has an open lumen and is circumscribed by stroma. Cribriform pattern 3 is rare and difficult to distinguish from cribriform high-grade PIN.

Gleason pattern 4

In Gleason pattern 4, the glands appear fused, cribriform or they may be poorly defined. Fused glands are composed of a group of glands that are no longer completely separated by stroma. The edge of a group of fused glands is scalloped and there are occasional thin strands of connective tissue within this group. Cribriform pattern 4 glands are large or they may be irregular with jagged edges. As opposed to fused glands, there are no strands of stroma within a cribriform gland. Most cribriform invasive cancers should be assigned a pattern 4 rather than pattern 3. Poorly defined glands do not have a lumen that is completely encircled by epithelium. The hypernephromatoid pattern described by Gleason is a rare variant of fused glands with clear or very pale staining cytoplasm.

Gleason pattern 5

In Gleason pattern 5, there is an almost complete loss of glandular lumina. Only occasional lumina may be seen. The epithelium forms solid sheets, solid strands or single cells invading the stroma. Care must be applied when assigning a Gleason pattern 4 or 5 to limited cancer on needle biopsy to exclude an artefact of tangential sectioning of lower grade cancer. Comedonecrosis may be present.

Grade progression

The frequency and rate of grade progression is unknown. Tumour grade is on average higher in larger tumours. However, this may be due to more rapid growth of high grade cancers. It has been demonstated that some tumours are high grade when they are small.

Many studies addressing the issue of grade progression have a selection bias, because the patients have undergone a repeat transurethral resection or repeat biopsy due to symptoms of tumour progression.

The observed grade progression may be explained by a growth advantage of a tumour clone of higher grade that was present from the beginning but undersampled. In patients followed expectantly there is no evidence of grade progression within 1-2 years.

Grading minimal cancer on biopsy

It is recommended that a Gleason score be reported even when a minimal focus of cancer is present. The correlation between biopsy and prostatectomy Gleason score is equivalent or only marginally worse with minimal cancer on biopsy. It is recommended that even in small cancers with one Gleason pattern that the Gleason score be reported. If only the pattern is reported, the clinician may misconstrue this as the Gleason score.

Tertiary Gleason patterns

The original Gleason grading system does not account for patterns occupying less than 5% of the tumour or for tertiary patterns.

In radical prostatectomy specimens, the presence of a tertiary high
grade component adversely affects prognosis. However, the prognosis is not necessarily equated to the addition of the primary Gleason pattern and the tertiary highest Gleason pattern.

For example, the presence of a tertiary Gleason pattern 5 in a Gleason score 4+3=7 tumour worsens the prognosis compared to the same tumour without a tertiary high grade component.

However, it is not associated with as adverse prognosis as a Gleason score 4+5=9. When this tertiary pattern is pattern 4 or 5, it should be reported in addition to the Gleason score, even when it is less than 5% of the tumour.

Although comparable data do not currently exist for needle biopsy material, in the setting of three grades on biopsy where the highest grade is the least common, the highest grade is incorporated as the secondary pattern.

An alternative option is in the situation with a tertiary high grade pattern (i.e. 3+4+5 or 4+3+5) is to diagnose the case as Gleason score 8 with patterns 3, 4 and 5 also present.

The assumption is that a small focus of high grade cancer on biopsy will correlate with a significant amount of high grade cancer in the prostate such that the case overall should be considered high grade, and that sampling artefact accounts for its limited nature on biopsy.

Reporting Gleason scores in cases with multiple positive biopsies

In cases where different positive cores have divergent Gleason scores, it is controversial whether to assign an averaged (composite) Gleason score or whether the highest Gleason score should be considered as the patient’s grade.

In practice, most clinicians take the highest Gleason score when planning treatment options.

Grading of variants of prostate cancer

Several morphological variants of prostate adenocarcinoma have been described (e.g. mucinous and ductal cancer).

They are almost always combined with conventional prostate cancer and their effect on prognosis is difficult to estimate.

In cases with a minor component of a prostate cancer variant, Gleason grading should be based on the conventional prostate cancer present in the specimen.

In the rare case where the variant form represents the major component, it is controversial whether to assign a Gleason grade.

Grading of specimens with artefacts and treatment effect

Crush artefacts

Crush artefacts are common at the margins of prostatectomy specimens and in core biopsies. Crush artefacts cause disruption of the glandular units and consequently may lead to overgrading
of prostate cancer. These artefacts are recognized by the presence of noncohesive epithelial cells with fragmented cytoplasm and dark, pyknotic nuclei adjacent to preserved cells. Crushed areas should not be Gleason graded.

Hormonal and radiation treatment

Prostate cancer showing either hormonal or radiation effects can appear artefactually to be of higher Gleason score. Consequently, Gleason grading of these cancers should not be performed. If there is cancer that does not show treatment effect, a Gleason score can be assigned to these components.

Correlation of needle biopsy and prostatectomy grade

Prostate cancer displays a remarkable degree of intratumoural grade heterogeneity. Over 50% of total prostatectomy specimens contain cancer of at least three different Gleason grades, and cancer of a single grade is present in only 16% of the specimens.

Of individual tumour foci, 58% have a single grade, but most of these foci are very small.

Several studies have compared biopsy and prostatectomy Gleason score. Exact correlation has been observed in 28.2-67.9% of the cases. The biopsies undergraded in 24.5-60.0% and overgraded in 5.2-32.2%.

Causes for biopsy grading discrepencies are undersampling of higher or lower grades, tumours borderline between two grade patterns, and misinterpretation of patterns.

The concordance between biopsy and prostatectomy Gleason score is within one Gleason score in more than 90% of cases.

Reproducibility

Pathologists tend to undergrade. The vast majority of tumours graded as Gleason score 2 to 4 on core biopsy are graded as Gleason score 5 to 6 or higher when reviewed by experts in urological pathology.

In a recent study of interobserver reproducibility amongst general pathologists, the overall agreement for Gleason score groups 2-4, 5-6, 7, and 8-10 was just into the moderate range.

Undergrading is decreased with teaching efforts and a substantial interobserver reproducibility can be obtained.

Prognosis

Multiple studies have confirmed that Gleason score is a very powerful prognostic factor on all prostatic samples. This includes the prediction of the natural history of prostate cancer and the assessment of the risk of recurrence after total prostatectomy or radiotherapy.

Several schedules for grouping of Gleason scores in prognostic categories have been proposed.

Gleason scores 2 to 4 behave similarly and may be grouped.

Likewise, Gleason scores 8 to 10 are usually grouped together, although they could be stratified with regard to disease progression in a large prostatectomy study.

There is evidence that Gleason score 7 is a distinct entity with prognosis intermediate between that of Gleason scores 5-6 and 8 to 10, respectively.

Although the presence and amount of high grade cancer (patterns 4 to 5) correlates with tumour prognosis, reporting the percentage pattern 4/5 is not routine clinical practice.

Gleason score 7 cancers with a primary pattern 4 have worse prognosis than those with a primary pattern 3.

ISUP 2005 modifications

A group of urological pathologists convened at the 2005 United States and Canadian Academy meeting in San Antonio in an attempt to achieve consensus in controversial areas relating to the Gleason grading system.

The goal of the meeting was to achieve consensus amongst leading urological pathologists in specific areas of Gleason grading, including areas where there was either a lack of data or scant information as to the optimal method of grading.

In the latter instances, the consensus was based on personal and institutional experience with a large number of cases. Over 70 urological pathologists from around the world were invited to attend, with most attending.

For the purposes of this meeting, we defined “consensus” when two-thirds of the participants were in agreement, although for almost all of the issues discussed a much higher degree of agreement was reached.

See also : ISUP 2005 modifified Gleason score

At the turn of the century, attempts and recommendations were made in order to clarify how the Gleason system should be applied in practice, since it was evident that differences in Gleason system interpretation and application existed.

However, several issues remained unresolved, as this system was ultimately dependent on a subjective interpretation of various morphological patterns of cancer.

For example, it was unclear what extent of variations in size and shape of neoplastic glands should be scored as Gleason pattern (GP) 3 and what represented the scope of gland fusion patterns, interpreted as GP4.

Additional problematic issues included the grading of ill-defined glands with poorly formed lumina, defining the morphological spectrum of cribriform glands, and the grading of a tertiary grade, when it was higher than the primary and secondary grades.

In order to resolve these and other issues pertaining to Gleason grading in practice, the International Society of Urological Pathology (ISUP) convened a consensus conference on Gleason grading at the 2005 United States and Canadian Academy of Pathology Annual Meeting in San Antonio, TX, USA.

Uropathologists from 20 countries attempted to clarify and standardize the contemporary use of the Gleason system by providing consensus recommendations, based on accumulated evidence and practice standards, as to how the Gleason system should be applied and reported in contemporary practice.

Thus, a 2005 ISUP modified Gleason system was proposed, outlining the morphological patterns 1–5, which were accompanied by a modified diagram, similar to the original Gleason system.

It was reiterated that GP1 and GP2 are quite rare on biopsy and prostatectomy.

The most significant modifications pertained to patterns 3 and 4.

