Ross HM, Kryvenko ON, Cowan JE, Simko JP, Wheeler TM, Epstein JI
Am J Surg Pathol 2012;36:1346–52
Ross et al. evaluated >14 000 cases according to the upgraded Gleason score (GS) system from the International Society of Urological Pathology (ISUP). They reviewed the cases of radical prostatectomies with GS ≤6 and positive lymph node involvement obtained from the databases of four large academic centers in the United States. In 22 patients, that is, 0.002% of the population with a GS ≤6 tumor, lymph node involvement was reported. All 19 patients for whom tissue was available for review were upgraded to at least 3 + 4 = 7. Thus, the introduction of the ISUP grading system in 2005 has led to a significant decrease in understaging thanks to a better definition of Gleason patterns 4 and 5. The authors concluded that GS ≤6 tumors do not appear to metastasize to the lymph nodes and that Gleason pattern 4 or 5 is responsible for metastatic spread.
Expert's comments:In the management of patients with prostate cancer by active surveillance (AS), there is a risk of understaging ranging from 20% to 30%, as shown in radical prostatectomy series looking at patients who would have qualified for AS based on the initial biopsy and who ended up with more aggressive or advanced disease  and . The risk of understaging can be addressed only by repeated biopsies and will always remain a potential danger to the patient. A further argument raised by opponents against AS is based on the fact that in many of the published series in the literature, there are patients with GS ≤6 that have lymph node metastases. This concern that even these low-risk tumors might metastasize in the course of the disease is understandable. The article by Ross and colleagues is reassuring that GS ≤6 tumors do not metastasize to the lymph nodes. These findings underscore the responsibility of the pathologist to scrutinize biopsies closely and raise the relevant issue of second review by an independent reviewer before putting a patient on AS. Given the knowledge gained by this study, we can more securely offer this therapeutic option with hardly any morbidity to our patients, in these days of criticism about potential overdetection and thus potential overtreatment. It is up to us as urologists to show guidance and wisdom in the management of this complex disease and to prove our critics wrong by showing that we are able to treat these patients critically and wisely.
Conflicts of interest
The author has nothing to disclose.
-  G. Ploussard, L. Salomon, E. Xylinas, et al. Pathological findings and prostate specific antigen outcomes after radical prostatectomy in men eligible for active surveillance—does the risk of misclassification vary according to biopsy criteria?. J Urol. 2010;183:539-545 Crossref
-  S.L. Conti, M. Dall’Era, V. Fradet, J.E. Cowan, J. Simko, P.R. Carroll. Pathological outcomes of candidates for active surveillance of prostate cancer. J Urol. 2009;181:1628-1634 Crossref
Department of Urology, University Hospital Berne, Berne, Switzerland
University Hospital Berne, Department of Urology, Anna Seiler Haus, Berne, 3010, Switzerland.
© 2013 Published by Elsevier B.V.