What does a diagnosis of prostate adenocarcinoma with Gleason score 3 + 4 indicate?

Prostate Adenocarcinoma Gleason 3 + 4 = 7 (Grade Group 2)

A diagnosis of prostate adenocarcinoma with Gleason score 3 + 4 = 7 means you have intermediate-risk prostate cancer where the predominant (most common) pattern of cancer cells shows moderately abnormal architecture (pattern 3), with a smaller secondary component showing more aggressive, poorly formed glands (pattern 4). 1

What the Numbers Mean

• The Gleason score is calculated by adding the two most common cancer patterns seen under the microscope, each graded from 1 (least aggressive) to 5 (most aggressive). 2

• In your case, "3 + 4" means:

  • Pattern 3 (moderately differentiated cells) is the dominant pattern, comprising the majority of your tumor 1
  • Pattern 4 (poorly formed, fused, or cribriform glands) is the secondary pattern, present in a smaller proportion 3

• The total score of 7 places you in the intermediate-risk category, but the order matters critically: Gleason 3 + 4 = 7 has a significantly better prognosis than Gleason 4 + 3 = 7, because the primary pattern determines aggressiveness. 2, 1

Prognosis

• Gleason 3 + 4 = 7 disease carries an excellent long-term outlook, with 10-year prostate-cancer-specific survival exceeding 92%. 1

• The 5-year biochemical recurrence-free survival after radical prostatectomy is approximately 88% for favorable intermediate-risk patients. 1

• Each increase in Gleason score correlates with greater tumor aggressiveness, and the presence of any pattern 4 component (versus pure pattern 3) significantly worsens prognosis. 2, 4

Risk Stratification: Favorable vs. Unfavorable Intermediate-Risk

Your Gleason 3 + 4 = 7 cancer is classified as intermediate-risk, but this category is further subdivided based on additional tumor characteristics: 1

Favorable Intermediate-Risk (ALL of the following must be present):

• Primary Gleason pattern 3 (which you have: 3 + 4) 1
• Less than 50% of biopsy cores contain cancer 1
• Only one intermediate-risk factor (either PSA 10–20 ng/mL or clinical stage T2b-c, but not both) 1

Unfavorable Intermediate-Risk (ANY of the following):

• ≥50% of biopsy cores positive for cancer 1
• Multiple intermediate-risk factors (e.g., elevated PSA and advanced clinical stage) 1
• Primary Gleason pattern 4 (i.e., Gleason 4 + 3, which you do not have) 1

Treatment Recommendations Based on Life Expectancy

If Life Expectancy < 10 Years:

• Observation or active surveillance is appropriate, because definitive therapy often causes more harm than benefit when competing health risks are present. 1

If Life Expectancy ≥ 10 Years AND Favorable Intermediate-Risk:

• Active surveillance is now an acceptable option if you are fully informed and agree to close monitoring (regular PSA testing and repeat biopsies every 1–2 years). 1

• Radical prostatectomy with pelvic lymph-node dissection is recommended when the estimated risk of nodal involvement is ≥2%. 1

• External-beam radiation therapy (EBRT) combined with 4–6 months of androgen-deprivation therapy (ADT) is a guideline-supported definitive option. 1

• Brachytherapy alone or combined with EBRT is also acceptable. 1

If Life Expectancy ≥ 10 Years AND Unfavorable Intermediate-Risk:

• Definitive treatment is strongly recommended; active surveillance is not appropriate. 1

• Options include radical prostatectomy, EBRT ± ADT, or brachytherapy—the same modalities as favorable disease, but observation is excluded. 1

Common Pitfalls and Caveats

• Biopsy sampling error: Approximately 24% of patients with Gleason 3 + 4 on biopsy are upgraded to primary pattern 4 or higher on final prostatectomy pathology, which worsens prognosis. 5

• Grading variability: Non-genitourinary pathologists tend to assign higher Gleason scores than specialized genitourinary pathologists, with a tendency to overcall pattern 4. 6 Consider expert pathology review if treatment decisions are borderline.

• Pattern 4 proportion matters: Even within Gleason 3 + 4 = 7, the percentage of pattern 4 present influences outcomes—higher proportions confer worse prognosis. 4

• Not benign: Despite being "lower" intermediate-risk, Gleason 3 + 4 = 7 is true malignancy capable of infiltration, extraprostatic extension, and metastasis; it requires definitive management in patients with adequate life expectancy. 7