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Prostate Biopsy Results: How to Interpret Gleason and ISUP

For many men, receiving the biopsy report is the most anxious moment of the journey. Take a deep breath. Even a positive result rarely requires immediate decisions. Every word in the report carries precise clinical information that points to a specific path.

Dr. Bruno Benigno Urologist and Uro-oncologist CRM-SP 126.265 RQE 60022
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Important: this content is educational. Full interpretation of the report and treatment decisions require an in-person evaluation with a urologic oncologist.
Dr. Bruno Benigno View Full Profile

Dr. Bruno Benigno

  • Member of the AUA (American Urological Association)
  • Robotic Surgery and Focal Therapies
  • Hospital Alemão Oswaldo Cruz
  • Hospital Vila Nova Star
Hospital Alemão Oswaldo Cruz Hospital Vila Nova Star Sociedade Brasileira de Urologia American Urological Association

Understand the details of your report

The pathology report of a prostate biopsy is the most important document of the entire diagnostic journey. Watch the video to understand the key terms.

What the biopsy report means

The Gleason Score and the ISUP System

The Gleason score has been organized into 5 Grade Groups (ISUP Grade Groups). Today, every modern report shows both side by side. See what each group means in clinical practice.

ISUP Grade Group 1

Low Risk

Gleason: 3+3 = 6

Well-differentiated tumor with very slow growth. The probability of dying from prostate cancer within 15 years is often less than 1%.

Approach: Active surveillance is the preferred recommendation in selected patients.

ISUP Grade Group 2

Favorable Intermediate

Gleason: 3+4 = 7

The less aggressive pattern predominates. A real risk of progression, but the prognosis is generally good.

Approach: Active surveillance in very carefully selected cases, but active treatment (surgery or radiotherapy) is the more common option.

ISUP Grade Group 3

Unfavorable Intermediate

Gleason: 4+3 = 7

The more aggressive pattern predominates. Its behavior is quite different from ISUP 2 and requires closer attention.

Approach: Active treatment is generally indicated (radical prostatectomy or radiotherapy). Active surveillance is not recommended.

ISUP Grade Group 4

High Risk

Gleason: 8 (4+4, 3+5 or 5+3)

Poorly differentiated tumor. Significant risk of progression and metastatic disease. Requires thorough staging.

Approach: Active treatment is necessary, often combined (surgery with lymph node dissection, or radiotherapy with hormone therapy).

ISUP Grade Group 5

Very High Risk

Gleason: 9 or 10

Undifferentiated tumor. Very high risk of local and systemic progression. Aggressive, multidisciplinary management is mandatory.

Approach: Complete staging and multimodal treatment (surgery, radiotherapy, hormone therapy).

Other Findings

Be Aware

Terms such as ASAP (suspicious but not diagnostic), high-grade PIN (a precancerous lesion) and perineural invasion also shape the prognosis and require specialist attention when reading the report.

What comes after the diagnosis?

One of the most common worries is feeling there is no time. The scientific literature shows that making the right, well-planned decision matters more than making a rushed one.

Step 1

Interpretation Consultation

Review of the report with a uro-oncologist: core-by-core analysis, percentage of involvement and assessment of whether a second pathology opinion is needed.

Step 2

Staging (If Needed)

Depending on the ISUP Grade Group, additional tests may be ordered, such as MRI, PET-PSMA or a bone scan, to map the extent of the disease precisely.

Step 3

Treatment Decision (4 to 8 weeks)

A multidisciplinary discussion of the options: active surveillance, robotic surgery, radiotherapy or combined therapies. A 4- to 8-week planning period is safe and recommended for most cases.

Step 4

Start of Treatment or Monitoring

Carrying out the plan, focused on cure or close control, always aiming to preserve quality of life and urinary and sexual function.

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Facilities and Technology Working for the Patient

We work with the most advanced treatment protocols and robotic surgery at centers of excellence in São Paulo.

What our patients say

Stories from men who went through the journey from diagnosis to treatment with us.

"I was diagnosed with Gleason 7 and was terrified. The consultation with Dr. Bruno gave me the clarity I needed. The time he took to explain the report and the treatment options was key to my decision."

João S.

Google Reviews

"An excellent professional. He advised me on whether active surveillance was appropriate for my ISUP 1 case, based on solid evidence. I feel completely supported and at ease with the follow-up."

Carlos M.

Doctoralia

"The team was impeccable, from reviewing my biopsy to staging with PET-PSMA and robotic surgery. I recommend them to anyone looking for a serious, ethical and deeply caring uro-oncology specialist."

Roberto F.

Doctoralia
See all reviews on Doctoralia

Frequently Asked Questions (FAQ)

The most common questions about the results and terms in your biopsy report.

No. Gleason 6 (ISUP Grade Group 1) is the least aggressive form of prostate adenocarcinoma, with a very low risk of progression and death (often under 1% at 15 years). It is the scenario in which active surveillance is the preferred strategy in selected patients, with periodic monitoring by PSA, MRI and biopsies, without the need for immediate surgery or radiotherapy.
No. Although both add up to the same number (7), their clinical behavior is different. Gleason 3+4=7 (ISUP 2) has the less aggressive pattern predominating and tends to behave more favorably, so active surveillance may be an option in some cases. Gleason 4+3=7 (ISUP 3) has the more aggressive pattern predominating and a significantly higher risk of progression, almost always ruling out surveillance.
PET-PSMA is especially indicated in unfavorable intermediate-risk (ISUP 3), high-risk (ISUP 4) and very high-risk (ISUP 5) cases, where there is a real risk of regional or metastatic disease. It is also useful for persistent PSA after treatment. In low-risk (ISUP 1) or favorable intermediate-risk (ISUP 2 without adverse features) cases, the scan is not routinely indicated.
No. ASAP (Atypical Small Acinar Proliferation) means the pathologist identified a suspicious focus but could not confirm a cancer diagnosis with certainty because of the small number of cells or a borderline pattern. It requires reassessment, and in about 30 to 40% of cases a repeat biopsy confirms adenocarcinoma.
High-grade PIN (HGPIN) is a precancerous lesion. It is not cancer, but a potential precursor. If found in a single sample, the risk of progression is low. If extensive or present in multiple cores, the risk of coexisting adenocarcinoma increases, often prompting a repeat biopsy in 6 to 12 months.
In many cases, yes. Studies show that review of the report changes the ISUP Grade Group in 10 to 30% of cases, changing management in 15 to 20%. It is especially useful when the report is borderline between Gleason 3+3 and 3+4, or 3+4 and 4+3, when descriptions are vague, when ASAP is reported, or before deciding on complex treatments such as nerve-sparing surgery.
A positive biopsy is not an immediate medical emergency. For ISUP 1 and favorable ISUP 2, weeks or months are safe. For unfavorable ISUP 2 and ISUP 3, the plan should ideally be defined within 4 to 8 weeks. For ISUP 4 and 5, treatment should start within 4 to 6 weeks after staging. Time spent on planning and staging improves the outcome and is preferable to uninformed haste.

Hospitals Where We Operate in São Paulo

Hospital Alemão Oswaldo Cruz (Vila Mariana) Hospital Vila Nova Star (Itaim Bibi)

Your next consultation with Dr. Bruno Benigno

The results consultation is the most important moment of your journey. Every term in the report can influence the treatment decision. We see patients in person in São Paulo and via telemedicine throughout Brazil.

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Medical content reviewed by Dr. Bruno Benigno, urologist and uro-oncologist (CRM-SP 126.265 · RQE 60022), based on AUA, EAU and NCCN guidelines. Last reviewed:

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