2019, Volume 35, Number 3, Page(s) 185-192
Gleason Score Correlation Between Prostate Needle Biopsy and Radical Prostatectomy Materials
Neşe YELDIR1, Esin YILDIZ2, Gökçe DÜNDAR3
1Department of Pathology, Cizre Dr. Selahattin Cizrelioğlu State Hospital, ŞIRNAK, TURKEY
2Cumhuriyet University Hospital, SİVAS, TURKEY
3Department of Urology, Cizre Dr. Selahattin Cizrelioğlu State Hospital, ŞIRNAK, TURKEY
Keywords: Prostate, Adenocarcinoma, Needle biopsy, Radical prostatectomy, Gleason score
Prostate cancer is the second most common cancer in men. Digital rectal examination, transrectal ultrasonography and serum prostate
specific antigen represents a diagnostic triad for the detection of prostatic carcinoma. About 50 years ago, Dr. Donald Gleason created a grading
system for prostate cancer based on its histologic patterns. Currently, this system maintains its validity with various changes. New updates were
made in 2005 and 2014 by the International Society of Urological Pathology. The goal of biopsies is to determine the Gleason score and prognosis
in prostatectomy material. The aim of this study was to determine the concordance of the Gleason score, tumor volume and tumor laterality
between prostate needle biopsy and prostatectomy materials.
Material and Method: The study was performed with 112 patients who had biopsy and prostatectomy materials. The Gleason grades of the
tumors have been evaluated with the new grading system. Tumor volumes were calculated by the number of positive blocks while tumor laterality
was evaluated as unilateral or bilateral. Statistical analysis was performed on the obtained data.
Results: Gleason score, tumor volume and tumor laterality discordance between needle biopsy and prostatectomy materials was found to be
statistically significant. However, the concordance increased as the Gleason score and tumor volume increased.
Conclusion: Digital examination, serum prostate specific antigen value and needle biopsy together are very sensitive for a prostate adenocarcinoma
diagnosis. The Gleason score, localization and volume of the tumors are important for patient follow-up, treatment and prognosis.
Prostate cancer is the second most common cancer in men
all over the world and is the fifth among causes of cancerrelated
deaths. Approximately 75% of the diagnosed
patients are 65 years of age or older and it is very rare
at younger ages including adolescents. Typically, the
frequency and mortality rates are increasing with age 1-5
The triple combination of digital rectal examination,
transrectal ultrasonography (TRUS) and serum prostate
specific antigen (PSA) are used in screening and early
diagnosis. The main role of TRUS in diagnosing prostate
cancer is to guide the biopsy. PSA, a proteolytic enzyme, is
produced by both normal and tumoral prostatic epithelium.
A serum PSA level exceeding 4 ng/ml is abnormal. However,
this elevation is not specific to carcinomas but may be due
to benign prostatic hyperplasia, prostatitis, infarction and
trauma (such as transurethral resection, needle biopsy) 2-4.
Needle biopsy is performed with TRUS guidance in men
with a serum PSA and rectal examination abnormality.
Patients, who are diagnosed with adenocarcinoma as a
result of the biopsy are treated with radical prostatectomy
(RP) if clinically appropriate 2,3,5.
Prostate adenocarcinoma is divided into acinar and ductal.
Most prostate adenocarcinomas are of the acinar type and
usually arise from the peripheral zones of the prostate.
Most prostatic adenocarcinomas of peripheral zone origin
are multifocal, and therefore most needle biopsies aim
to sample posterior peripheral zone tissues from a large
number of areas 1-5.
Because the tumor volume in needle biopsy is related
to biochemical recurrence and even the radiotherapy
response, the core number with tumor and biopsy length
are important as well as parameters such as stage and
surgical marginal status in RP material 4,5.
In needle biopsy, many techniques have been developed
and applied to determine the amount of tumor. Tumor
volume may be reported by means of positive cores, ratios
of positive cores, millimetric measurement of tumor in all
cores, ratio of tumor in each core, and ratio of tumor in the
whole specimen 2,6.