GP3 was restricted to discrete glandular units (as in the original system) and to smoothly circumscribed but only small cribriform tumour nodules, which, in essence, reduced the spectrum of cribriform glands interpreted as pattern 3.

Pattern 4 included fused glands and large cribriform glands or cribriform glands with border irregularities, as well as hypernephromatoid glands.

Additionally, a category of ill-defined glands or glands containing poorly formed glandular lumina was introduced (not present previously) and was included under GP4.

GP5 was reserved for cancers containing essentially no glandular differentiation, composed of solid sheets, cords, and single cells, as in the original system.

Comedocarcinoma with central necrosis was also retained in pattern 5, regardless of whether it was surrounded by papillary, cribriform or solid sheets.

The consensus also provided clarifications on the grading of variants and variations of acinar adenocarcinoma of prostate, which were illustrated by examples.

These included the issues of interpretation and grading of: vacuoles, foamy gland cancer, ductal adenocarcinoma, colloid (mucinous) carcinoma, small cell carcinoma, adenocarcinoma with focal mucinous extravasation, mucinous fibroplasia (collagenous micronodules), glomeruloid structures, and pseudohyperplastic carcinoma.

The consensus also recommended that secondary patterns of higher grade when present to a limited extent (≤5% of the tumour area) should always be reported on needle biopsy, while there was no consensus on reporting on prostatectomy.

Secondary patterns of lower grade when present to a limited extent (≤5% of the tumour area) in needle biopsies, prostatectomies and transurethral resections of prostate should be ignored.

Regarding the issue of tertiary GP, it was recommended that the Gleason score (GS) on needle biopsy should be derived by adding the primary and the highest pattern, whereas tertiary pattern on prostatectomy, when it is higher than the primary and the secondary patterns, should be reported separately.

Another recommendation was that separate dominant tumour nodules of different Gleason patterns should be scored separately on prostatectomy.

Finally, it was recommended that individual Gleason scores should be reported on needle biopsy specimens with different cores showing different grades, as long as the cores are submitted in separate containers. In addition, it was left as an option to provide an overall GS at the end of the case.

The impact of these recommendations on prostatic cancer grading in contemporary practice remains unknown, because they were introduced relatively recently and because it is uncertain how much they have penetrated and potentially altered routine prostatic pathology practice.

Hence, the objective of this study was to determine whether and how the proposed ISUP consensus recommendations have influenced the application of the modified Gleason system in grading biopsy and prostatectomy specimens in a contemporary setting of a large uropathology practice.

Reporting secondary patterns of lower grade when present to a limited extent

It was the consensus of the ISUP group that in the setting of high-grade cancer one should ignore lower grade patterns if they occupy less than 5% of the area of the tumor.

For example, a needle biopsy core that is 100% involved by cancer, with 98% Gleason pattern 4 and 2% Gleason pattern 3 would be diagnosed as Gleason score 4+4=8.

These cases with extensive pattern 4 cancer, where a significant amount of tumor is available for examination, should be considered as high grade (Gleason score>8).

At the other extreme, one can occasionally see small foci of Gleason pattern 4 on needle biopsy with a few glands of pattern 3. In the setting of very limited cancer on needle biopsy, the few glands of pattern 3 would typically occupy over 5% of the area of the tumor focus, and one would grade these tumors as Gleason score 4+3=7. Given the significant potential in this scenario of a sampling error resulting from only limited cancer on biopsy, the presence of a relatively small amount of pattern 3 would most likely correspond to a Gleason score 7 tumor in the corresponding prostate. The same 5% cut off rule for excluding lower grade cancer also applies for TURPs and radical prostatectomy specimens, which in most cases would relate to extensive cancer with more than 95% Gleason pattern 4 tumor.

Reporting secondary patterns of higher grade when present to a limited extent

It was the consensus of the group that high-grade tumor of any quantity on needle biopsy, as long as it was identified at low to medium magnification (see General applications of the Gleason grading system) should be included within the Gleason score. Any amount of high grade tumor sampled on needle biopsy most likely indicates a more significant amount of high grade tumor within the prostate due to the correlation of grade and volume and the problems inherent with needle biopsy sampling. Consequently, a needle biopsy which is entirely involved by cancer with 98% Gleason pattern 3 and 2% Gleason pattern 4 would be diagnosed as Gleason score 3+4=7.

In radical prostatectomy specimens with the analogous situation of a tumor nodule having 98% Gleason pattern 3 and 2% pattern 4, there was no consensus within the group. Approximately half of the group would diagnose these foci in an analogous fashion to that done on needle biopsy and interpret the case as Gleason score 3+4=7 regardless of the percentage of pattern 4. The other half would note these tumors as Gleason score 3+3=6 with a minor component of Gleason pattern 4. The rationale for the latter method is based on radical prostatectomy data; cancers with more than 95% Gleason pattern 3 and less than 5% pattern 4 have pathological stages that are worse than a pure Gleason score 3+3=6 tumor yet not as adverse as a Gleason score 3+4=7 where pattern 4 occupies more than 5% of the tumor.

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Historical background

Donald F. Gleason in 1966 created a unique grading system for prostatic carcinoma based solely on the architectural pattern of the tumor [1, 2, 3]. Another innovative aspect of this system was, rather than assigning the worst grade as the grade of the carcinoma, the grade was defined as the sum of the two most common grade patterns and reported as the Gleason score. The original description of this system was based on a study of 270 patients from the Minneapolis Veterans Administration Hospital.

Initially, Gleason intended to classify carcinomas into four patterns, but a small group of distinctive tumors (clear cell) was observed and they were placed in a separate 5th category (pattern 4) [2]. Certain aspects of the original Gleason system would be interpreted differently in today’s practice. The cribriform pattern described, as a component of Gleason’s original pattern 2 and 3 would today typically be considered higher grade. Individual cells listed under Gleason’s original pattern 3 would also be currently assigned a higher grade. Pattern 4 has become significantly expanded beyond Gleason’s original description of tumors with clear cytoplasm that resembled renal cell carcinoma.

By 1974, Gleason and the Veterans Administration Cooperative Urological Research Group expanded their study to 1,032 men [4]. Gleason pattern 4 was described in a figure legend, as “raggedly infiltrating, fused-glandular tumor, frequently with pale cells, may resemble hypernephroma of kidney.” The Gleason system was further refined by Mellinger in 1977 when the papillary and cribriform tumor under Gleason pattern 3 was described as having a “smooth and usually rounded edge” [5]. In describing the breakdown of Gleason patterns amongst 2,911 cases, Gleason pattern 1 was seen in 3.5%; pattern 2 in 24.4%; pattern 3 in 87.7%; pattern 4 in 12.1%; and pattern 5 in 22.6% [5]. These percentages added up to approximately 150% since 50% of the tumors showed at least two different patterns.

In 1977, Gleason provided additional comments concerning the application of the Gleason system [6]. “Grading is performed under low magnification (40-100x).” He also stated “an occasional small area of fused glands did not change a pattern 3 tumor to pattern 4. A small focus of disorganized cells did not change a pattern 3 or 4 tumor to pattern 5.” The only comment relating to tertiary patterns was “occasionally, small areas of a third pattern were observed.”
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Why the need for a consensus on Gleason grading?

It is a testament to the enduring power of the original Gleason grading system that it is the accepted grading system throughout the world, despite its inception almost 40 years ago. How many other things in medicine have stood the test of time so well? Nonetheless, medicine in general and prostate carcinoma in specific has changed dramatically since the late 1960s, when the Gleason grading system was derived. In the 1960s, there was no screening for prostate cancer other than by digital rectal exam, as serum PSA had not yet been discovered. In Gleason’s 1974 study, the vast majority (86%) of men had advanced disease with either local extension out of the prostate on clinical exam or distant metastases. Only 6% of patients had nonpalpable tumor diagnosed by transurethral resection and 8% of patients were diagnosed with a localized nodule on rectal exam [4]. The method of obtaining prostate tissue was also very different from today’s practice. Typically, only a couple of thick gauge needle biopsies were directed into an area of palpable abnormality. The use of 18-gauge thin biopsy needles and the concept of sextant needle biopsies to more extensively sample the prostate were not developed until the 1980s [7]. Consequently, the grading of prostate cancer in thin cores and in multiple cores from different sites of the prostate were not issues in Gleason’s era.

In the 1960s, radical prostatectomy was relatively uncommon, prostates were not as often removed intact, and glands were not processed in their entirety or as extensively and systematically to the degree currently seen. Further issues relating to radical prostatectomy specimens such as the grading of multiple nodules within the same prostate or dealing with tertiary patterns were not addressed within the original Gleason system.

The Gleason system also predated the use of immunohistochemistry. It is likely that with immunostaining for basal cells many of Gleason’s original 1+1=2 adenocarcinomas of the prostate would today be regarded as adenosis (atypical adenomatous hyperplasia). Similarly, many of the cases in 1967 diagnosed as cribriform Gleason pattern 3 carcinoma would probably be currently referred to as cribriform high grade prostatic intraepithelial neoplasia (PIN) or intraductal carcinoma of the prostate, if labeled with basal cell markers [8, 9].

