question about prostate cancer….high Gleason’s / low PSA… can this be?


burn me once… shame on you…burn me twice…shame on me


  • When tumors are described by way of its differentiation, i.e. well differentiated, poorly differentiated, what they  are talking about is how close or how far away is from a normal one.
  • In prostate cancer the Gleason’s score  is a way to describe how a cell is differentiated.
  • A Gleason 6 is a well-moderately differentiated cancer.
  • A Gleason 8 or above is a poorly differentiated cancer.
  • A well differentiated prostate cancer is harder to call for the pathologist than a moderately differentiated cancer because the well differentiated cell more closely resembles the normal prostate cell.
  • A poorly differentiated prostate cancer cell is  an easy to call for the pathologist because its architecture is so far removed from how a normal cell looks…it is sometimes described as “bizarre.”
  • A poorly differentiated cell however can be tricky for the pathologist because it can be so bizarre looking that it loses all the characteristics of a prostate cell.
  • So if a patient has a lymph node somewhere and the doctors  don’t know the primary cancer (i.e. the origin of the primary cancer) and it is biopsied and it comes back as a “poorly differentiated cancer” the pathologist sometimes can’t tell you where the cancer in the lymph node is from…it is too bizarre to categorize.
  • Poorly differentiated cancers are very aggressive, usually don’t respond well to treatment and the patients that have this type of cancer don’t do as well as those as ones with well differentiated cancer.
  • Gleason’s 6 patients as a rule  will respond to treatment better than a Gleason’s 8 patient.
  • Gleason’s 6 well-mod differentiated , Gleason’s 9 poorly differentiated.
  • If some prostate cancers don’t produce a  high PSA then this makes the case of being sure a rectal exam is always done. That patient who avoids a rectal exam thinking that “I am Okay, my PSA is normal” runs the risk of having prostate cancer and not knowing it.

Now to the question. A poorly differentiated prostate  cancer with bizarre  features under the microscope can be so “cancerous” that it also has lost the functions of  a normal prostate cancer cell.

In this case the most probable reason for a low PSA and an aggressive prostate cancer is that the prostate cancer cell is so bizarre it has lost some of the normal functions of a normal cell and in this case the ability to produce PSA.

Gleason’s score is another way that is prostate cancer specific to describe the differentiation of the cancer and in turn gives one insight to the aggressiveness of their disease.

I have had patients come in for their path report only to find that the pathologist has called one of the cores as suspicious and that more time and stains will be necessary to “call” the diagnosis. I have told them that in some ways this type of report is a good  thing.  I have said, ” The bad cancers are the easy ones to call. So you either don’t have prostate cancer or it will be a low Gleason’s or the good kind.” My fear for my biopsy was not that I would have cancer, but that I’d have “the bad kind…the Frank Zappa kind.”

6 Replies to “question about prostate cancer….high Gleason’s / low PSA… can this be?”

  1. Hi Dr. McHugh –

    My husband has prostate cancer. He had cryosurgery in March of 2010 as his initial treatment. His follow-up psa’s have been: Jun 2010, 1.98; Sep 2010, 1.8; Dec 2010, 2.2; Mar 2011, 3.2. I know this is not good.

    I am wondering what options he has at this time. I would still like to try for a cure, if possible.

    His Doc is talking ADT. I am very frightened of this option. I don’t want to see my man lose his manliness, but I don’t want him to die either.

    My husband in 77, but he and his entire family are extremely strong. His older sister had open heart surgery at 85, and she bounced back in 8 weeks.

    Any ideas or suggestions you have would be greatly appreciated. I have a great deal of respect for your expertise and wisdom.

    Thank you!


  2. Hi Mrs. Cassey, I addressed your question on the following post. Your doctor maybe “talking hormones” but you still can get from him all the options and with that make a decision that fits for you and yours. Men are funny…they usually take the path of least resistance in matters such as these. A big part of yall’s next decision will be based on your husband’s mindset…you may already know what that is…wives’ are funny that way. Good luck….John


  3. Hallo,
    I am from Holland and would like to ask a question. I have prostate cancer since 6 years. My Gleason is 9 and my PSA is 18, slowly rising. Can you tell me about the prospects, if possible. Thank you in advance.
    PS., what a beautiful house and a lovely dog.
    Wim Hohage


  4. Does a poorly differentiated high Gleason scenario usually play out with a palpable mass detected by a rectal exam? Or is it sometimes non palpable along with a low PSA which would R/O a biopsy? Would symptoms alone then trigger a biopsy?


    1. Any combination of findings do occur but most commonly high Gleason is associated with a high psa and a palpable finding on rectal however this is not always the case. I diagnosed a man with a psa of 1.2 and suspicious prostate and 5/12 cores positive for Gleason’s 7/8, A strong history of prostate cancer is very important. Normally biopsies are not done because of voiding symptoms. JM


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