Prostate adenocarcinoma has been graded for approximately
50 years by the system recommended by Donald
F. Gleason 7. The well-established relationship with
the prognosis has made the Gleason grading system an
important factor in determining the treatment. Although
the Gleason scoring has changed since its first definition to
this day, its basic features have not been changed. The last
change was made at the International Urological Pathology
Community (ISUP) in 2005 and the problems were largely
resolved 8. Some postponed issues were also resolved at
the November 2014 Chicago meeting. In this meeting, it
was also recommended that Gleason scoring be divided into
simpler prognostic groups 9. These recommendations
were also included in the World Health Organizations
(WHO) 2016 Classification of Urinary System and Male
Genital Organ Tumors book 3.
In needle biopsies, the aim is to assess the Gleason score in
the RP material and thus the prognosis 3,7-9. Regarding
this goal, we aimed to investigate the adenocarcinoma
Gleason score, tumor volume and tumor location laterality
accordance between prostate needle biopsy and RP
materials in this study.
A total of 112 patients with prostate adenocarcinoma
diagnosed with needle biopsy and treated by RP between
2008 and 2016 were included in the study. Archival slides
were re-evaluated for Gleason score, tumor extensity and
tumor laterality. In addition, concordance between biopsy
and RP findings were examined.
When the Gleason score was assessed, the patterns in the
2005 and 2014 updates and new score assessments and the
prognostic groups recommended at the 2014 meeting were
considered 3,8,9. The most common and worst patterns
were detected in the biopsies and the Gleason score was
determined by the sum of these scores. In addition, five
newly identified prognostic groups were identified for each
case (Grade groups 1-5).
Tumor volume in the biopsy material was calculated by
the proportion of the tumor length in the tumor-bearing
cores to total length of all the cores in mm. In cases where the tumor extended to reveal benign prostate tissue in
the biopsy core, the entire tissue was included in the
measurement from one end of the tumor to the other 2,10.
Tumor volume of RP materials was calculated by
proportioning the number of tumor-positive paraffin
blocks to that of all specimens 11.
With the results obtained, cases were divided into three
according to the tumor volumes. These groups were limited
(<20%), moderately extensive (20-50%) and extensive (>
Tumor laterality was assessed as unilateral (right or left)
and bilateral (right and left), in both the biopsy and RP
Immunohistochemical studies (p63, HMWCK, AMACR)
performed beforehand and during the study on foci with a
difficult differential diagnosis (e.g., PIN-adenocarcinoma,
adenocarcinoma-ductal carcinoma, PIN-urothelial carcinoma
in situ ) and new sections obtained from the blocks
and then stained with H&E were examined.
Immunohistochemical analysis was performed using the
Ventana Brand Benchmark XT model automated device.
In the study, the kappa coefficient was used for statistical
analysis. Kappa (к) was measured for grade, volume and
laterality between biopsy and RP. The K value ranges
between -1 and +1. A value of к equal to +1 implies perfect
concordance between the two methods, while that of -1
implies perfect discordance. If к assumes the value of 0, then
this implies that is was no relationship between the ratings
of the two methods, and any concordance or discordance is
due to chance alone 12.
The ages of the 112 patients included in the study ranged
from 48 to 78 years and the mean age was 64.84. Of these
patients, 85 (75.9%) were over 60 years old, 25 (22.3%)
were between 50 and 60 years old, and only 2 (1.8%) were
under 50 years of age.
All needle biopsies and RP materials of the 112 patients had
acinar type prostate adenocarcinoma. Gleason grades of
tumoral areas in the biopsies and RP materials of the cases
were evaluated and the grade groups were determined.
The distribution of the Gleason grading results of the needle
biopsies of the 112 cases was 51 in Grade group 1 (46%), 16
in Grade group 2 (14%), 17 in Grade group 3 (15%), 23 in
Grade group 4 (21%), and 5 in Grade group 5 (4%).
When the Gleason grading results of RP materials were
examined, 26 were in Grade group 1 (23%) (Figure 1A,B),
28 were in Grade group 2 (25%), 28 were in Grade group
3 (25%) (Figure 2), 23 were in Grade group 4 (21%), and 7
were in Grade group 5 (6%).
Click Here to Zoom
|Figure 1: Gleason score 3+3=6 (Grade group 1) adenocarcinoma (H&E; x100, A & x400, B).
