The 2019 genitourinary pathology society (GUPS) white paper on contemporary grading of prostate cancer

Jonathan I. Epstein, Mahul B. Amin, Samson W. Fine, Ferran Algaba, Manju Aron, Dilek E. Baydar, Antonio Lopez Beltran, Fadi Brimo, John C. Cheville, Maurizio Colecchia, Eva Comperat, Isabela Werneck da Cunha, Warick Delprado, Angelo M. DeMarzo, Giovanna A. Giannico, Jennifer B. Gordetsky, Charles C. Guo, Donna E. Hansel, Michelle S. Hirsch, Jiaoti HuangPeter A. Humphrey, Rafael E. Jimenez, Francesca Khani, Qingnuan Kong, Oleksandr N. Kryvenko, L. Priya Kunju, Priti Lal, Mathieu Latour, Tamara Lotan, Fiona Maclean, Cristina Magi-Galluzzi, Rohit Mehra, Santosh Menon, Hiroshi Miyamoto, Rodolfo Montironi, George J. Netto, Jane K. Nguyen, Adeboye O. Osunkoya, Anil Parwani, Brian D. Robinson, Mark A. Rubin, Rajal B. Shah, Jeffrey S. So, Hiroyuki Takahashi, Fabio Tavora, Maria S. Tretiakova, Lawrence True, Sara E. Wobker, Ximing J. Yang, Ming Zhou, Debra L. Zynger, Kiril Trpkov

Research output: Contribution to journalReview articlepeer-review

151 Scopus citations


Context.—Controversies and uncertainty persist in prostate cancer grading. Objective.—To update grading recommendations. Data Sources.—Critical review of the literature along with pathology and clinician surveys. Conclusions.—Percent Gleason pattern 4 (%GP4) is as follows: (1) report %GP4 in needle biopsy with Grade Groups (GrGp) 2 and 3, and in needle biopsy on other parts (jars) of lower grade in cases with at least 1 part showing Gleason score (GS) 4 þ 4 ¼ 8; and (2) report %GP4: less than 5% or less than 10% and 10% increments thereafter. Tertiary grade patterns are as follows: (1) replace ‘‘tertiary grade pattern’’ in radical prostatectomy (RP) with ‘‘minor tertiary pattern 5 (TP5),’’ and only use in RP with GrGp 2 or 3 with less than 5% Gleason pattern 5; and (2) minor TP5 is noted along with the GS, with the GrGp based on the GS. Global score and magnetic resonance imaging (MRI)targeted biopsies are as follows: (1) when multiple undesignated cores are taken from a single MRI-targeted lesion, an overall grade for that lesion is given as if all the involved cores were one long core; and (2) if providing a global score, when different scores are found in the standard and the MRI-targeted biopsy, give a single global score (factoring both the systematic standard and the MRI-targeted positive cores). Grade Groups are as follows: (1) Grade Groups (GrGp) is the terminology adopted by major world organizations; and (2) retain GS 3 þ 5 ¼ 8 in GrGp 4. Cribriform carcinoma is as follows: (1) report the presence or absence of cribriform glands in biopsy and RP with Gleason pattern 4 carcinoma. Intraductal carcinoma (IDC-P) is as follows: (1) report IDC-P in biopsy and RP; (2) use criteria based on dense cribriform glands (.50% of the gland is composed of epithelium relative to luminal spaces) and/or solid nests and/or marked pleomorphism/necrosis; (3) it is not necessary to perform basal cell immunostains on biopsy and RP to identify IDC-P if the results would not change the overall (highest) GS/GrGp part per case; (4) do not include IDC-P in determining the final GS/GrGp on biopsy and/or RP; and (5) ‘‘atypical intraductal proliferation (AIP)’’ is preferred for an intraductal proliferation of prostatic secretory cells which shows a greater degree of architectural complexity and/or cytological atypia than typical high-grade prostatic intraepithelial neoplasia, yet falling short of the strict diagnostic threshold for IDC-P. Molecular testing is as follows: (1) Ki67 is not ready for routine clinical use; (2) additional studies of active surveillance cohorts are needed to establish the utility of PTEN in this setting; and (3) dedicated studies of RNA-based assays in active surveillance populations are needed to substantiate the utility of these expensive tests in this setting. Artificial intelligence and novel grading schema are as follows: (1) incorporating reactive stromal grade, percent GP4, minor tertiary GP5, and cribriform/intraductal carcinoma are not ready for adoption in current practice.

Original languageEnglish (US)
Pages (from-to)461-493
Number of pages33
JournalArchives of Pathology and Laboratory Medicine
Issue number4
StatePublished - Apr 2021

ASJC Scopus subject areas

  • Pathology and Forensic Medicine
  • Medical Laboratory Technology


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