SSDI and Grade Lookup

Notes

1. Grade Clinical must not be blank.

   • Grade Clinical must not be blank.

2. Assign the highest grade from the primary tumor assessed during the clinical time frame.

   • Assign the highest grade from the primary tumor assessed during the clinical time frame.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Codes 1-5 take priority over A-E.

   • Codes 1-5 take priority over A-E.

5. For prostate, a TURP or simple prostatectomy qualifies for a clinical grade only.

   • For prostate, a TURP or simple prostatectomy qualifies for a clinical grade only.

6. Code 9 (unknown) when

   • Grade from primary site is not documented
   • Clinical workup is not done (for example, cancer is an incidental finding during surgery for another condition)
   • Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

7. If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a Grade Clinical and code appropriately per Grade Clinical categories for that site, and then code unknown (9) for Grade Pathological, and blank for Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp).

   • If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a Grade Clinical and code appropriately per Grade Clinical categories for that site, and then code unknown (9) for Grade Pathological, and blank for Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp).

8. If you are assigning an AJCC Staging System stage group

   • Grade is required to assign stage group
   • Codes A-E are treated as an unknown grade when assigning AJCC stage group
   • An unknown grade may result in an unknown stage group

Code Table

Notes

1. Grade Pathological must not be blank.

   • Grade Pathological must not be blank.

2. There is a preferred grading system for this schema. If the clinical grade given uses the preferred grading system and the pathological grade does not use the preferred grading system, do not record the Grade Clinical in the Grade Pathological field. Assign Grade Pathological using the applicable generic grade codes (A-D).

   • *Example:* Biopsy of prostate, adenocarcinoma, Gleason Patterns 2+3, Score =5. Tue surgical resection states a moderately differentiated adenocarcinoma
   • - Code Grade Clinical as 1 since Gleason Score Clinical is less than 6 and this is the preferred grading system
   • - Code Grade Pathological as B (moderately differentiated), per the Coding Guidelines for Generic Grade Categories

3. Assign the highest grade from the primary tumor.

   • Assign the highest grade from the primary tumor.

4. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

5. Codes 1-5 take priority over A-E.

   • Codes 1-5 take priority over A-E.

6. For prostate, a TURP or simple prostatectomy does not qualify for surgical resection. A radical prostatectomy must be performed.

   • For prostate, a TURP or simple prostatectomy does not qualify for surgical resection. A radical prostatectomy must be performed.

7. Use the grade from the **clinical work up** from the primary tumor in different scenarios based on behavior or surgical resection

   • **Behavior**
   • - Tumor behavior for the clinical and the pathological diagnoses are the same AND the clinical grade is the highest grade
   • - Tumor behavior for clinical diagnosis is invasive, and the tumor behavior for the pathological diagnosis is in situ
   • **Surgical Resection**
   • - Surgical resection is done of the primary tumor and there is no grade documented from the surgical resection
   • - Surgical resection is done of the primary tumor and there is no residual cancer
   • **No surgical resection**
   • - Surgical resection of the primary tumor has not been done, but there is positive microscopic confirmation of distant metastases during the clinical time frame

8. The Grade Pathological may differ from Gleason Patterns Pathological [NAACCR #3839] and Gleason Score Pathological [NAACCR #3841] if the Grade Clinical, based on Gleason Patterns Clinical [NAACCR #3838] and Gleason Score Clinical [NAACCR #3840], is higher.

   • *Example:* Prostate biopsy, Gleason Pattern 4+4 and Gleason Score 8. Prostatectomy, Gleason Pattern 3+ 3 and Gleason Score 6.
   • - Both Grade Clinical and Grade Pathological would be coded 4 based on the Gleason Score Clinical of 8
   • - Gleason Patterns Pathological would be coded 33 and Gleason Score Pathological would be coded 06

9. Code 9 (unknown) when

   • Grade from primary site is not documented
   • No resection of the primary site (see exception in Note 8, Surgical resection, last bullet)
   • Neo-adjuvant therapy is followed by a resection (see Grade Post Therapy Path (yp))
   • Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available
   • Clinical case only (see Grade Clinical)
   • There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

10. If you are assigning an AJCC Staging System stage group

    • Grade is required to assign stage group
    • Codes A-E are treated as an unknown grade when assigning AJCC stage group
    • An unknown grade may result in an unknown stage group

Code Table

Notes

1. Leave Grade Post Therapy Clin (yc) blank when

   • No neoadjuvant therapy
   • Clinical or pathological case only
   • Neoadjuvant therapy completed, no microscopic exam is done prior to surgery/resection of primary tumor
   • There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

2. Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.

   • Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Codes 1-5 take priority over A-E.

   • Codes 1-5 take priority over A-E.

5. For prostate, TURP or simple prostatectomy qualify for a clinical grade only.

   • For prostate, TURP or simple prostatectomy qualify for a clinical grade only.

6. Code 9 (unknown) when

   • Microscopic exam is done after neoadjuvant therapy and grade from the primary site is not documented
   • Microscopic exam is done after neoadjuvant therapy and there is no residual cancer
   • Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available

7. If you are assigning an AJCC Staging System stage group

   • Grade is required to assign stage group
   • Codes A-E are treated as an unknown grade when assigning AJCC stage group
   • An unknown grade may result in an unknown stage group

Code Table

Notes

1. Leave Grade Post Therapy Path (yp) blank when

   • No neoadjuvant therapy
   • Clinical or pathological case only
   • Neoadjuvant therapy completed; surgical resection not done
   • There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

2. There is a preferred grading system for this schema. If the post therapy clinical grade given uses the preferred grading system and the post therapy pathological grade does not use the preferred grading system, do not record the Grade Post Therapy Clin (yc) in the Grade Post Therapy Path (yp) field. Assign Grade Post Therapy Path (yp) using the applicable generic grade codes (A-D).

   • *Example:* Neoadjuvant therapy completed. Biopsy of prostate, adenocarcinoma, Gleason Patterns 2+3, Score=5. The surgical resection states a moderately differentiated adenocarcinoma
   • Code Grade Post Therapy Clin (yc) as 1 since score is less than 6 and this is the preferred grading system
   • Code Grade Post Therapy Path (yp) as B (moderately differentiated), per the Coding Guidelines for Generic Grade Categories

3. Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

   • Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

4. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

5. Codes 1-5 take priority over A-E.

   • Codes 1-5 take priority over A-E.

6. For prostate, a TURP or simple prostatectomy does not qualify for surgical resection. A radical prostatectomy must be performed.

   • For prostate, a TURP or simple prostatectomy does not qualify for surgical resection. A radical prostatectomy must be performed.

7. Use the grade from the post therapy **clinical work up** from the primary tumor in different scenarios based on behavior or surgical resection

   • **Behavior**
   • Tumor behavior for the post therapy clinical and the post therapy pathological diagnoses are the same AND the post therapy clinical grade is the highest grade
   • Tumor behavior for post therapy clinical diagnosis is invasive, and the tumor behavior for the post therapy pathological diagnosis is in situ
   • **Surgical Resection**
   • Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no grade documented from the surgical resection
   • Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no residual cancer

8. Code 9 (unknown) when

   • Surgical resection is done after neoadjuvant therapy and grade from the primary site is not documented and there is no grade from the post therapy clinical work up
   • Surgical resection is done after neoadjuvant therapy and there is no residual cancer and there is no grade from the post therapy clinical work up
   • Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

9. If you are assigning an AJCC Staging System stage group

   • Grade is required to assign stage group
   • Codes A-E are treated as an unknown grade when assigning AJCC stage group
   • An unknown grade may result in an unknown stage group

Code Table

Description

PSA (Prostatic Specific Antigen) is a protein produced by cells of the prostate gland and is elevated in patients with prostate cancer. This data item pertains to PSA lab value. Serum PSA is the most sensitive tumor marker for monitoring individuals with prostate cancer, including progression of disease and response to therapy. Although originally not intended to be a screening test, this relatively simple blood test has become a very common method of detecting new prostate cancer in its earliest stages. PSA can be totally negative when prostate cancer is found on digital rectal exam. In such cases, PSA will not be helpful in monitoring for recurrence. * ***Note:*** Serum PSA is not the same as free PSA or precursor PSA—do not record values from either of these tests in this field.