Another issue not dealt with in the original Gleason grading system is how to grade newly described variants of adenocarcinoma of the prostate. Some of the more common variants where grading controversy exists include: mucinous carcinoma, ductal adenocarcinoma, foamy gland carcinoma, and pseudohyperplastic adenocarcinoma of the prostate. In addition, there are certain patterns of adenocarcinoma of the prostate such as those with glomeruloid features and mucinous fibroplasia (collagenous micronodules) where the use of Gleason grading was not defined.

The application of the Gleason system for all of the reasons noted above varies considerably in contemporary surgical pathology practice and has led to several recent attempts to achieve consensus on Gleason grading.
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2005 ISUP consensus conference

A group of urological pathologists convened at the 2005 United States and Canadian Academy meeting in San Antonio in an attempt to achieve consensus in controversial areas relating to the Gleason grading system [10]. The goal of the meeting was to achieve consensus amongst leading urological pathologists in specific areas of Gleason grading, including areas where there was either a lack of data or scant information as to the optimal method of grading. In the latter instances, the consensus was based on personal and institutional experience with a large number of cases. Over 70 urological pathologists from around the world were invited to attend, with most attending. For the purposes of this meeting, we defined “consensus” when two-thirds of the participants were in agreement, although for almost all of the issues discussed a much higher degree of agreement was reached.
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General applications of the Gleason grading system

As described by Gleason, the initial grading of prostate carcinoma should be performed at low magnification using a 4x or 10x lens. After one assesses the case at scanning magnification, one may proceed to use the 20x lens to verify the grade. For example, at low magnification one may have the impression of fused glands or necrosis but may require higher magnification at 20x to confirm its presence. However, one should not initially use the 20x or 40x objectives to look for rare fused glands or a few individual cells seen only at higher power which would lead to an overdiagnosis of Gleason pattern 4 or 5, respectively.

Gleason patterns
Gleason score 1+1=2

It was the consensus that a Gleason score of 1+1=2 is a grade that should not be diagnosed regardless of the type of specimen, with extremely rare exception. Most cases which were diagnosed as Gleason score 1+1=2 in the era of Gleason would today be referred to as adenosis (atypical adenomatous hyperplasia).
Gleason scores 3-4

These low-grade tumor scores were assigned by members of the consensus panel occasionally on transurethral resection specimens (TURPs) and in multifocal low-grade tumors within radical prostatectomy specimens. In contrast to Gleason’s diagram and text, the consensus was that cribriform patterns are not allowed within Gleason pattern 2. It is now accepted that Gleason score 2-4 should not be assigned to cancer on needle biopsy for several reasons:

poor reproducibility even amongst experts;

poor correlation with prostatectomy grade with almost all cases showing higher grade at resection;

a diagnosis of Gleason score 3-4 may misguide clinicians and patients into believing that the patient has an indolent tumor [11, 12].

The major limitation of rendering a diagnosis of Gleason score 4 on needle biopsy is that one cannot see the entire edge of the lesion to determine if it is completely circumscribed. Consequently, most of the lesions that appear to be very low grade on needle biopsies are diagnosed by urological pathologists as Gleason score 2+3=5 or 3+2=5.
Gleason pattern 3

A departure from the original Gleason classification system is that “individual cells” would not be allowed within Gleason pattern 3. Rather, Gleason pattern 3 cancer consists of variably sized individual glands. A further area of divergence from the original Gleason system is the controversial area of cribriform Gleason pattern 3. Within Gleason’s original illustrations of his cribriform pattern 3, he depicts large cribriform glands, which the consensus panel would uniformly diagnose as cribriform pattern 4. The consensus panel required extremely stringent criteria for the diagnosis of cribriform pattern 3, with remaining cribriform patterns typically falling into Gleason pattern 4. The criteria used to diagnose cribriform pattern 3 were rounded, well circumscribed glands of the same size of normal glands. When various images were shown to the consensus panel of potential candidates for cribriform Gleason pattern 3, almost none of them met the criteria based on subtle features, such as slight irregularities of the outer border of the cribriform glands. Subsequent to the 2005 meeting, this author reviewed 3590 consecutive prostate cancers sent to me over seven months; 30 needle biopsy cases were selected that possibly represented cribriform Gleason pattern 3 cancer [13], 36 digital images were taken and sent to ten experts in prostate pathology with a consensus defined when at least 7/10 experts agreed on the grade. Even in this highly selected set of images thought to be the best candidates for cribriform pattern 3 from a busy consult service, most experts interpreted the cribriform patterns as pattern 4. There was only one consensus pattern 3 case. Furthermore, most of the cribriform foci investigated (73%) were associated with more definitive pattern 4 elsewhere on the needle biopsy specimen. There was poor reproducibility amongst experts as to cribriform pattern 3 vs. pattern 4 due to:

disagreement as to what are the key diagnostic features in a given case (i.e. irregular distribution of lumina and variable slit-like lumina, favor pattern 4 vs. small glands and regular contour, favor pattern 3;

disagreement as to assessment of given criteria: regular vs. irregular distribution of lumina and regular vs. irregular contour.

Conceptually, one would expect the change in grade from pattern 3 to pattern 4 to be reflected in a distinct architectural paradigm shift where cribriform as opposed to individual glands are formed, rather than merely a subjective continuum of differences in size, shape and contour of cribriform glands.

The only reason why cribriform pattern 3 even exists is because of the original Gleason schematic diagram. Gleason never specifically published the prognostic difference between what he called cribriform Gleason pattern 3 compared to Gleason pattern 4. Many of Gleason’s cribriform Gleason pattern 3 cancers may not even have been infiltrating carcinomas due to the lack of availability of immunohistochemistry for basal cell markers. Today we might have diagnosed them either as cribriform high-grade PIN or intraductal carcinoma of the prostate (concepts not present in Gleason’s era). Based on all the above data, all cribriform cancer should be interpreted as Gleason pattern 4 and not pattern 3.
Gleason pattern 4

A controversial area where consensus was reached was that ill-defined glands with poorly formed glandular lumina also warrant the diagnosis of Gleason pattern 4. Only a cluster of such glands, where a tangential section of Gleason pattern 3 glands cannot account for the histology, would be acceptable as Gleason pattern 4. It was also noted that in most cases ill-defined glands with poorly formed glandular lumina are accompanied by fused glands. Very small, well-formed glands still are within the spectrum of Gleason pattern 3. This definition differs from Gleason’s original description of pattern 4 which only included the hypernephromatoid pattern [2]. Only in subsequent years were fused glandular masses added to the definition [5]. The original schematic diagram of Gleason pattern 4 consisted almost entirely of cribriform patterns without depicting fused glands or ill-defined glands with poorly formed glandular lumina. Gleason pattern 4 closely resembling renal cell carcinoma (hypernephromatoid pattern) makes up only a very small percentage of Gleason pattern 4 cases.
Gleason pattern 5

Gleason pattern 5 consists of individual cells, cords of cells, and sheets of tumor. Although typically one sees comedonecrosis with solid nests, occasionally one can see necrosis with cribriform masses that by themselves might be cribriform pattern 4. If there is true comedonecrosis, the consensus was that these patterns should be regarded as Gleason pattern 5. One must be stringent as to the definition of comedonecrosis, requiring intraluminal necrotic cells and/or karyorrhexis, especially in the setting of cribriform glands. We have noted in two studies using different patient populations the tendency for pathologists to undergrade Gleason pattern 5 in almost 50% of cases sent for a second opinion at the request of the patient of urologist where this author has diagnosed Gleason pattern 5. Pattern 5 was missed more frequently when it was not the primary pattern.

Grading variants and variations of acinar adenocarcinoma of the prostate
Vacuoles

Adenocarcinomas of the prostate may contain clear vacuoles and these should be distinguished from true signet-ring carcinomas which contain mucin. Whereas vacuoles in adenocarcinoma of the prostate are not uncommon, true mucin-positive signet-ring cell carcinomas of prostate are exceedingly rare with only a handful of bona fide cases reported in the literature. Vacuoles may distort the architecture and it is controversial as to what grade should be assigned. Gleason’s only mention of vacuoles described them as signet cells under pattern 5 tumor [6]. The panel concluded that although typically vacuoles are seen within Gleason pattern 4 cancer, it may be seen within Gleason pattern 5 and even Gleason pattern 3 tumors. The consensus was that tumors should be graded, as if the vacuoles were not present, by only evaluating the underlying architectural pattern.
Foamy gland carcinoma

In an analogous fashion to handling cancers with vacuoles, it was the consensus of the panel that in grading foamy gland carcinomas one should ignore the foamy cytoplasm and grade the tumor solely based on the underlying architecture. Whereas most cases of foamy gland carcinoma would be graded as Gleason score 3+3=6, higher grade foamy gland carcinomas exist and should be graded accordingly based on the pattern [14, 15].
Ductal adenocarcinoma

Ductal adenocarcinomas of the prostate most commonly are composed of either papillary fronds or cribriform structures [16]. Ductal adenocarcinomas are recognized as being aggressive tumors with most studies showing comparable behavior to acinar cancer with a Gleason score 4+4=8. The consensus of the panel was that ductal adenocarcinomas should be graded as Gleason score 4+4=8, while retaining the diagnostic term of ductal adenocarcinoma to denote their unique clinical and pathological findings. This can be achieved by diagnosing such a tumor as “prostatic ductal adenocarcinoma (Gleason score 4+4=8).” In cases with mixed ductal and acinar patterns, the ductal patterns should be assigned Gleason pattern 4. The only exceptions to grading ductal adenocarcinoma as Gleason pattern 4 are:

PIN-like ductal adenocarcinoma;

ductal adenocarcinoma with comedonecrosis.

