There is a worldwide debate involving clinicians, uropathologists as well as patients and their families on whether Gleason score 6 adenocarcinoma should be labelled as cancer. There are those in favor of continuing to call it cancer, while others are in favor of removing the label of cancer from Gleason 6 tumors [ 1 - 5 ]. Such hot debate is based on both clinical data and personal view. Those who speak in favor of leaving the label of cancer base their opinion on the fact that Gleason score 6 cancer is composed of Gleason pattern 3 cancer, which shares cytological and molecular alterations associated with higher Gleason patterns acinar adenocarcinoma della prostata has the ability to extend locally beyond the prostate and metastasize [ 2 ].
A recent paper by Ross et al. Finley et al. We report a case of man diagnosed with low risk Gleason score 6 acinar adenocarcinoma whose radical prostatectomy specimen was reported to harbor Gleason score 6 adenocarcinoma with lymphovascular invasion and metastasis in a periprostatic lymph node.
The case presentation includes an epilogue that could better explain the tumor behavior. There was no history of other medications or hormonally-active supplements. No comorbidities, including diabetes, were present. His most recent preoperative total serum PSA was 7. Transrectal ultrasound revealed a hypoechoic area in the left mid part of the prostate.
Induration of the same prostate zone was detected by digital rectal examination. Twelve random ultrasound guided prostatic needle cores were taken. The tumor was classified in the low risk category.
Even though the patient was considered a potential candidate for active surveillance, open radical prostatectomy monolateral nerve sparing in the right side was performed.
Pelvic acinar adenocarcinoma della prostata node dissection was not carried out. The prostate specimen was received fresh from the operating room.
Its weight without the seminal vesicles 33 grams and all three dimensions acinar adenocarcinoma della prostata recorded, the latter used for prostate volume calculation The seminal vesicles were cut into two halves and processed in toto. Staging was done according to the TNM revision [ 10 ].
The nodule, 1. Acinar adenocarcinoma della prostata left posterolateral periprostatic adipose tissue, adjacent to the prostate dominant cancer nodule, contained a lymph node, 0.
Whole mount section. The dominant nodule, contained in the circled area, with acinar adenocarcinoma Gleason score 6 Insert A ; thin bleu arrow and lymphovascular invasion insert B ; thin green arrow. The adjacent periprostatic fat tissue shows a lymph node thick red arrow with metastasis light pink part of the lymph node. In our current presentation, the index tumor consisted of variably sized individual well-formed gland, without cribriform glands, individual cells and glomeruloid features, i.
The same score was observed in the biopsy, dominant nodule of the specimen and lymph node deposit. The Gleason grading system of prostatic carcinoma is the quintessential prognostic factor in predicting findings in radical prostatectomy, biochemical failure, local recurrences, lymph node or distant metastasis in patients receiving no treatment, radiation therapy, radical prostatectomy and other therapies, including cryotherapy and high intensity focal ultrasound therapy [ 911 - 13 ].
Clinicians use routinely various tools, such as Partin tables or Kattan nomograms, to predict outcomes, including pathological stage or prognosis following treatment [ 1415 ]. All of these tools incorporate the Gleason score. Lesions previously referred to as Gleason scores 2 to 4 in the classic system are now assigned a higher grade Gleason score 6 in the modified system; however, those previously graded as Gleason score 6 in the classic system are often graded as Gleason score 7 tumors in the modified system.
It has recently been recommended by Dr JI Epstein that all cribriform patterns are diagnosed as Gleason pattern 4 rather acinar adenocarcinoma della prostata pattern 3. It has also been suggests that glomerulations most likely represent an early stage of acinar adenocarcinoma della prostata pattern 4 cancer and should likely be graded as pattern 4.
The general theme of such changes was acinar adenocarcinoma della prostata limit the definition of pattern 3 carcinoma and widen acinar adenocarcinoma della prostata scope of pattern 4 carcinoma. The Gleason system and its revisions are acinar adenocarcinoma della prostata on the architectural patterns of PCa. The contribution of nuclear morphology to its further refinement has been investigated only to a limited acinar adenocarcinoma della prostata. This was recently confined in a morphometric study in which it was shown that the nuclear signature is important to better define risk groups in PCa patients [ 17 ].
In our current case the WHO grade was 3. Based on the findings of the present case, it is suggested that, in those patients who meet the current criteria for active surveillance, the tumor should also be evaluated for the presence of a WHO grade. If this finding is observed, the patient should be further evaluated for the presence of additional prognostic factors that can better define the aggressiveness of the lesion and require immediate therapy. This is a reproduction of the original diagram given by Dr Acinar adenocarcinoma della prostata to one of the authors RM.