Click Here to Zoom
|Figure 2: Gleason score 4+3=7 (Grade group 3) adenocarcinoma
Sixty-four (57%) cases had the same Gleason scores in
biopsies and RP materials. Gleason grade distribution of
the 64 cases were 24 with 1, 8 with 2, 11 with 3, 17 with 4,
and 4 with 5. Gleason scores were higher in RP materials
compared to biopsies in 39 (35%) cases and lower in nine
Kappa values for grade were 0.24 (Table I). According to
these results, the concordance between the two methods
was fair. However, as the Gleason score of the tumor
increases, the concordance also increases. The most
common discordance type is that the grade of the tumor in
needle biopsy is lower than the tumor grade in RP material.
A total of 86 cases were limited (77%), 20 cases were
moderately extensive (18%), and 6 cases were extensive
(5%) in biopsy materials when 112 cases were evaluated in
terms of tumor volume. There were 55 (49%) cases with
limited amount of tumor in the RP material, 42 (38%) cases
with moderately extensive tumor and 15 (13%) cases with
extensive tumor. Ten of the 46 cases with tumor volume
below 5% in the biopsy material also had a tumor volume
below 5% in RP material and 3 had extensive tumor in RP
material. The amount of tumor in the RP material of the
remaining 33 cases was thought to be moderately extensive.
Kappa value for tumor volume was 0.21 (Table II). The
concordance was fair for tumor volume between biopsy and RP materials of similar tumor grade. The most common
incompatibility type was the appearance of a tumor in the
lower volume in needle biopsy compared to RP material.
When the laterality of the cases was examined, there were
32 bilateral cases and 80 unilateral cases in biopsy materials.
All of the 32 cases with bilateral tumors had undergone RP
and there were also bilateral tumors in the RP material. In
80 cases of RP materials with unilateral tumors, there were
18 unilateral and 62 bilateral tumors. The compatibility
rate of showing the same laterality of these two methods
was 44.6%. Kappa value for tumor laterality was 0.14 (Table
III). According to this result, the concordance was slight.
The sensitivity of prostate needle biopsy in identifying
adenocarcinoma was 98%, the positive predictive value was
100%, and the negative predictive value was 0 (Table IV).
Click Here to Zoom
|Table IV: Positive and Negative Predictive Values Tabulation for Prostate Needle Biopsy.
Immunohistochemical study (p63, HMWCK, AMACR)
was performed for 36 needle biopsies and 6 RP cases.
Tumoral areas were positively stained with AMACR,
negatively with p63 and HMWCK, and PIN areas were
positively stained with three antibodies. In two of the cases,
immunohistochemistry results for suspected foci outside
the tumoral area were positively stained with AMACR, p63
and HMWCK, and thus these foci were also considered to
represent tumor (Figure 3A,B).
Click Here to Zoom
|Figure 3: A single microscopic focus of the prostate needle biopsy reveals a tumoral focus less than 1 mm (H&E; x200, A) and shows
positive staining with AMACR (IHC; x100, B).
Prostate cancer is the second most common malignancy
worldwide. The incidence of a prostate cancer diagnosis
differs significantly between the world regions and
countries. The highest incidence is in South America, the
Caribbean, Brazil, some Western European countries,
Australia and New Zealand. The incidence for prostate
cancer is 28 per 100,000 in the world, 60 per 100,000 in
Europe. The lowest incidence is in Asia, a few Middle
Eastern countries and Africa. Both environmental and
genetic factors influence this incidence difference 2-4,13,14
. In Turkey, it is among the most common malignancies in men, ranking second after lung cancer, and the incidence
Prostate cancer is fifth among cancers causing death in
men worldwide. The mortality rate is higher in regions
where the black population dominates. The mortality rate
is lower in Asia, a few Middle Eastern countries and South
Patient age is strongly associated with the presence of
prostate cancer. Most people with cancer are over 60 years
old. Only 1% of patients with prostate cancer are under 50
years of age 4. The age distribution of the 112 patients
included in the study was 48-78 and the mean age was
64.84. Of these patients, 85 (75.9%) were over 60 years of
age, 25 (22.3%) were between 50 and 60 years old, and only
2 (1.8%) were under 50 years of age.
Prostate adenocarcinoma may be suspected clinically
with high serum PSA and/or an abnormal digital rectal
examination. Digital rectal examination is not sensitive or
specific for prostate cancer. Digital rectal examination may
not detect 25-50% of prostate cancers detected by PSA.