PIN-like ductal adenocarcinoma consists of individual glands lined by tall pseudostratified columnar cells resembling high grade PIN [17]. Its prognosis appears comparable to Gleason pattern 3. Although it has not been specifically studied, ductal adenocarcinoma with comedonecrosis is graded as Gleason pattern 5.
Colloid (mucinous) carcinoma

The majority of cases with colloid carcinoma consist of irregular cribriform glands floating within a mucinous matrix [18, 19]. It was the uniform consensus that these cases would be scored Gleason score 4+4=8. However, uncommonly one may see individual round discrete glands floating within mucinous pools. There was no consensus in these cases whether such cases should be diagnosed as Gleason score 4+4=8 or Gleason score 3+3=6. Approximately half of the group said that by definition all colloid carcinomas should be assigned a Gleason score of 8, while the other half felt that one should ignore the extracellular mucin and grade the tumor based on the underlying architectural pattern. The excellent prognosis of mucinous carcinomas in a large study of mucinous carcinoma at radical prostatectomy supports grading mucinous prostate carcinomas based on the underlying architectural pattern rather than assuming that all of these tumors are aggressive [20].
Small cell carcinoma

It was the consensus that small cell carcinoma of the prostate has unique histological, immunohistochemical, and clinical features [21]. Comparable to its more common pulmonary counterpart, chemotherapy is the mainstay of therapy for prostatic small cell carcinomas. These clinicopathologic features differ from those associated with Gleason pattern 5 prostatic acinar carcinoma, such that small cell carcinoma should not be assigned a Gleason grade.
Adenocarcinoma with focal mucin extravasation

There was consensus amongst the group that adenocarcinomas of the prostate with focal mucinous extravasation should not be by default graded as Gleason score 4+4=8. Rather, one should ignore focal mucinous extravasation and grade the tumor based on the underlying architecture of the glands. The distinction between focal mucinous extravasation and colloid carcinoma is the presence of epithelial elements floating within the mucinous matrix within the latter whereas with mucinous extravasation there is only focal acellular mucin adjacent to cancer.
Mucinous fibroplasia (collagenous micronodules)

The delicate ingrowth of fibrous tissue seen with mucinous fibroplasia can result in glands appearing to be fused resembling cribriform structures although the underlying architecture is really that of individual discrete rounded glands invested by loose collagen. The tumor should be graded on the underlying glandular architecture, whereby the majority are graded as Gleason score 3+3=6 [22]. Only when there are distinct cribriform glands in areas of mucinous fibroplasias does this author diagnose Gleason pattern 4.
Glomeruloid structures

Glomeruloid glands in prostatic adenocarcinoma are characterized by dilated glands containing intraluminal cribriform structures with a single point of attachment, resembling a renal glomerulus [22]. On prostate biopsy, glomeruloid glands are exclusively associated with carcinoma and not associated with benign mimickers. The grading of such glomeruloid structures is controversial. Some urological pathologists do not assign a grade to glomeruloid patterns and rather just grade the surrounding tumor. According to some experts for the rare case where the entire tumor is composed of glomeruloid glands, a grade of 3+3=6 is assigned as long as the glomeruloid structures are small. Larger glomeruloid structures are uniformly accepted by urological pathologists as Gleason pattern 4. Other experts in the field feel that all glomeruloid structures should be assigned a Gleason pattern 4. A study of ours, subsequent to the consensus conference, indicated that glomerulations were overwhelmingly associated with concurrent Gleason pattern 4 or higher-grade carcinoma [23]. In several cases, transition could be seen among small glomerulations, large glomeruloid structures, and cribriform pattern 4 cancer. These data suggest that glomerulations represent an early stage of cribriform pattern 4 cancer and are best graded as Gleason pattern 4.
Pseudohyperplastic adenocarcinoma

Uncommonly, adenocarcinomas of the prostate share some architectural features with benign glands, including larger size, branching, and papillary infolding. These cancers should be graded as Gleason score 3+3=6 with pseudohyperplastic features [24, 25]. This convention is in large part based on the recognition that they are most often accompanied by more ordinary Gleason score 3+3=6 adenocarcinoma.

Reporting secondary patterns of lower grade when present to a limited extent

It was the consensus of the group that in the setting of high-grade cancer one should ignore lower grade patterns if they occupy less than 5% of the area of the tumor. For example, a needle biopsy core that is 100% involved by cancer, with 98% Gleason pattern 4 and 2% Gleason pattern 3 would be diagnosed as Gleason score 4+4=8. These cases with extensive pattern 4 cancer, where a significant amount of tumor is available for examination, should be considered as high grade (Gleason score>8). At the other extreme, one can occasionally see small foci of Gleason pattern 4 on needle biopsy with a few glands of pattern 3. In the setting of very limited cancer on needle biopsy, the few glands of pattern 3 would typically occupy over 5% of the area of the tumor focus, and one would grade these tumors as Gleason score 4+3=7. Given the significant potential in this scenario of a sampling error resulting from only limited cancer on biopsy, the presence of a relatively small amount of pattern 3 would most likely correspond to a Gleason score 7 tumor in the corresponding prostate. The same 5% cut off rule for excluding lower grade cancer also applies for TURPs and radical prostatectomy specimens, which in most cases would relate to extensive cancer with more than 95% Gleason pattern 4 tumor.

Reporting secondary patterns of higher grade when present to a limited extent

It was the consensus of the group that high-grade tumor of any quantity on needle biopsy, as long as it was identified at low to medium magnification (see General applications of the Gleason grading system) should be included within the Gleason score. Any amount of high grade tumor sampled on needle biopsy most likely indicates a more significant amount of high grade tumor within the prostate due to the correlation of grade and volume and the problems inherent with needle biopsy sampling. Consequently, a needle biopsy which is entirely involved by cancer with 98% Gleason pattern 3 and 2% Gleason pattern 4 would be diagnosed as Gleason score 3+4=7.

In radical prostatectomy specimens with the analogous situation of a tumor nodule having 98% Gleason pattern 3 and 2% pattern 4, there was no consensus within the group. Approximately half of the group would diagnose these foci in an analogous fashion to that done on needle biopsy and interpret the case as Gleason score 3+4=7 regardless of the percentage of pattern 4. The other half would note these tumors as Gleason score 3+3=6 with a minor component of Gleason pattern 4. The rationale for the latter method is based on radical prostatectomy data; cancers with more than 95% Gleason pattern 3 and less than 5% pattern 4 have pathological stages that are worse than a pure Gleason score 3+3=6 tumor yet not as adverse as a Gleason score 3+4=7 where pattern 4 occupies more than 5% of the tumor [26, 27].

Tertiary Gleason patterns

Needle biopsy

On needle biopsies with patterns 3, 4, and 5, both the primary pattern and the highest grade should be recorded, which is a departure from the original Gleason grading system [10]. For example, tumors with Gleason score 3+4 and a tertiary pattern 5 would be recorded as Gleason score 3+5=8. Men with biopsy Gleason score 7 with tertiary pattern 5 have a higher risk of PSA failure whether treated with radical prostatectomy or radiation therapy when compared to men with Gleason score 7 without tertiary grade 5 and have a comparable risk with men with Gleason score 8-10 [28, 29]. In cases where there are three patterns consisting of patterns 2, 3, and 4, pattern 2 is ignored and the biopsy is graded as Gleason score 3+4=7 or Gleason score 4+3=7, depending on whether pattern 3 or pattern 4 was more prevalent.

Radical prostatectomy

In radical prostatectomy specimens, tertiary Gleason patterns are associated with higher pathological stage and biochemical recurrence as compared to the same Gleason score cancers without tertiary patterns. [26, 27, 30, 31, 32, 33, 34, 35]. The presence of a tertiary higher grade component is associated with an increased risk of biochemical recurrence, typically raising the risk of recurrence to a level intermediate between those of cancers without a tertiary component in the same Gleason score category and cancers in the next higher Gleason score category. The one exception is Gleason score 4+3=7 with tertiary pattern 5, which has progression rates more comparable to Gleason score 8. Typically, the tertiary pattern is added to the Gleason score (i.e. 3+4=7 with tertiary pattern 5).