Notes

1. **Physician Statement**

   • Physician statement of prostatic specific antigen (PSA) pre-diagnosis can be used to code this data item when no other information is available.

2. **Staging related**

   • PSA is a prognostic factor required for AJCC staging. It affects the stage group in most cases.

3. **PSA Adjustment**

   • A discrepancy between the PSA documented in the lab report and the PSA documented by the clinician may arise due to the clinician's adjusting the PSA value. Certain medications for benign prostatic hypertrophy (BPH) decrease the PSA.
   • If there is documentation by a clinician within the medical record of an adjusted PSA value, record the adjusted value.
   • The registrar does not adjust the PSA value based on BPH medication use.
   • If there is no documentation by a clinician within the medical record of an adjusted PSA value, record the PSA value provided.
   • The fact that an adjusted PSA value is being recorded should be documented in the Dx Proc - Lab Tests text field (NAACCR Item # 2550).

Code Table

Description

This data item represents the number of positive cores documented in the pathology report from needle biopsy of the prostate gland. Two data items record the number of positive and examined cores that are microscopically confirmed. A diagnostic procedure, such as a needle core biopsy, can take as many as 20 or more core biopsies to determine the extent of the cancer within the prostate. Together these two data items can provide researchers with a surrogate estimate of the percentage of the prostate involved by tumor, if that figure is not stated in the pathology report Number of Cores Positive must ALWAYS be less than or equal to Number of Cores Examined. For Prostate, there are 2 data items that record information on the number of cores positive and examined. These related data items should be coded from the same test. * 3897: Number of Cores Examined * 3898: Number of Cores Positive ***Note:*** Do not make assumptions about the number of cores positive or examined based on the number of areas biopsied within the prostate (laterality, lobes, apex, base, or mid-prostate). Several cores may be taken from each area.

Notes

1. **Physician Statement**

   • Physician statement of Number of Cores Positive can be used to code this data item when there is no other information available, provided the priority order has been met (See Note 2).

2. **Priority order**

   • **Final diagnosis**
   • If the core biopsy pathology report contains a summary of the number of cores positive, use the summary provided
   • Do not include cores of other areas like seminal vesicles
   • **Gross description**
   • Information from the gross description of the core biopsy pathology report can be used to code this data item when the final diagnosis is not available and the gross findings provide the actual number of cores and not pieces, chips, fragments, etc.
   • **Physician statement (see Note 1)**

3. **Transperineal template-guided saturation biopsy (TTSB)**

   • A stereotactic prostate biopsy technique that typically produces 30 to 80 core biopsies. This is an alternative biopsy technique used for some high-risk patients including men with persistently elevated PSA, those who have atypia on prior prostate biopsies, or men with biopsies showing high grade prostatic intraepithelial neoplasia (PIN).

4. **Related data item**

   • The number of cores examined is recorded in the related data item 3897: Number of Cores Examined.

Code Table

Description

This data item represents the number of cores examined as documented in the pathology report from needle biopsy of the prostate gland. Two data items record the number of positive and examined cores that are microscopically confirmed. A diagnostic procedure, such as a needle core biopsy, can take as many as 20 or more core biopsies to determine the extent of the cancer within the prostate. Together these two data items can provide researchers with a surrogate estimate of the percentage of the prostate involved by tumor, if that figure is not stated in the pathology report Number of Cores Positive must ALWAYS be less than or equal to Number of Cores Examined. For Prostate, there are 2 data items that record information on the number of cores positive and examined. These related data items should be coded from the same test. * 3897: Number of Cores Examined * 3898: Number of Cores Positive ***Note:*** Do not make assumptions about the number of cores positive or examined based on the number of areas biopsied within the prostate (laterality, lobes, apex, base, or mid-prostate). Several cores may be taken from each area.

Notes

1. **Physician Statement**

   • Physician statement of Number of Cores Examined can be used to code this data item when there is no other information available, provided the priority order has been met (See Note 2).