Benign conditions, such as benign prostatic hyperplasia
and inflammation, can also be suspected as tumors, giving
rise to abnormal palpation 1,4.
TRUS is performed as a primary diagnostic method for
patients with suspected clinical prostate cancer with
abnormal digital rectal examination and/or serum PSA
elevation. TRUS biopsy has significantly increased the
prostate cancer diagnosis rate. However, since TRUS is
suboptimal in determining tumor volume and extraprostatic extension, its use for local grading of prostatic cancer is
Open, laparoscopic, or robotic RP is the definitive
treatment of localized prostate cancer. RP specimens are
needed to characterize the tumor, such as grade, volume,
pathologic grade, and surgical margin conditions, which
guide treatment management and prognostic assessment
In the histopathological evaluation of prostate adenocarcinoma,
the system suggested by Donald F. Gleason has been
used widely around the world for about 50 years. Donald
F. Gleason has developed a classification only based on a
structural pattern, and the increased mitosis, which is not
a hallmark feature of nuclear properties and prostate adenocarcinoma,
has no place in determining patterns. Patterns
from 1 to 5 have been identified. According to these
patterns, the most common and second most common
patterns between 1 and 5 are detected and their sum make
up the Gleason score. The most common pattern is called
primary pattern and the second most common pattern is
called secondary pattern 8,17,18.
In the study, in the light of current advances in the
Gleason system, a Gleason score was given to the needle
biopsies regardless of how small the tumor was, and
immunohistochemical studies were performed when
necessary to confirm the diagnosis 3,9.
The Gleason scores of the cases included in the study
ranged from 6 to 10. Pattern 3 was seen in 68% of cases and
was the most common pattern.
Distribution of cases according to new prognostic groups
was as follows: in biopsies, 51 (46%) cases were grade group
1, 16 (14%) cases were grade group 2, 17 (15%) cases were
grade group 3 and 23 (21) cases were grade group 4 and 5
(4%) cases were grade group 5. Distribution in RPs was as
follows: 26 (23%) cases were grade group 1, 28 (25%) cases
were grade group 2, 28 (25%) cases were grade group 3,
23 (21%) cases were grade group 4, and 7 (6%) cases were
grade group 5.
No difference was present between biopsies and RP
materials of sixty-four (57%) cases in terms of Gleason
score. RP materials of thirty nine (35%) RP cases had
higher Gleason scores than biopsies, and 9 (8%) patients
had lower scores.
In a study conducted by Pourmand et al., 25 (48%) of the
52 patients had the same Gleason scores in biopsies and RP
materials, while 19 (36%) had higher scores and 8 (16%)
had lower scores in RP materials 19. The results in this
study were similar to those of Pourmand et al.
In a study conducted by Khoddami et al., Gleason scores
remained the same in 68.2% of cases, while 32.8% showed
a score difference of 1 or 2. In RP material obtained after
biopsy, grade decreased in 9.1% of cases and grade increased
in 22.7%. Sensitivity and positive predictive value of biopsy
were 86% and 79% for low grade tumors, 67% and 75% for
moderate grade tumors, and 80% and 80% for high grade
tumors, respectively 20. In this study of Khoddami et al.,
the rate of similar scores on biopsy and RP is somewhat
higher, and the rate of grade being higher and lower in RP
was lower than in this study.
It is important to determine this distinction, since the
Gleason score (3+4) and (4+3) cases have prognostic
differences in tumors containing areas 3 and 4 pattern 8,21. We found that 28 (25%) of the patients in this study
were grade group 2 (3+4) and 28 (25%) were grade group
In needle biopsies, the aim is to determine the Gleason
score in the RP material and thus the prognosis with the
best possibility and in as many patients as possible. The aim
of this study was to determine the compatibility of Gleason
score and values of tumor volume and tumor laterality in
needle biopsies of prostate adenocarcinomas with the RP
Incompatibility between Gleason scores in needle biopsies
and postdiagnostic RP materials is reported at a rate of up
to 50% 2. According to results of this study, as the tumor
Gleason score increases, the incompatibility between the
Gleason scores decreases.