Radical prostatectomy specimens with separate tumor nodules

It was recommended that radical prostatectomy specimens should be processed in an organized fashion where one can make some assessment as to whether one is dealing with a dominant nodule or separate tumor nodules. This does not necessarily require serially sectioning and embedding a radical prostatectomy in its entirety. Rather, multiple sampling techniques have described how one can subtotally submit the prostate, yet still maintain orientation in order to distinguish between different tumor nodules [36, 37, 38]. This issue becomes critical in the situation where one has a higher-grade peripheral nodule and a smaller, typically transition zone, lower-grade nodule. One can have a nodule of Gleason score 4+4=8 within the peripheral zone and a Gleason score 2+2=4 nodule within the transition zone. Occasionally these Gleason score 2+2=4 transition zone tumors may even reach relatively sizable proportions although typically they are organ-confined. If one were to assign an overall score considering all of the tumor within the prostate as one lesion, the score of such a tumor would be Gleason score 4+2=6 or Gleason score 2+4=6. It was the consensus of the group that such a grade would be misleading as it is not logical to expect that the presence of a lower grade tumor that is discrete from a separate high grade tumor nodule could in some way mitigate the poor prognosis associated with the higher grade tumor nodule. It was also recognized that if a tumor was graded, for example, as Gleason score 4+2=6 or 2+4=6, the presence of pattern 4 within such a diagnosis would not be emphasized and the patient would typically merely be recorded as having a Gleason score 6 tumor, which would not accurately reflect the nature of his lesion. The recommendation of the consensus conference was that one should assign a separate Gleason score to each dominant tumor nodule(s). With only a couple of exceptions, pathologists within the consensus conference who were authors of large radical prostatectomy series had already adopted this method of grading and the prognostic impact of the Gleason score within these series already reflects this approach. Most often, the dominant nodule is the largest tumor, which is also the tumor associated with the highest stage and highest grade. In the unusual occurrence of a non-dominant nodule (i.e. smaller nodule) that is of higher stage, one should also assign a grade to that nodule. If one of the smaller nodules is the highest grade focus within the prostate, the grade of this smaller nodule should also be recorded. In general this will be the exception; in most cases, separate grades will be assigned to only one or at most two dominant nodules.

Needle biopsy with different cores showing different grades

In current practice within the United States, a minimum of ten to 12 cores are sampled for the initial biopsy to rule out prostate cancer. In cases where multiple cores are positive for cancer, different cores may have a different Gleason grade. What overall grade should be assigned to such a patient for purposes of treatment and prognosis? This issue assumes its greatest importance when one or more of the cores show pure high-grade cancer (i.e. Gleason score 4+4=8) and the other cores show pattern 3 (3+3=6, 3+4=7, 4+3=7) cancer. Should the overall grade be the core with the highest grade or does one assign the grade by mentally adding all the cancer together as if it was one long core. Assume a case with Gleason score 4+4=8 on one core with pattern 3 (3+3=6, 3+4=7, 4+3=7) on other cores. The “Global” score for the entire case, averaging all involved needle biopsies together as if they were one long positive core, would be 4+3=7 or 3+4=7 depending on whether pattern 4 or 3 predominated.

Several studies have demonstrated that in cases with different cores having different grades, the highest Gleason score on a given core correlates better with stage and Gleason score at radical prostatectomy than the average or most frequent grade amongst the cores [39, 40, 41]. Additional support for giving cores a separate grade rather than an overall score for the entire case is that all of the various tables (i.e. Partin tables) and nomograms that have been validated and proven to be prognostically useful have used the highest core grade in cases where there are multiple cores of different grades.

It is therefore incumbent on pathologists to report the grades of each core separately as long as the cores are submitted in separate containers or the cores are in the same container yet specified by the urologist as to their location (i.e. by different color inks). As a consequence, the core with the highest grade tumor can be selected by the clinician as the grade of the entire case to determine treatment [42, 43]. In addition to giving separate cores individual Gleason scores, it is an option for pathologists to also give an overall score at the end of the case.

There is no consensus how to grade different cores with different grades when the different cores are present within the same specimen container without a designation as to site [10]. For example, there may be two cores of tissue from the left base in one jar without further designation, or multiple cores divided into containers from the left and right side of the gland. If more than one core contains cancer in the setting of multiple cores per container, some urological pathologists still grade each core separately with the remaining experts in the field giving an overall grade for the involved cores per specimen container. A rationale for the latter approach is that it is implicit that clinicians submitting multiple cores together in one container do not value the specific information derived from the cores within a given container. On the other hand, assigning a Gleason score to each core even when there are multiple positive cores in a given jar provides the most accurate information for patient care.

In cases with multiple fragmented cores in a jar, only an overall Gleason score for that jar can be assigned. For example, diagnosing Gleason score 4+4=8 on a tiny tissue fragment where there are other fragments with Gleason score 3+3=6 could be in error; if the cores were intact and the tumor was all on one core, it would be assigned a Gleason score 3+4=7 or 4+3=7.

Prognostic Gleason grade grouping

A problem with the current system is that Gleason score 6 is typically recommended as the lowest grade assigned on biopsy material. However, the Gleason scale ranges from 2-10, such that patients are unduly concerned when told they have Gleason score 6 cancer on biopsy, logically but incorrectly assuming that their tumor is in mid-range of aggressiveness. Another problem is that Gleason score 7 tumor is often considered as one grade, without distinction of 3+4=7 and 4+3=7. Finally, most studies combine Gleason scores 8-10 as high grade cancer without differentiating Gleason score 9-10 from Gleason score 8.

Based on a series of 6,462 men treated by radical prostatectomy (RP) where both the needle biopsy and RP were graded using the current modified Gleason grading system, the 5-year biochemical free survival rates for men with 3+3, 3+4, 4+3, 8, and 9-10 at biopsy were 94.6%, 82.7%, 65.1%, 63.1%, and 34.5% respectively (p < 0.001 for trend); and 96.6%, 88.1%, 69.7%, 63.7%, and 34.5% based on RP pathology respectively (p < 0.001).

It has been proposed the following Gleason grade groups and reporting of grade that accurately reflects prognosis while incorporating descriptive terminology:

- Gleason score 2-6 (well-differentiated), prognostic grade group I/V;
- Gleason score 3+4=7 (moderately differentiated), prognostic grade group II/V;
- Gleason score 4+3=7 (moderately-poorly differentiated), prognostic grade group III/V;
- Gleason score 8 (poorly differentiated), prognostic grade group IV/V;
- Gleason score 9-10 (undifferentiated), Prognostic grade group V/V.

See also

- tumoral grade
- prostate cancer

  • prostate adenocarcinoma
    • prostate acinar adenocarcinoma

References

- Update on the Gleason grading system. Jonathan I. Epstein. Ann Pathol. 2011 Nov;31(5 Suppl):S20-6. PMID: 22054451. (Link)

- Diagnosis of limited adenocarcinoma of the prostate. Epstein JI. Histopathology. 2012 Jan;60(1):28-40. PMID: 22212076

- The impact of the 2005 International Society of Urological Pathology (ISUP) consensus on Gleason grading in contemporary practice. Zareba P, Zhang J, Yilmaz A, Trpkov K. Histopathology. 2009 Oct;55(4):384-91. PMID: 19817888

- Gleason DF. Classification of prostatic carcinoma. Cancer Chemother. Rep. 1966; 50; 125–128.

- Bailar JC 3rd, Mellinger GT, Gleason DF. Survival rates of patients with prostatic cancer, tumor stage, and differentiation: preliminary report. Cancer Chemother. Rep. 1966; 50; 129–136.

- Mellinger GT, Gleason DF, Bailar JC 3rd. The histology and prognosis of prostatic cancer. J. Urol. 1967; 97; 331–337.

- Gleason DF, Mellinger GT. Prediction of prognosis for prostatic adenocarcinoma by combined histological grading and clinical staging. J. Urol. 1974; 111; 58–64.

- Gleason DF and the Veterans Administration Cooperative Urological Research Group. Histologic grading and clinical staging of prostate carcinoma. In TannenbaumM ed. Urologic pathology: the prostate. Philadelphia, PA: Lea & Febiger, 1977; 171–198.

- Mellinger GT. Prognosis of prostatic carcinoma. Recent Results Cancer Res. 1977; 60; 61–72.

- Association of Directors of Anatomical and Surgical Pathology. Recommendations for reporting of resected prostate carcinomas. Am. J. Clin. Pathol. 1996; 105; 667–670.

- Srigley JR, Amin MB, Bostwick DG et al. Updated protocol for the examination of specimens from patients with carcinoma of the prostate gland: a basis for checklist. Arch. Pathol. Lab. Med. 2000; 124; 1034–1039.

- Epstein JI. Gleason score 2–4 adenocarcinoma of the prostate on needle biopsy: a diagnosis that should not be made. Am. J. Surg. Pathol. 2000; 24; 477–478.

- Epstein JI, Yang XJ. Grading of prostatic adenocarcinoma. In EpsteinJI, YangXJ eds. Prostate biopsy interpretation, 3rd edn. Philadelphia: Lippincott Williams & Wilkins, 2002; 154–176.

- Amin MB, Grignon DJ, Humphrey PA, Srigley JR. Reporting of prostate carcinoma by the Gleason system. In AminMB, GrignonDJ, HumphreyPA, SrigleyJR eds. Gleason grading of prostate cancer: a contemporary approach. Philadelphia, PA: Lippincott Williams & Wilkins, 2004; 101–111.