2. **Priority order**

   • **Final diagnosis**
   • If the core biopsy pathology report contains a summary of the number of cores examined from all specimens, use the summary provided
   • Do not include cores of other areas like seminal vesicles
   • **Gross description**
   • Information from the gross description of the core biopsy pathology report can be used to code this data item when the final diagnosis is not available and the gross findings provide the actual number of cores and not pieces, chips, fragments, etc.
   • **Physician statement (see Note 1)**

3. **Transperineal template-guided saturation biopsy (TTSB)**

   • A stereotactic prostate biopsy technique that typically produces 30 to 80 core biopsies. This is an alternative biopsy technique used for some high-risk patients including men with persistently elevated PSA, those who have atypia on prior prostate biopsies, or men with biopsies showing high grade prostatic intraepithelial neoplasia (PIN).

4. **Related data item**

   • The number of cores positive are recorded in the related data item 3898: Number of Cores Positive.

Code Table

Description

Prostate cancers are graded using Gleason score or pattern. This data item represents the Gleason primary and secondary patterns from needle core biopsy or TURP. The pathologist determines the Gleason patterns by looking at the prostate tissue under the microscope. The pathologist assigns a grade to the most predominant pattern (largest surface area of involvement, more than 50% of tissue) and a grade for the secondary pattern (second most predominant) based on published Gleason criteria. When a patient undergoes radical prostatectomy, the pathologist may look for a third or tertiary pattern in the specimen. When Gleason pattern 5 is present as a tertiary pattern, its presence should be indicated in the pathology report, as a high Gleason pattern appears to be an indicator for worse outcome (shortened time to recurrence). Studies indicate that a Gleason score 7, with tertiary pattern 5, is associated with a worse prognosis than without tertiary pattern 5 and is similar to the prognosis for Gleason score 8 – 10. * For example, in a specimen where the primary Gleason pattern is 3, the secondary is 4 and there is less than 5% Gleason 5, the report should indicate a Gleason score of 7 (3+4) with tertiary Gleason pattern 5. Gleason grades (patterns) range from 1 (small, uniform gland) to 5 (lack of glands, sheets of cells.) For the Gleason Patterns data items, there is a long list of codes and definitions in the table, but it may be easier to assign a value if you understand the structure of the code. This is a two-digit field. * First digit is the Gleason primary pattern value * Second digit is the Gleason secondary pattern value The Gleason system for grading prostate cancer is the one recommended by the AJCC and College of American Pathologists. The following related data items are used to collect information on Gleason.

Notes

1. **Physician Statement**

   • Physician statement of Gleason Patterns Clinical can be used to code this data item when there is no other information available.

2. **Procedures**

   • Code the Gleason Patterns Clinical from a needle core biopsy, trans rectal ultrasound (TRUS) guided biopsy, transurethral resection of prostate (TURP), and/or simple prostatectomy in this field.
   • Gleason primary and secondary patterns provided for any prostate tissue identified from a transurethral resection of a bladder tumor (TURBT) specimen can also be used in this field

3. **Neoadjuvant Treatment**

   • Code the Gleason primary and secondary patterns prior to neoadjuvant treatment.

4. **Gleason Grading**

   • Usually, prostate cancers are graded using Gleason score or pattern. Gleason grading for prostate primaries is based on a 5-component system (5 histologic patterns). Prostatic cancer generally shows two main histologic patterns. The primary pattern, the pattern occupying greater than 50% of the cancer, is usually indicated by the first number of the Gleason grade, and the secondary pattern is usually indicated by the second number. These two numbers are added together to create a pattern score.
   • If there are two numbers, assume that they refer to two patterns (the first number being the primary pattern and the second number the secondary pattern), and sum them to obtain the score.
   • If only one number is given, and it is less than or equal to 5, assume that it describes a pattern (since scores of 5 or less would reflect Primary or Secondary Pattern Scores of 1 or 2). Code the number as the primary pattern and code the secondary pattern as Unknown.
   • * For ***example,*** if only one number is given and it is a 3, code "39" for Gleason Patterns and "X9" for Gleason Score.
   • If only one number is given, and it is greater than 5, assume that it is a score.
   • * For ***example,*** if only one number is given, and it is a 7, code "X6" for Gleason Patterns and "07" for Gleason Score.
   • If the pathology report specifies a specific number out of a total of 10, the first number given is the score.
   • * For ***example,*** if the pathology report says Gleason 7/10, code "07' for Gleason Score and "X6" for Gleason Patterns.

