Perspectives on the upgradation of Gleason score after radical prostatectomy: Why our uropathologists need to remain abreast with current concepts

Indian J Urol, Jul-Sept 2010, Vol 26, Issue 3 Dear Editor, I read with interest the manuscript by Nayyar et al. on the upgradation of Gleason score in radical prostatectomy specimens in relation to the tissue obtained from preoperative needle core biopsies (NCB).[1] According to this well-designed study, 177 patients undergoing radical prostatectomy from 2002 to 2008 had their fi nal Gleason score upgraded from 5.51 ± 1.52 (range 2–9) to 6.2 ± 1.42 (range 2–9) after radical prostatectomy. The authors correctly concluded that this unreliability of preoperative assessment casts a doubt on our ability to offer surveillance protocols to patients with low Gleason scores on preoperative biopsy and may render clinical comparisons between various treatment modalities diffi cult.

Dear Editor, I read with interest the manuscript by Nayyar et al. on the upgradation of Gleason score in radical prostatectomy specimens in relation to the tissue obtained from preoperative needle core biopsies (NCB). [1] According to this well-designed study, 177 patients undergoing radical prostatectomy from 2002 to 2008 had their fi nal Gleason score upgraded from 5.51 ± 1.52 (range 2-9) to 6.2 ± 1.42 (range 2-9) after radical prostatectomy. The authors correctly concluded that this unreliability of preoperative assessment casts a doubt on our ability to offer surveillance protocols to patients with low Gleason scores on preoperative biopsy and may render clinical comparisons between various treatment modalities diffi cult.
In my view, however, this study also highlights the need to have dedicated uropathologists coordinating with urology teams to administer the best possible diagnostic care to the patients. It has been well established since a while now that a Gleason score of 2-4 should never be diagnosed on NCB with recent suggestions that even a Gleason score of 5 is becoming out of bounds for pathologists interpreting these specimens. These suggestions, which were first espoused by Epstein in 2000, became established in the 2005 consensus conference of the International Society of Urological Pathology (ISUP). The reasons for these conclusions include the following: poor reproducibility even among experts, upgradation of almost all cases after prostatectomy, inability to assess the edge of the lesion, and

Letters to Editor
Perspectives on the upgradation of Gleason score after radical prostatectomy: Why our uropathologists need to remain abreast with current concepts KUB was done in initial 100 patients; it was normal in the fi rst 100 patients and it was discontinued in subsequent population as it was adding cost without much help in selection or exclusion of healthy population. There are many studies on nomogram preparation not using urine routine microscopy and USG KUB as screening for healthy population. [3][4][5] This original study was presented in USICON 2009 and was awarded the Prof C K P Menon prize after being reviewed by USI chairpersons and judges. The error in total number of patients (mentioned 1011 in place of 1017) occurred because of typing mistake and it does not affect our nomogram preparation and statistical analysis. This minor mistake had happened after editing and typing in manuscript format that was not there in my presentation and sent to the USI before its acceptance as consideration for the Prof C K P Menon prize. So we still think this original study was worthy enough to be accepted for the prize and its acceptance for publication in an indexed journal (Ĳ U).
As for the last query, the article published by Ganpule et al. [6] is not the study for drawing Uroflowmetry nomogram. We were unable to fi nd this article after putting "Urofl owmetry nomogram" as search option in Pubmed, hence we missed this article. Secondly, this study is conducted in patients with LUTS and community patients of a specifi c age group (mean age 62.1 years, SD 9.5, range 40-82, male patients). The aim was to know the prevalence of LUTS in community and correlation between LUTS, age, prostate volume and quality of life, but in our study we have taken healthy population including all age groups and different gender and prepared the Uroflowmetry nomogram. Therefore, we totally disagree with the opinion drawn that earlier study concluded the same as we have come out with.
propagation of a misconception that the urologist may be dealing with an "indolent" tumor. In the year 2001, only 2.4% of all pathologists surveyed, were diagnosing Gleason score 2-4 on NCB. Accordingly, the proportion of biopsies reported as Gleason 2-4 also decreased from 2.7% to 0% after this conference. [2] Well, apparently not.
This study is another case in point that we as urologists and urooncologists need the support of our pathology colleagues, who in turn owe it to our patients to stay abreast with the latest in uropathologic literature and update their diagnostic services in line with the ever-changing standard of care.