- Egevad L, Allsbrook WC, Epstein JE. Current practice of Gleason grading among genitourinary pathologists. Hum. Pathol. 2005; 36; 5–9.

- Epstein JI, Allsbrook WC Jr, Amin MB, Egevad LL and the ISUP Grading Committee. The 2005 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma. Am. J. Surg. Pathol. 2005; 29; 1228–1242.

- Nakanishi H, Wang X, Ochai A et al. A nomogram for predicting low-volume/low grade prostate cancer: a tool in selecting patients for active surveillance. Cancer 2007; 110; 2441–2447.

- Trpkov K, Warman L. Use of digital maps and sampling of radical prostatectomy specimens. Arch. Pathol. Lab. Med. 2006; 130; 1751–1752.

- Schellhammer P, Moriarty R, Bostwick D, Kuban D. Fifteen-year minimum follow-up of a prostate brachytherapy series: comparing the past with the present. Urology 2000; 50; 436–439.

- Gilliland FD, Gleason DF, Hunt WC, Stone N, Harlan LC, Key CR. Trends in Gleason score for prostate cancer diagnosed between 1983–1993. J. Urol. 2001; 165; 846–850.

- Smith EB, Frierson HF Jr, Mills SE, Boyd JC, Theodorescu D. Gleason score of prostate biopsy and radical prostatectomy specimens over past 10 years. Cancer 2002; 94; 2282–2287.

- Chism DB, Hanlon AL, Troncoso P, Al-Saleem T, Horowitz EM, Pollack A. The Gleason score shift: score four and seven years ago. Int. J. Radiat. Oncol. Biol. Phys. 2003; 56; 1241–1247.

- Kondylis FI, Moriarty RP, Bostwick D, Schellhammer P. Prostate cancer grade assignment: the effect of chronological, interpretative and translation bias. J. Urol. 2003; 170; 1189–1193.

- Albertsen PC, Hanley JA, Barrows GH et al. Prostate cancer and the Will Rogers phenomenon. J. Natl Cancer Inst. 2005; 97; 1248–1253.

- Helpap B, Egevad L. The significance of modified Gleason grading of prostatic carcinoma on biopsy and radical prostatectomy specimens. Vichows Arch. 2006; 449; 622–627.

- Billis A, Guimaraes MS, Freitas LL, Meirelles L, Magna LA, Fereira U. The impact of the 2005 International Society of Urological Pathology consensus conference on standard Gleason grading of prostatic carcinoma in needle biopsies. J. Urol. 2008; 180; 548–552.

- Lin KK. Pathologic findings in 5912 prostate biopsies. [Abstract.] Mod. Pathol. 2008; 21 (Suppl. 1); 166A.

- Gofrit ON, Zorn KC, Steinberg GD, Zagaja GP, Shalhav AL. The Will Rogers phenomenon in urological oncology. J. Urol. 2008; 179; 28–33.

- Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon: stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. New Engl. J. Med. 1985; 312; 1604–1608.

Regards,
Greg_L-W.

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Treat life-threatening SEPSIS within the hour, says NICE, to Save Lives & Limbs …

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10 March 2017

Treat life-threatening sepsis within the hour, says NICE

NICE is urging hospital staff to treat people with life-threatening sepsis symptoms within one hour.

In a new draft quality standard, NICE says people showing signs of sepsis must be checked carefully. Once someone is classed as high-risk they should be seen by senior staff and given the right treatment within an hour.

Professor Gillian Leng, NICE deputy chief executive, said: “Severe symptoms can develop in sepsis very quickly. If high-risk patients are not identified and treated promptly, people can be left with debilitating problems. In the worst cases, they may die.

“This quality standard highlights priorities in the continued fight to improve sepsis care. We know from recent case reviews that there are inconsistencies in how people’s symptoms are assessed in different settings. More can be done to provide rapid treatment.”

The quality standard highlight areas from NICE’s 2016 sepsis guideline that will help health professionals improve care for those who are at risk of becoming seriously ill.

It stresses that staff in any setting, from GPs to paramedics, should check people for specific signs that will show if their symptoms are life-threatening. This includes taking their temperature or heart rate, or checking for rashes and skin discolouration.

Anyone found to be high-risk should be seen by senior hospital staff immediately. This review would be carried out by an available doctor or nurse who is authorised to prescribe antibiotics.

Dr Ron Daniels BEM, Chief Executive of the UK Sepsis Trust, comments: “An emphasis on timely treatment and diagnosis is crucial if we are to improve outcomes for people with sepsis, and this quality standard could be a hugely impactful reinforcement of the recent guideline recommendation that sepsis is treated with same urgency as heart attacks.” 

NICE says that high-risk sepsis patients should get antibiotics and IV fluid treatment within the hour. If it will take more than an hour to get someone to hospital, GPs or ambulance staff can also administer antibiotics.

Prompt treatment means people are more likely to survive and it reduces the risk of further problems like heart failure or limb amputation.

The 2015 report from the National Confidential Enquiry into Patient Outcome and Death found that 40% of people admitted to A&E with sepsis did not have a timely review by a senior clinician. It also reported avoidable delays in administering antibiotics in more than a quarter (29%) of cases and inconsistencies in early use of intravenous (IV) fluid.

Health Secretary Jeremy Hunt said: “Every death from sepsis is a tragedy, yet too often the warning signs are missed – we need to get far better at spotting sepsis across the NHS and this advice shows how vital it is for clinicians to treat life-threatening symptoms as soon as possible.

sepsis symptoms hospital check in screen

“Our relentless drive to raise awareness of this deadly condition, as well as the tireless efforts of campaigners and families who have lost loved ones, has seen a million leaflets and posters already distributed to GP clinics, hospitals and other public places – helping raise awareness to fight against this devastating condition.”

A recent study from the York Health Economics Consortium suggests that 260,000 people in the UK develop sepsis every year. And the UK Sepsis Trust estimates that sepsis kills around 44,000 people per year.

Not everyone with sepsis will be at risk of getting seriously ill. NICE says that people who are classed as low-risk should get information on what to do if they continue to feel unwell and how to get further medical help.

NICE is asking for views on the draft quality standard. It is out for public consultation until Friday 7 April 2017.

To view the original of this article CLICK HERE

To view additional information on SEPSIS CLICK HERE
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  18. I value the NHS as a HEALTH SERVICE NOT a Lifestyle support
  19. I believe in a DEATH PENALTY for serial or GBH rape.
  20. I believe in a DEATH PENALTY for serial, terrorist, mass or for pleasure murder.
  21. I believe in a DEATH PENALTY for serial gross child abuse including sexual.
  22. I do NOT trust or believe in armed police
  23. I do NOT believe in prolonging human life beyond reasonable expectation of sentient participatory intellectual existence
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Enlarged Prostate Treatment Without Surgery …

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Enlarged Prostate Treatment Without Surgery …
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Posted by:
Greg Lance – Watkins
Greg_L-W

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Hi,

having had my VERY enlarged Prostate [Benign Prostatic Hyperplasia (BPH)] operated on on Tuesday I was waiting to be TWOCed (Trial Without Catheter) on Wednesday morning in a hospital bed when the hospital paper trolley came round and the front page headline was:

Prostate therapy without surgery: Thousands of men to benefit from new technique that uses plastic beads to block blood supply and shrink the enlarged gland 

  • Successful trial in Portugal being followed up in UK with results due this year
  • If it is successful the technique could be rolled out for routine use on the NHS 
  • Researchers expect it to largely replace surgery as the standard treatment

Tens of thousands of men could benefit from a breakthrough prostate treatment announced today.

The technique uses tiny plastic beads to block the blood supply and shrink the enlarged gland – all without an operation.

A successful trial in Portugal is being followed up in Britain, with results due back later this year. If successful it could be rolled out for routine use on the NHS.

Half of all men over 50 suffer from an enlarged prostate and every year 45,000 have risky surgery to remove part of it.

As well as being painful and invasive, the operation can cause loss of sexual function and even incontinence. The technique uses tiny plastic beads to block the blood supply and shrink the enlarged gland – all without an operation

The technique uses tiny plastic beads to block the blood supply and shrink the enlarged gland – all without an operation

Last night, researchers said they expected the new technique – prostate artery embolisation – to largely replace surgery as the standard treatment.

An enlarged prostate presses on the bladder, while also blocking the urethra. This means sufferers need to make repeated night-time trips to the toilet, often to find they cannot urinate at all.

This can lead to a build-up of toxins that cause severe kidney problems. The bead technique has been tested on 1,000 middle-aged men in Portugal.

Joao Martins Pisco, who led the study at St Louis Hospital in Lisbon, said: ‘Within five years I think this will replace surgery as the standard treatment.

‘Prostate artery embolisation gives men a treatment option that is less invasive than other therapies and allows them to return to their normal lives sooner. 

Time and time again, I see patients who are relieved to find out about prostate artery embolisation because they are not able to tolerate medications due to their side effects.

‘These men also don’t want traditional surgery because it involves greater risks, has possible sexual side effects, and has a recovery time that is relatively long compared to prostate artery embolisation, which is generally performed under local anaesthesia and on an outpatient basis.’