5. **Different patterns**

   • If different patterns are documented on multiple needle core biopsies, code the pattern that reflects the highest or most aggressive score regardless of if the pathologist provides an overall pattern in a final summary. If different patterns equal the same high score, give priority to the highest primary pattern and then the highest secondary pattern.
   • For ***example,*** both Gleason 3, 4 and Gleason 4, 3 equal Gleason score 7; code 43. Do not mix patterns from multiple specimens.

6. **Multiple procedures**

   • If multiple procedures are performed (e.g., needle core biopsy, trans rectal ultrasound (TRUS) guided biopsy, transurethral resection of prostate (TURP), and/or simple prostatectomy), code the pattern that reflects the highest score.

7. **Related data item**

   • The clinical score is recorded in the related data item 3840: Gleason Score Clinical.

Code Table

Description

This data item records the Gleason score based on adding the values for primary and secondary patterns in Needle Core Biopsy or TURP. The Gleason system for grading prostate cancer is the one recommended by the AJCC and College of American Pathologists. The following related data items are used to collect information on Gleason. * 3838: Gleason Patterns Clinical * 3839: Gleason Patterns Pathological * 3840: Gleason Score Clinical * 3841: Gleason Score Pathological * 3842: Gleason Tertiary Pattern The Gleason score is the sum of the values of the Gleason primary and secondary patterns. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread.

Notes

1. **Physician Statement**

   • Physician statement of Gleason Score Clinical can be used to code this data item when there is no other information available.

2. **Procedures**

   • Code the Gleason Score Clinical from a needle core biopsy, trans rectal ultrasound (TRUS) guided biopsy, transurethral resection of prostate (TURP), and/or simple prostatectomy in this field.
   • Gleason primary and secondary patterns provided for any prostate tissue identified from a transurethral resection of a bladder tumor (TURBT) specimen can also be used in this field

3. **Neoadjuvant Treatment**

   • Code the Gleason primary and secondary patterns prior to neoadjuvant treatment.

4. **Gleason Grading**

   • Usually, prostate cancers are graded using Gleason score or pattern. Gleason grading for prostate primaries is based on a 5-component system (5 histologic patterns). Prostatic cancer generally shows two main histologic patterns. The primary pattern, the pattern occupying greater than 50% of the cancer, is usually indicated by the first number of the Gleason grade, and the secondary pattern is usually indicated by the second number. These two numbers are added together to create a pattern score.
   • If there are two numbers, assume that they refer to two patterns (the first number being the primary pattern and the second number the secondary pattern), and sum them to obtain the score.
   • If only one number is given, and it is less than or equal to 5, assume that it describes a pattern (since scores of 5 or less would reflect Primary or Secondary Pattern Scores of 1 or 2). Code the number as the primary pattern and code the secondary pattern as Unknown.
   • For ***example,*** if only one number is given and it is a 3, code "39" for Gleason Patterns and "X9" for Gleason Score.
   • If only one number is given, and it is greater than 5, assume that it is a score.
   • For ***example,*** if only one number is given, and it is a 7, code "X6" for Gleason Patterns and "07" for Gleason Score.
   • If the pathology report specifies a specific number out of a total of 10, the first number given is the score.
   • For ***example***, if the pathology report says Gleason 7/10, code "07' for Gleason Score and "X6" for Gleason Patterns.

5. **Multiple procedures**

   • If multiple procedures are performed (e.g., needle core biopsy, trans rectal ultrasound (TRUS) guided biopsy, transurethral resection of prostate (TURP), and/or simple prostatectomy), code the pattern that reflects the highest score.

6. **Related data item**

   • Record the Gleason score based on the addition of the primary and secondary patterns coded in the related data item 3838: Gleason Patterns Clinical.

