Prognostic significance of Gleason score 3+4 versus Gleason score 4+3 tumor at radical prostatectomy

Objectives. To determine the clinical significance of Gleason score 3+4 ver sus 4+3 on radical prostatectomy. Methods. Of 2390 men who underwent radical prostatectomy by a single surgeo n, 570 had Gleason score 7 tumors without lymph node metastasis, seminal ve sicle invasion, or tertiary Gleason pattern 5. Patients were evaluated for biochemical recurrence (prostate-specific antigen progression) and distant metastases. Results. Eighty percent of patients had Gleason score 3+4, 20% had 4+3. The rate of established extraprostatic extension at radical prostatectomy for Gleason score 3+4 and 4+3 tumors was 38.2% and 52.7%, respectively (P = 0.0 08). With a mean follow-up of 4.6 years for men without progression, Gleaso n score 4+3 tumors had an increased risk of progression independent of stag e and margin status (P <0.0001). The 5-year actuarial risk of progression w as 15% and 40% for Gleason score 3+4 and 4+3 tumors, respectively The mean time to progression was 4.4 years for Gleason score 3+4 tumors and 3.2 year s for Gleason score 4+3 tumors. We stratified the patients into four progno stic groups on the basis of organ-confined status, margin status, and Gleas on score (3+4 Versus 4+3). The 5-year actuarial risk of progression was 10% , 35%, 45%, and 61%, with 10-year progression rates of 29%, 42%, 69%, and 8 4%, for the four groups. 3.9% of patients with Gleason score 3+4 and 10.5% with Gleason score 4+3 tumors developed metastatic disease within a mean of 5.7 and 5.6 years, respectively. A Gleason score of 4+3 Versus 3+4 was pre dictive of metastatic disease (P = 0.002) but not local recurrence. Conclusions. Gleason score 7 tumors are heterogeneous in their biologic beh avior. The differences in prognosis for patients with Gleason scores 3+4 an d 4+3 tumors at radical prostatectomy are significant. Although the assessm ent of the percentage of pattern 4 at radical prostatectomy is not likely t o be reproducible, the distinction between Gleason score 3+4 and 4+3 should be easier for pathologists to perform. UROLOGY 56: 823-827, 2000. (C) 2000 , Elsevier Science Inc.