The Portuguese team, which will present its findings at the Society of Interventional Radiology in Washington DC today, concluded the procedure is as effective as surgery and the benefits may last as long. 

Half of all men over 50 suffer from an enlarged prostate and every year 45,000 have risky surgery to remove part of it

Half of all men over 50 suffer from an enlarged prostate and every year 45,000 have risky surgery to remove part of it

Only two patients in the seven-year trial had clinical side effects.

Performed under local anaesthetic, the procedure involves injecting hundreds of 0.2mm plastic beads into an artery in the groin. 

The beads are directed with a thin tube into the blood vessels that flow to the prostate, blocking blood supply to the enlarged gland so that it shrinks.

Dr Pisco added: ‘I have had nine babies born to men who were able to continue their sex lives after having the treatment.’ 

His team saw a 89 per cent success rate six months after surgery, 82 per cent success up to three years, and 78 per cent beyond three years.

Two hundred patients in Southampton General, Guy’s Hospital in London and 16 other clinics are involved in the British trial, which is part-funded by the clinical watchdog NICE.

Dr Nigel Hacking, who is leading the study, said: ‘It is very encouraging. I am always cautious about new techniques but this procedure seems to be showing promise and it seems to be safe.’

Louise de Winter of the Urology Foundation said: ‘This research is very exciting.

‘As the population ages these problems are going to get even more acute.’

An estimated 45,000 men undergo surgery for enlarged prostates every year in the UK.

Dr Pisco claims most of these could be replaced by prostate artery embolisation – although others say the less invasive procedure is not be suitable for all men, and many will have to continue to have surgery.

Two hundred patients in Southampton General (pictured) Guy’s Hospital in London and 16 other clinics are involved in the British trial

Two hundred patients in Southampton General (pictured) Guy’s Hospital in London and 16 other clinics are involved in the British trial

Dr Hacking said that in his own experience, roughly 40 per cent of patients who have embolisation later have to undergo operations.

But having initial embolisation may enable them to delay that operation while retaining sexual function, and this usually means that when they do come to have an operation it is less invasive and there is a lower risk of side effects.

‘Even if they do need to go back and have surgery it’s a smaller operation,’ he said.

Dr Hacking said it was unlikely the procedure will completely replace surgery, because it requires a highly trained interventional radiologist.

‘It is a fiddly procedure and it would be potentially dangerous for someone without the skills to do it,’ he said.

‘But I think it may give men another option alongside surgery.’

Surgery, conducted either with a hot wire or lasers, have a high success rate – but they come with side effects which can include loss of sexual function, bleeding and incontinence.

The symptoms of enlarged prostate include a frequent need to urinate, but also difficulty starting to urinate and difficulty fully emptying a bladder. 

These symptoms, however, also might be a sign of prostate cancer, so anyone in this way should be seen by a urologist.

To view the original article CLICK HERE

 For another take on the same issue but in a different paper, minded this was added 2 days later & is largely a lift from the first article:

Bead treatment can save men from prostate surgery

About 45,000 men are offered surgery to relieve the symptoms of an enlarged prostate every yearJEFF PACHOUD/Getty Images

Doctors have welcomed an “exciting” technique that could spare tens of thousands of men surgery for an uncomfortable prostate problem.

The NHS treatments adviser is studying closely a procedure that injects tiny plastic beads into arteries to block blood flow to the prostate after research found it safe and effective.

About half of older men have an enlarged prostate. Although it is not a serious health threat, sufferers have problems urinating and their nights are disrupted by frequent lavatory visits.

Medication is often used and an estimated 45,000 men a year are offered surgery to cut away part of the prostate and relieve the pressure of the gland against the urethra.

This requires at least a night in hospital. It also often requires several weeks of recuperation and carries the risk of complications.

Now a trial of 1,000 men has found that the less invasive method of starving the prostate appears to be as good as surgery.

Success rates were 89 per cent after six months, 82 per cent after more than a year and 78 per cent after more than three years, researchers told the Society of Interventional Radiology in Washington yesterday. Only two patients suffered side-effects such as pain.

João Martins Pisco, who led the study at St Louis Hospital in Lisbon, told the Daily Mail: “Within five years I think this will replace surgery as the standard treatment. Prostate artery embolisation gives men a treatment option that is less invasive than other therapies and allows them to return to their normal lives sooner.

“Time and time again, I see patients who are relieved to find out about prostate artery embolisation because they are not able to tolerate medications due to their side-effects.

“These men also don’t want traditional surgery because it involves greater risks, has possible sexual side effects, and has a recovery time that is relatively long compared to prostate artery embolisation, which is generally performed under local anaesthesia and on an outpatient basis.”

A British trial is under way with help from the National Institute for Health and Care Excellence (Nice), which will look at whether the method should be routine on the NHS. Nigel Hacking, of University Hospitals Southampton, who is leading the British research, said: “It is very encouraging. I am always cautious about new techniques but this procedure seems to be showing promise and it seems to be safe.”

Louise de Winter, of the Urology Foundation, said: ‘This research is very exciting. As the population ages these problems are going to get even more acute.”

Last year Nice approved a laser treatment for enlarged prostates to destroy excess tissue, achieving the same results as surgery but allowing men to spend a third less time in hospital.

To view the original article CLICK HERE

Regards,
Greg_L-W.

~~~~~~~~~~#########~~~~~~~~~~
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  16. I see no evidence to trust POLITICIANS at any level or of any persuasion
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A TURP op. (PROSTATE) Royal Gwent Urology Dept. Day Unit 07-Mar-2017 …

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A TURP op. (PROSTATE) Royal Gwent Urology Dept. Day Unit 07-Mar-2017 …
~~~~~~~~~~#########~~~~~~~~~~

Posted by:
Greg Lance – Watkins
Greg_L-W

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.

Hi,

a TURP (Trans Urithral Resection of the Prostate)

prostate-03-turp-trans-urithral-resection-of-prostate

Yesterday afternoon I received a phonecall from Steff, in the Gwent Urology Unit, offering me the chance of bringing forward my appointment, due on 23-Mar-2017, for my TURP (Trans Urethral Resection of the Prostate) to tomorrow morning!

Steff suggested that I came into the Urology Day Unit by 10am, having nothing to eat or drink after midnight, so that I could be ready for anaesthetic in the morning if there was any delay or drop out by another patient – meanwhile assuring me that Adam Carter (my consultant urology surgeon) and the consultant anaethetist he had wanted for my op. would deffinitely have an alocated time for me in the afternoon if there was no morning cancellation.

As it turned out my op. was done just before lunch using an epidural anaesthetic – that is the one administered by an injection into the lower back, the downside of this form of anaesthetic, which deadens the nerves roughly below the point of the injection, is that it can, when the patient is taking anti-coagulants as I am, that if ANY mistake is made it can lead to bleeding into the spinal column which in turn CAN lead to long term paralysis!

The advantage, on the other hand is that it does not lead to unconciousness, as with a GA (General Anaesthetic) thus not only does it not leave anaesthetic in the system for a prolongued period after the operation, but it also meant, which I have alwaqys favoured, that I would be fully conscious and able to watch the operation being done on the screen.

Watching the surgeon slice away your own prostate from inside the bladder, whilst chatting about what he is doing, is a VERY strange experience!

The operation went well and just over an hour after the injection in the spine it was finished and after Adam had shown me the glass jar containing all the little bits he had cut away, which was quite a lot, I was transfered from the operating table onto the trolley and wheeled off to recovery where it took quite a while to get my temperature back up!

During the operation there is a constant flow of saline from the stand via the tube, into the bladder and out, sluicing the debris and clearing the blood so that the surgeon can see exactly what he is doing. During the operation I counted around 19 x 2L square plastic bottles of fluid so around 40Ls of relatively cold fluid, which drops the body temperature during the hour of the operation.

Then with a guage 22 three way catheter in place it was off to Ward D5East for a couple of days until the bleeding had slowed down a bit! Eventually, although I was still bleeding quite heavily and still had a 3 way catheter in, Adam Carter responded to my pleas to go home, where I could recover in greater comfort and with much better food! 3 days later the bleeding had reduced dramatically and I went back into the Gwent where despite no allocated ‘slot’ Steff fitted me in between other patients and and removed my catheter so that I could be TWOCed (Trial With Out Catheter), which once I had proved I could safely pass urine I was able to go home.

That is not to say that the bleeding has stopped! Minded that the operation was on the 8th. and it is now the 31st. there is still a small amount of bleeding – I guess mowing the lawn today didn’t help!

That said there seems no doubt that the operation would seem to have been a great success and at least I am not having to get up 3, 4 or 5 times a night to go to the toilet, which was the outcome of having a greatly enlarged prostate! The other great result of the operation was a letter from Adam Carter, the day before yesterday, to tell me that all the tissue he removed from my prostate (the jar!) had been biopsied and had been found to be perfectly normal prostate tissue free of any signs or traces of cancer.