Patients with Gleason score i. Our case showed LVI in the peritumoral parenchyma. LVI has been defined as the unequivocal presence of tumor cells within endothelial-lined spaces with no underlying muscular walls or as the presence of tumor emboli in small intraprostatic vessels. Baydar et al. Studies have demonstrated an association between the presence of lymphovascular invasion and decreased time to biochemical progression, distant metastases, and overall survival after radical prostatectomy [ 18 - 20 ].
Our case showed metastasis in a periprostatic lymph node, i. In the study by Kothari et al. Sizes ranged from 0. Distribution was 2 of 39 5. A recent study by Hansen et al. These findings implicate that patients who seem to have low-risk PCa may harbor PCa metastases within lymph nodes of the periprostatic fat even if they do not have positive pelvic lymph acinar adenocarcinoma della prostata. Von Bodman et al and Acinar adenocarcinoma della prostata et acinar adenocarcinoma della prostata reported that the number of positive lymph nodes affects prognosis in PCa patients with lymph node metastases and reported cut-offs acinar adenocarcinoma della prostata 1 and 2 positive lymph nodes associated with adverse disease-related outcomes, respectively [ 2324 ].
When the paper based on the current case was considered ready for submission, we thought about a possible comment from a reader: Was the paraffin block containing the prostate slice with the dominant nodule and the lymph node serially sectioned to see whether the lesion changed in deeper sections?
To give an answer to this possible question, deeper sections were cut to the point that almost all the slice was sectioned. This lead us to acquire some information on the follow-up of the patient whose radical prostatectomy was done in He is under complete androgen blockade therapy for a postoperative rising PSA levels and pelvic lymph node metastasis. They found that 2 of their cases had tertiary pattern 4 with small cribriform glands.
However, it was unknown whether it was the tertiary pattern 4 to confer the metastatic potential to the disease. An answer to this was given by Haffner et al. They tracked the evolution of the lethal cell clone from the primary cancer to metastases through samples collected during disease progression and at the time of death.
Surprisingly, these analyses revealed that the lethal clone arose from a small Gleason pattern 3 cancer focus in the primary tumor, and not from the bulk, higher-grade primary cancer or from a lymph node metastasis resected at prostatectomy. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
A copy of the written consent is available for review by the Editor-in-Chief of this journal. The content of acinar adenocarcinoma della prostata paper is solely the responsibility of the authors and does not necessarily represent the official views of the Polytechnic University of the Marche Region Acinar adenocarcinoma della prostata, Italy.
Rodolfo Montironi and Marina Scarpelli contributed equally to this acinar adenocarcinoma della prostata. Competing interests. Drs S and M: conception and design of the study.
Dr M: acquisition of data. Dr S and B: drafting of the manuscript. Drs L-B and Acinar adenocarcinoma della prostata critical revision of the manuscript for important intellectual content. Dr M: supervision. All authors read and approved the final manuscript. Rodolfo Montironi, Email: ti.
Marina Scarpelli, Email: ti. Roberta Mazzucchelli, Email: ti. Antonio Lopez-Beltran, Email: moc. Matteo Santoni, Email: ti. Alberto Briganti, Email: ti. Francesco Montorsi, Email: ti. Liang Cheng, Email: moc. National Center for Biotechnology InformationU. Journal List Diagn Pathol v. Diagn Pathol. Published online Oct Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Aug 22; Accepted Sep Abstract Background There is a worldwide debate involving clinicians, uropathologists as well as patients and their families on whether Gleason score 6 adenocarcinoma should be labelled as cancer.
Keywords: Prostate cancer, Gleason score 6 adenocarcinoma, Gleason score, Lymphovascular invasion, Lymph node metastasis, Periprostatic lymph node. Background There is a worldwide debate involving clinicians, uropathologists as well as patients and their families on whether Gleason score 6 adenocarcinoma should be labelled as cancer. Open in a separate window.
Figure 1. Figure 2. Conclusions When the paper based on the current case was considered ready for submission, we thought about a possible comment from a reader: Was the paraffin block containing the prostate slice with the dominant nodule and the lymph node serially sectioned to see whether the lesion changed in deeper sections?
Figure 3. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Footnotes Rodolfo Montironi and Marina Scarpelli contributed equally to this work.