Gleason Patterns Pathological
Notes
**Note 1:** Physician statement of Gleason Patterns Pathological can be used to code this data item when there is no other information available. **Note 2:** 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 **Note 3:** 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. **Note 4:** If the only information available is the Gleason Score, code the patterns X6 (primary pattern unknown, secondary pattern unknown). **Note 5:** 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. **Note 6:** If neoadjuvant therapy was given, code Gleason pathological patterns as X9. **Note 7:** Do not infer Gleason Primary and Secondary Pattern from Grade Group (Code X9). **Note 8:** If a tertiary pattern is documented on prostatectomy or autopsy, code in 3842: Gleason Tertiary Pattern. **Note 9:** The pathological score is recorded in 3841: Gleason Score Pathological.| Code | Description |
|---|---|
| 11 | Primary pattern 1, secondary pattern 1 |
| 12 | Primary pattern 1, secondary pattern 2 |
| 13 | Primary pattern 1, secondary pattern 3 |
| 14 | Primary pattern 1, secondary pattern 4 |
| 15 | Primary pattern 1, secondary pattern 5 |
| 19 | Primary pattern 1, secondary pattern unknown |
| 21 | Primary pattern 2, secondary pattern 1 |
| 22 | Primary pattern 2, secondary pattern 2 |
| 23 | Primary pattern 2, secondary pattern 3 |
| 24 | Primary pattern 2, secondary pattern 4 |
| 25 | Primary pattern 2, secondary pattern 5 |
| 29 | Primary pattern 2, secondary pattern unknown |
| 31 | Primary pattern 3, secondary pattern 1 |
| 32 | Primary pattern 3, secondary pattern 2 |
| 33 | Primary pattern 3, secondary pattern 3 |
| 34 | Primary pattern 3, secondary pattern 4 |
| 35 | Primary pattern 3, secondary pattern 5 |
| 39 | Primary pattern 3, secondary pattern unknown |
| 41 | Primary pattern 4, secondary pattern 1 |
| 42 | Primary pattern 4, secondary pattern 2 |
| 43 | Primary pattern 4, secondary pattern 3 |
| 44 | Primary pattern 4, secondary pattern 4 |
| 45 | Primary pattern 4, secondary pattern 5 |
| 49 | Primary pattern 4, secondary pattern unknown |
| 51 | Primary pattern 5, secondary pattern 1 |
| 52 | Primary pattern 5, secondary pattern 2 |
| 53 | Primary pattern 5, secondary pattern 3 |
| 54 | Primary pattern 5, secondary pattern 4 |
| 55 | Primary pattern 5, secondary pattern 5 |
| 59 | Primary pattern 5, secondary pattern unknown |
| X6 | Radical prostatectomy done, primary pattern unknown, secondary pattern unknown |
| X7 | No radical prostatectomy/autopsy performed |
| X8 | Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code X8 may result in an edit error.) |
| X9 | Not documented in medical record Gleason Patterns Pathological not assessed or unknown if assessed Unknown if radical prostatectomy done |