A very reassuring outcome – I can recommend this operation to anyone with Benign prostate enlargement (BPE), also known as benign prostatic hyperplasia (BPH), a condition that affects older men (yep that’s me at 71!). Several friends of mine have had the op. with great outcomes and at the moment a friend of mine in his mid 50s is in The Royal Gloucester hospital with an enlarged prostate, which has inhibitted voiding of the bladder that has led to a severe UTI (Urinary Tract Infection), which in turn led to blocking of the urethra last Sunday night, leading to a blue lit ride in an ambulance, in extreme pain, in the early hours of Monday and now in the early hours of Saturday they finally removed his catheter but are still battling to control the infection and get his temperature down!

I expect that a TURP is very much on the cards for him, once the infection is cleared and his regular urologist can get him a bed in the Royal Gwent for the operation.

In my case – thanks to Adam Carter, Steff and the rest of the team who looked after me in the Gwent.

Regards,
Greg_L-W.

~~~~~~~~~~#########~~~~~~~~~~
Posted by: Greg Lance-Watkins
tel: 44 (0)1594 – 528 337
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23-Feb-2017 – 10:30hrs. Royal Gwent Urology Dept. Day Unit for A TURP op.

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23-Feb-2017 – 10:30hrs. Royal Gwent Urology Dept. Day Unit for A TURP op. :
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Posted by:
Greg Lance – Watkins
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~~~~~~~~~~#########~~~~~~~~~~

.

Hi,

well if I was in any doubt that I needed this op. the numberr of times I woke and had to go to the toilet during the last few nights was fairly convincing! One starts to wonder why one goes to bed if you get up in the morning more tired than you were at bed time, the odd nap not withstanding!

So anyway we got up showered etc. in a less leisurely manner than normal – then checked I had meds. and other kit sorted and off to the Royal Gwent, in Lee’s car the buffeting of Storm Doris was considerably more noticeable than in the Volvo!
Lee dropped me off and ensured that I wasn’t subject to an NHS unscheduled cancellation but all is well and at least I know all the medical staff apart from the young Doctors on rotation! I must have had around 14 or 15 trans urithral procedures for bladder cancer etc. over the years.
This is somewhat more consequential but much the same.
So it was now the waiting game I had to check in in the morning but I am on Adam Carter’s afternoon list due for 14:00hrs.
Registrar Matt came round explained procedure yet again.
Then Catlin (Consultant Anaethatist) was with me for about half an hour! Going through details and facts and finally arriving at the conclusion that she was not happy to do the op. without a direct instruction and further discussion as she felt on a rough estimate that there was a 10 to 15% chance that due to anti coagulents I might well bleed sufficiently to catastophicly drop my haemaglobin level qand supply of oxygen to my heart thus inducing a heart attack that could/would prove fatal for me.
So it was time for all to think again!
I said I believed that the risk was mine to take and if this was the best odds available I would go ahead!
After prolongued conversation with Adam Carter (Head of Urology) who I have had as my consultant for many years and further talk with Catlin we have decided to try to improve the odds by closer contact with my cardiology consultant Patrick and ensuring Catlin & Adam were hands on for the op. and a HDU (High Dependency Unit) bed was available, pre booked for 3 or 4 days, for me so that I can be closely monitored after the op.
So now we are aiming for 23-Mar-2017 to go ahead with everything in place!
If you are reading this as a prospective TURP patient or a friend of someone about to have one DO NOT PANIC – each person is very different and my case is fairly extreme as I have no lefy coronary artery, and have had a massive heart attck as a result and already I am a bit of a miracle to be here atall! My coronary consultant has said I must take anti coagulant daily and this increases bleeding and the risk as a TURP under those circumstances can bleed heavily and take longer to heal. So don’t panic – I’ve had TURPs previously to my heart attack and had absolutely no problems.
Regards,
Greg_L-W.

~~~~~~~~~~#########~~~~~~~~~~
Posted by: Greg Lance-Watkins
tel: 44 (0)1594 – 528 337
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  5. I DO have a Voice Mail Message System
  6. I ONLY GUARANTEE to answer identifiable eMails
  7. I ONLY GUARANTEE to phone back identifiable UK Land Line Messages
  8. I do NOT accept phone calls from witheld numbers
  9. I Regret due to BT in this area I have a rubbish Broadband connection
  10. I AM opposed to British membership of The EU
  11. I AM opposed to Welsh, Scottish or English Independence within an interdependent UK
  12. I am NOT a WARMIST
  13. I do NOT believe the IPCC Climate Propaganda re Anthropogenic Global Warming
  14. I AM strongly opposed to the subsidy or use of failed technologies eg. WIND TURBINES
  15. I AM IN FAVOUR of rapid research & development of NEW NUCLEAR technologies
  16. I see no evidence to trust POLITICIANS at any level or of any persuasion
  17. I do NOT believe in GODS singular or plural, Bronze Age or Modern
  18. I value the NHS as a HEALTH SERVICE NOT a Lifestyle support
  19. I believe in a DEATH PENALTY for serial or GBH rape.
  20. I believe in a DEATH PENALTY for serial, terrorist, mass or for pleasure murder.
  21. I believe in a DEATH PENALTY for serial gross child abuse including sexual.
  22. I do NOT trust or believe in armed police
  23. I do NOT believe in prolonging human life beyond reasonable expectation of sentient participatory intellectual existence
  24. I believe in EUTHENASIA under clearly defined & legal terms
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pre-op for TURP – 08-Feb-2017 – 14:30hrs. Royal Gwent Urology Dept.

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pre-op for TURP – 08-Feb-2017 – 14:30hrs. Royal Gwent Urology Dept. :
~~~~~~~~~~#########~~~~~~~~~~

Posted by:
Greg Lance – Watkins
Greg_L-W

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www.InfoWebSite.UK

~~~~~~~~~~#########~~~~~~~~~~

.

Hi,

well that was very straightforward!

I arrived very early as the management of the Royal Gwent leaves much to be desired, most noticeably on the issue of parking! For over a year now the car park at the hospital has been a building site where they have been building a really ugly structure that looks for all the world like porta cabins faced with tedious red brick with defacing paterns in a yellowy coloured brick – to replace the porta cabins that have housed A&E for years.

There is now virtually no parking at the Royal Gwent rendering the hospital even more dysfunctional than control of the Trust has increasingly been under5 the aegis of the National Ass. for Wales! (so aptly named).

I was fotunate and found space at my regular side street parking (sorry no clues 😉

Arriving at the urology department I popped in to see a few ‘old friends’ staff who have been providing me with excellent treatment for almost 20 years now, yes there are a few who have been in that department that long including two nurse practitioners Maureen and Janet.

I was fortunate to bump into Adam Carter my Consultant, who I last saw in June last year when we discussed the advisability of my having a TURP (Trans Urithral Resection of the Prostate)

prostate-03-turp-trans-urithral-resection-of-prostate

and he decided this should be scheduled as urgent! The aim being not to remove the prostate gland, which should be about the size of a walnut, but in many older men (& yes I have reached that stage!) the prostate becomes enlarged. Thus the aim is to cut away (resection) part of the gland to reduce its size as it can cause difficulty in urinating but also causes increased fgrequency, poor flow and urgency! We had a somewhat woefull laugh at the state of the service under the National Ass. for Wales’ management such that urgent had finally brought me in 7 months later for my pre op.!

Once again Teresa carried out my pre op. with the normal range of urine test, questions, swabs of mouth, nose and groin to check for any infections, blood test, normal obs. (weight, blood pressure, Oxygen levels, pulse rate, temperature etc.) + a detailed check on my all too dodgey heart and finally an ECG.

I was pronounced fit to join Adam Carter’s list for surgery but with the proviso that my results were cleared by my Cardiologist and the Anasthetic Department was aware and appointed a suitable consultant anethetist to manage any problems that might develope during the procedure – including, I pressume, the detail that my heart might stop!

The normal procedure in the Gwent Urology Department is that on the next working day, Bridget who is responsible for scheduling and the battle with the bed management department in the hospital phones and lets you know when and where to turn up to be sliced and diced!

Because of the checks with other departments it was not until the following Thursday that she was able to alocate a ‘slot’.

I am now due in at 10:30hrs. on Thursday the 23-Feb-2017 showered (no creams or talcs. etc) having had nothing to eat and only a small amount of plain water to drink that day – I will be on Adam Carter’s list for operation that afternoon and since I have to have a full anasthetic I will be in, at least, overnight!

I would normally have had this op. on an epidural block where they inser a needle into the lower spine and anethatise the nerve serving the body from there down – however as I am on blood thinners to cope with my heart and the absence of a Right Coronary Artery a needle in the spine can cause a bleed that could result in paralysis, if not worse!

My urology consultant would rather I stopped taking the blood thinners but my cardiologist rather ruefully points out that I can continue to function with a hugely enlarged prostate and a dodgey bladder but I wont last much over a few minutes without a hear!

All rather a simple decision, but it does make my surgeon’s job a little harder and calls for a consultant anethetist!

Somewhat like Arnie – ‘I will be back’ with details after the op. I may even have some diagrams but I promise no photos!

Think of Lee on Thursday for whilst I’m sleeping my way through the whole procedure she will, yet again, be concerned about the outcome!

Regards,
Greg_L-W.

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Posted by: Greg Lance-Watkins
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