Code Table

Description

Prostate cancers are graded using Gleason score or pattern. This data item represents the Gleason primary and secondary patterns from a radical prostatectomy or autopsy. The pathologist determines the Gleason patterns by looking at the prostate tissue under the microscope. The pathologist assigns a grade to the most predominant pattern (largest surface area of involvement, more than 50% of tissue) and a grade for the secondary pattern (second most predominant) based on published Gleason criteria. When a patient undergoes radical prostatectomy, the pathologist may look for a third or tertiary pattern in the specimen. When Gleason pattern 5 is present as a tertiary pattern, its presence should be indicated in the pathology report, as a high Gleason pattern appears to be an indicator for worse outcome (shortened time to recurrence). Studies indicate that a Gleason score 7, with tertiary pattern 5, is associated with a worse prognosis than without tertiary pattern 5 and is similar to the prognosis for Gleason score 8 – 10. * For example, in a specimen where the primary Gleason pattern is 3, the secondary is 4 and there is less than 5% Gleason 5, the report should indicate a Gleason score of 7 (3+4) with tertiary Gleason pattern 5. Gleason grades (patterns) range from 1 (small, uniform gland) to 5 (lack of glands, sheets of cells.) For the Gleason Patterns data items, there is a long list of codes and definitions in the table, but it may be easier to assign a value if you understand the structure of the code. This is a two-digit field. * First digit is the Gleason primary pattern value * Second digit is the Gleason secondary pattern value The Gleason system for grading prostate cancer is the one recommended by the AJCC and College of American Pathologists. The following related data items are used to collect information on Gleason.

Notes

1. **Physician Statement**

   • Physician statement of Gleason Patterns Pathological can be used to code this data item when there is no other information available.

2. **Procedures**

   • Code the Gleason primary and secondary patterns from a radical prostatectomy or autopsy only in this field. Unlike Grade Group Pathological, do not include patterns from tissues taken prior to prostatectomy.
   • Code results from a transurethral resection of prostate (TURP) or simple prostatectomy in Gleason Patterns Clinical

3. **Gleason Grading**

   • Usually, prostate cancers are graded using Gleason score or pattern. Gleason grading for prostate primaries is based on a 5-component system (5 histologic patterns). Prostatic cancer generally shows two main histologic patterns. The primary pattern, the pattern occupying greater than 50% of the cancer, is usually indicated by the first number of the Gleason grade, and the secondary pattern is usually indicated by the second number. These two numbers are added together to create a pattern score.
   • If there are two numbers, assume that they refer to two patterns (the first number being the primary pattern and the second number the secondary pattern), and sum them to obtain the score.
   • If only one number is given, and it is less than or equal to 5, assume that it describes a pattern (since scores of 5 or less would reflect Primary or Secondary Pattern Scores of 1 or 2). Code the number as the primary pattern and code the secondary pattern as Unknown.
   • * For ***example,*** if only one number is given, and it is a 3, code "39" for Gleason Patterns and "X9" for Gleason Score.
   • If only one number is given, and it is greater than 5, assume that it is a score.
   • * For ***example,*** if only one number is given, and it is a 7, code "X6" for Gleason Patterns and "07" for Gleason Score.
   • If the pathology report specifies a specific number out of a total of 10, the first number given is the score.
   • * For ***example,*** if the pathology report says Gleason 7/10, code "07' for Gleason Score and "X6" for Gleason Patterns.

4. **Different patterns**

   • If different patterns are documented on multiple specimens, code the pattern that reflects the highest or most aggressive score regardless of if the pathologist provides an overall pattern in a final summary. If different patterns equal the same high score, give priority to the highest primary pattern and then the highest secondary pattern.

5. **Tertiary pattern**

   • If a tertiary pattern is documented on prostatectomy or autopsy, code in the related data item 3842: Gleason Tertiary Pattern.

6. **Neoadjuvant therapy**

   • Code X9 when neoadjuvant therapy was given

7. **Active surveillance, then Radical Prostatectomy**

   • Code X9 when first course of treatment is active surveillance, but a radical prostatectomy is done at a later date due to disease progression or the patient changed their mind

8. **Related data item**

   • The pathological score is recorded in the related data item 3841: Gleason Score Pathological.

