Unifying Concepts

Staging of Prostate Cancer

The Tumor-Node-Metastasis (TNM) System

Stage (TNM)

Definition of Stage





Not palpable, found following TURP or biopsy

Focal, <5% of tissue, not high grade

Diffuse, >5% of tissue, and/or high grade

Biopsy for PSA elevation only





Palpable disease limited to the prostate

Disease < ½ of one lobe

Disease > ½ of one lobe but < 1 lobe

Disease > 1 lobe





Palpable disease beyond the prostate

Unilateral disease beyond the capsule

Bilateral disease beyond the capsule

Spread to seminal vesicles


Metastatic spread to adjacent organs (e.g., bladder, pelvic sidewall)

Metastatic cancer

N+ Tumor that has spread to pelvic lymph nodes

M+ Tumor that has spread beyond pelvic lymph nodes

TURP = transurethral resection of the prostate; PSA = prostate-specific antigen.

The Gleason Grading System

The Gleason histological scoring system, tumors are graded from one to five based upon the degree of glandular differentiation and structural architecture. Grade one represents the most well-differentiated appearance and grade five represents the most poorly differentiated. A primary score and a secondary score is then reported. The most differentiated cancers have a score of “one plus one” or two; the most undifferentiated cancers are scored as “five plus five” or ten. Combined scores (primary and secondary scores) of two, three, and four usually represent well-differentiated cancers; scores of five, six, or seven represent moderately differentiated cancers; and scores of eight, nine, or ten represent poorly differentiated cancers. The prognosis is directly related to the pattern score.


Grading System:

1 Simple round glands, closely packed in rounded masses with well-defined edges.

2 Simple round glands, loosely packed in vague, rounded masses with loosely packed edges.

3A Medium-sized single glands of irregular shape and irregular spacing with ill-defined infiltrating edges.

3B Very similar to 3A, but small to very small glands which must not form significant chains or cords.

3C Papillary and cribriform epithelium in smooth, rounded cylinders and masses; no necrosis.

4A Small, medium, or large glands fused into cords, chains or ragged, infiltrating masses.

4B Very similar to 4A, but with many large clear cells, sometimes resembling “hypernephroma.”

5A No glandular differentiation, solid sheets, cords, single cells, or solid nests of tumor with central necrosis.

5B Anaplastic adenocarcinoma in ragged sheets.




  1. Rees MA, Resnick MI, Oesterling JE. Use of prostate-specific antigen, Gleason score, and digital rectal examination in staging patients with newly diagnosed prostate cancer. Urol Clin North Am. 1997 May;24(2):379-88. [Medline]
  2. Gleason DF. Histologic grading of prostate cancer: a perspective. Hum Pathol. 1992 Mar;23(3):273-9. [Medline]


Created: Jan 14, 2006

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