Incompatibility is often caused by sampling errors in
needle biopsies or from cases in which it is not possible to
determine exactly which pattern is present. Sampling errors
include minimal tumor presence in needle biopsies despite
extensive tumors in the RP materials and limited tumor
tissue observation due to the use of fine needles 2-5.
One study concluded that needle biopsies had a higher
error potential in grading well differentiated tumors and
Gleason score <7 tumors 22.
Tavangar et al. concluded that the frequency of scoring well
differentiated cancers low and poorly differentiated cancers
high is very high in biopsies and they draw attention to
that the biopsy score of low grade tumors might be lower
than the actual score in the RP material in the reporting
of prostate specimens and in the management of patients
Although there are many studies evaluating Gleason score
compatibility between biopsy and prostatectomy, a small
number of these studies have focused on possible causes
and effects of incompatibility 2.
The tumor volume in the RP material correlates with the
pathological grade and Gleason score. Several methods
have been introduced to measure tumor volume. There
are controversial studies on the role of tumor volume as
an independent predictor in the progression of post-radical
prostatectomy disease after the pathological grade and
stage have been determined. The International Society of
Urological Pathology recommends that tumor volume be
measured and indicated objectively in RP materials. The
reasoning for the society is to record tumor volume in
organ tumors in other systems too 9.
Since the tumor volume in needle biopsy is related to
biochemical recurrence, even the radiotherapy response,
as well as parameters such as stage and surgical marginal
status in RP material, it is also important to determine the
number of cores with tumor and the needle biopsy length.
2-5. According to the results of the study, the presence
of tumor in the needle biopsy in a few cores and small
areas does not accurately reflect the volume of the tumor
in the RP material in most cases. The tumor can be seen
more extensively in RP material. When an extensive tumor
is seen in needle biopsy, frequently an extensive tumor is
encountered in RP material too.
Among the cases in the study, Gleason score distribution
of 4 cases with an extensive tumor volume over 80% in RP
material was 3 with a score of 4+4 = 8 (GG4) and 1 with a
score of 3+4 = 7 (GG2). Although the number of cases was
small, the grade may be high if tumor volume is high.
Percentage of the volume (length) covered by the biopsy of
the tumor is a measure that seems simple, but is difficult,
and yet has a significant role in determining the treatment
for the patient. Prostate adenocarcinomas are tumors
that cannot be described macroscopically and are often
multifocal. For this reason, benign areas are left in needle
biopsies in most cases. The commonly accepted method
used in this study is to give the ratio or length by adding
the benign areas to the tumor in the needle biopsy tumor
Although the prognostic effect of tumor volume in RP
materials and the method used to determine tumor volume
in RP materials are controversial, it is suggested that the
tumor extent should still be noted. A positive block ratio
to determine tumor extent is an independent predictor
of PSA recurrence, and this simple tumor measurement
method is an indicator to determine the amount of tumor
We found a positive paraffin block ratio when calculating
tumor volume in RP materials as mentioned above. When
the tumor volumes of all cases were examined, 84 cases had
limited (75%), 20 cases had moderately extensive (18%)
and 6 cases had extensive tumors (5%) in biopsy materials.
There were 55 (49%) cases with a limited amount of tumor
in RP material, 42 (38%) cases with moderately extensive
tumor, and 15 (13%) cases with extensive tumor. The
concordance was fair for tumor volume between biopsy
and RP materials.
Among the cases in the study, Gleason score distribution of
4 cases with tumor volume over 80% in RP materials was 3
with a score of 4+4 = 8 (GG4), and 1 with a score of 3+4 = 7
(GG2). Although the number of cases was small, the grade
may be high if the tumor volume is high.
We diagnosed 31 of the 46 cases with tumor volume below
5% as adenocarcinoma according to the IHC result and
the remaining 15 cases were diagnosed without IHC in the
biopsy materials included in this study. Of these 46 cases,
22% had a tumor volume below 5% while 6% had extensive
tumor volume in the RP materials.
The Gleason score distribution of the 15 patients with
tumor volume below 5% in RP materials in the study is as
follows: 7 with score of 3+3=6 (GG1), 4 with score of 3+4=7
(GG2), 2 with a score of 4+3=7 (GG3), and 2 with score
of 4+4=8 (GG4). The grade can be high although tumor
volume is low.