Code Table

Description

This data item records the Gleason score based on adding the values for primary and secondary patterns from a radical prostatectomy or autopsy. The Gleason system for grading prostate cancer is the one recommended by the AJCC and College of American Pathologists. The following related data items are used to collect information on Gleason. * 3838: Gleason Patterns Clinical * 3839: Gleason Patterns Pathological * 3840: Gleason Score Clinical * 3841: Gleason Score Pathological * 3842: Gleason Tertiary Pattern The Gleason score is the sum of the values of the Gleason primary and secondary patterns. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread.

Notes

1. **Physician Statement**

   • Physician statement of Gleason Score Pathological can be used to code this data item when there is no other information available.

2. **Procedures**

   • Code the Gleason Score Pathological from a radical prostatectomy or autopsy only in this field. Unlike Grade Group Pathological, do not include patterns from tissues taken prior to a radical prostatectomy.
   • Code results from a transurethral resection of prostate (TURP) or simple prostatectomy in Gleason Score Clinical

3. **Gleason Grading**

   • Usually, prostate cancers are graded using Gleason's score or pattern. Gleason's grading for prostate primaries is based on a 5-component system (5 histologic patterns). Prostatic cancer generally shows two main histologic patterns. The primary pattern, the pattern occupying greater than 50% of the cancer, is usually indicated by the first number of the Gleason's grade, and the secondary pattern is usually indicated by the second number. These two numbers are added together to create a pattern score, ranging from 2 to 10.
   • If there are two numbers, assume that they refer to two patterns (the first number being the primary pattern and the second number the secondary pattern), and sum them to obtain the score.
   • If only one number is given, and it is less than or equal to 5, code the total score to X9, unknown or no information.
   • If only one number is given, and it is greater than 5, assume that it is a score and code as stated.
   • If the pathology report specifies a specific number out of a total of 10, the first number given is the score.
   • ***Example:*** The pathology report says Gleason's 3/10. The Gleason's score would be 3 and coded as 03.

4. **Neoadjuvant therapy**

   • Code X9 when neoadjuvant therapy was given

5. **Active surveillance, then Radical Prostatectomy**

   • Code X9 when first course of treatment is active surveillance, but a radical prostatectomy is done at a later date due to disease progression or the patient changed their mind

6. **Related data item**

   • Record the Gleason score based on the addition of the primary and secondary patterns coded in the related data item 3839: Gleason Patterns Pathological.

Code Table

Description

Prostate cancers are graded using Gleason score or pattern. This data item represents the tertiary pattern value from a radical prostatectomy or autopsy. A high Gleason Tertiary Pattern appears to be an indication for a worse outcome. The Gleason system for grading prostate cancer is the one recommended by the AJCC and College of American Pathologists. The following related data items are used to collect information on Gleason. * 3838: Gleason Patterns Clinical * 3839: Gleason Patterns Pathological * 3840: Gleason Score Clinical * 3841: Gleason Score Pathological * 3842: Gleason Tertiary Pattern

Notes

1. **Physician Statement**

   • Physician statement of Gleason tertiary pattern can be used to code this data item when there is no other information available.

2. **Procedures**

   • Record the tertiary pattern documented on radical prostatectomy or autopsy only. Record the tertiary pattern prior to neoadjuvant treatment.
   • If a tertiary pattern is documented on needle core biopsy or transurethral resection of prostate (TURP), it should be disregarded.
   • Do not code the tertiary pattern on radical prostatectomy or autopsy in Gleason Patterns Pathological.

3. **Tertiary Patterns 1 and 2**

   • The CAP Prostate Protocol does not include Patterns 1 and 2 for Tertiary Pattern.

4. **Neoadjuvant therapy**

   • Code X9 when neoadjuvant therapy was given

5. **Active surveillance, then Radical Prostatectomy**

   • Code X9 when first course of treatment is active surveillance, but a radical prostatectomy is done at a later date due to disease progression or the patient changed their mind

Code Table