In one study, prostate TRUS biopsy material revealed
clinically significant tumor presence in the majority of cases with a tumor volume below 0.5 ml and TRUS biopsies were
therefore inadequate for the diagnosis and management
of tumors with limited tumor volumes. However, it was
thought that men with prostate cancer diagnosed with
TRUS biopsy should be considered to have a clinically
significant tumor in current practice, and that the age,
health status and wishes of the patient should also be
taken into consideration when determining the treatment
approach until a more reliable method for distinguishing
the disease in low-volume tumors is established 25.
Another study concluded that TRUS biopsy from 12 cores
was a powerful method for predicting locally advanced
disease, including the lymph node status in RP 26.
The sensitivity of prostate needle biopsy in identifying
adenocarcinoma was 98%, the positive predictive value was
100%, and the negative predictive value was 0.
Studies related to the correlation between tumor laterality
in needle biopsies and materials of RP performed afterwards
are limited. According to the study, the concordance of
tumor laterality between needle biopsies and RP materials
was slight and more insignificant than tumor volume and
In the study od Lowenthal et al. conducted with 75 patients,
the tumor was reported as unilateral in biopsies and RP
materials in 16 cases and unilateral in biopsies and bilateral
in RP materials in 59 cases 27.
In the case of prostate adenocarcinoma, studies involving
broader analyses are required to reach a definitive
conclusion on the prognostic and diagnostic value of
laterality. However, since tumor located in both lobes
changes the stage from pT2b to pT2c, it is important to
determine the laterality of the tumor 23.
In conclusion, digital examination, serum PSA value
and needle biopsy together are very sensitive for prostate
adenocarcinoma diagnosis. The application of RP to a
localized disease diagnosed with adenocarcinoma in needle
biopsy is an up-to-date procedure. Needle biopsy is a very
reliable method to detect prostate adenocarcinoma and
the rate of reflection of Gleason score, tumor volume and
laterality in material of RP performed afterward is increased
with increasing Gleason score and tumor volume. Gleason
score, localization and volume of tumors is important
for patient follow-up, treatment and prognosis. The
concordance rates will undoubtedly increase with serial
sections and immunohistochemical studies on ultrasoundguided
needle biopsies of the prostate, which will obtain
samples from more cores and in longer sizes.
CONFLICT of INTEREST
The authors declare no conflict of interest.
1) Epstein JI, Lotan TL. The lower urinary tract and male genital
system. In: Kumar V, Abul KA, Aster JC, editors. Robbins and
Cotran pathologic basis of disease. 9th ed. Philadelphia: Saunders
Elsevier; 2015. 859-990.
2) Epstein JI. The prostate and seminal vesicles. In: Mills SE, Carter
D, Greenson JK, Oberman HA, Reuter V, Stoler MH, editors.
Sternbergs diagnostic surgical pathology. 5th ed. Philadelphia:
Lippincott Williams Wilkins; 2004. 2083-132.
3) Moch H, Humprey PA, Ulbright TM, Reuter VE. Tumours of the
prostate. WHO classification tumours of the urinary system and
male genital organs. 4th ed. Lyon: IARC Press; 2016. 136-83.
4) Rosai J. Male reproductive system. Rosai and Ackermans surgical
pathology. 10th ed. Sydney: Mosby Elsevier; 2011. 1287-398.
5) Neşe N. Prostate and seminal vesicle. In: Yörükoğlu K, Tuna
B editors. Uropathology. 1st ed. Izmir: Congress Bookshop,
Kanyılmaz Printing House; 2016. 319-473.
6) Cupp MR, Bostwick DG, Myers RP, Oesterling JE. The volume
of prostate cancer in the biopsy specimen can not reliably predict
the quantity of cancer in the radical prostatectomy specimen on
an individual basis. J Urol. 1995;153:1543-8.
7) Brimo F, Vollmer RT, Corcos J, Kotar K, Begin LR, Humphrey
PA, Bismar TA. Prognostic value of various morphometric
measurements of tumour extent in prostate needle core tissue.
8) Epstein JI, Allsbrook WC Jr, Amin MB, Egevad LL; ISUP Grading
Committe. The 2005 international society of urologic pathology
(ISUP) consensus conference on Gleason grading of prostatic
carcinoma. Am J Surg Pathol. 2005;29:1228-42.
9) Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley JR, John K,
Humphrey PA; The Grading Committee. The 2014 international
society of urological pathology (ISUP) consensus conference on
Gleason grading of prostatic carcinoma: Definition of grading
patterns and proposal for a new grading system. Am J SurgPathol.
10) Gleason DF, Mellinger GT. Prediction of prognosis for prostatic
adenocarcinoma by combined histologic grading and clinical
staging. J Urol. 1974;111:58-64.
11) Marks RA, Lin H, Koch MO, Cheng L. Positive-block ratio in
radical prostatectomy specimens is an independent predictor
of prostate-specific antigen recurrence. Am J Surg Pathol.
12) Özdamar K. Biostatistics with SPSS. 4th ed. Eskişehir: Kaan
13) Prostate Cancer, Nutrition, and Dietary Supplements. PDQ
integrative, alternative, and complementary therapies editorial
board. PDQ Cancer Information Summaries (Internet). Bethesda
(MD): National Cancer Institute (US);2002.2019.
14) Genetics of Prostate Cancer. PDQ Cancer Genetics Editorial
Board. PDQ Cancer Information Summaries (Internet). Bethesda
(MD): National Cancer Institute (US);2002.2018.
15) Conti DV, Wang K, Sheng X, Bensen JT, Hazelett DJ, Cook
MB. Two novel susceptibility loci for prostate cancer in men of
African ancestry. J Natl Cancer Inst. 2017;109.
16) Cormier L, Kwan L, Reid K, Litwin MS. Knowledge and beliefs
among brothers and sons of men with prostate cancer. Urology.
17) Yörükoğlu K. Current developments in uropathology. Turkiye
Klinikleri J Med Pathol-Special Topics. 2016;1:35-40.
18) Pierorazio PM, Walsh PC, Partin AW, Epstein JI. Prognostic
Gleason grade grouping: Data based on the modified Gleason
scoring system. BJU Int. 2013;111:753-60.
19) Pourmand G, Gooran S, Hossieni SR, Guitynavard F, Safavi M,
Sharifi A, Mokhtari E. Correlation of preoperative and radical
prostatectomy Gleason score: Examining the predictors of
upgrade and downgrade results. Acta Medica Iran. 2017;55:249-53.
20) Khoddami M, Khademi Y, Aghdam MK, Soltanghoraee H.
Correlation between Gleason scores in needle biopsy and
correspondig radical prostatectomy specimens: A Twelve-year
review. Iran J Pathol. 2016;11:120-6.
21) Gonzalgo ML, Bastian PJ, Mangold LA, Trock BJ, Epstein JI,
Walsh PC, Partin AW. Relationship between primary Gleason
pattern on needle biopsy and clinicopathologic outcomes among
men with Gleason score 7 adenocarcinoma of the prostate.
22) Shen BY, Tsui KH, Chang PL, Chuang CK, Hsieh ML, Huang ST,
Wang TM, Lee SH, Huang HC, Huang SC. Correlation between
the Gleason scores of needle biopsies and radical prostatectomy
specimens. Chang Gung Med J. 2003;26: 919-24.
23) Tavangar SM, Razi A, Mashayekhi R. Correlation between
prostate needle biopsy and radical prostatectomy Gleason
grading of 111 cases with prostatic adenocarcinoma. Urol J.
24) Epstein JI. Prognostic significance of tumor volume in
radical prostatectomy and needle biopsy specimens. J Urol.
25) Honig SC, Stilmant MM, Klavans MS, Freedlund MC, Siroky
MB. The Role of fine needle aspiration biopsy of the prostate in
staging adenocarcinoma. Cancer. 1992;69:2978-82.
26) Kryvenko ON, Diaz M, Meier FA, Ramineni M, Menon M,
Gupta NS. Findings in 12-core transrectal ultrasound-guided
prostate needle biopsy that predict more advanced cancer at
prostatectomy: Analysis of 388 biopsy-prostatectomy pairs. Am J
Clin Pathol. 2012;137:739-46.
27) Lowenthal BM, Liao X, Wen F, Bagherzadeh N, Mahooti S.
Discontinuous unilateral involvement of 12 part core biopsies
by adenocarcinoma predicts bilateral involvement of subsequent
radical prostatectomy. Pathol Int. 2016; 66:438-43.