Pathologic Upgrading in Biopsy Grade Group 1, PI-RADS ≥ 3 Prostate Cancer: Factors Associated With Clinically Significant Disease on Radical Prostatectomy.

The early diagnosis of prostate cancer (PCa) is mainly based on prostate-specific antigen (PSA) blood levels and digital rectal examination. However, this approach may result in a high rate of negative biopsies and increased detection of clinically insignificant PCa (CS-PCa). An important prognostic biomarker, PSA density (PSA-D) demonstrated improved performance in PCa detection compared to PSA. The relationship between prostate volume and the prognostic accuracy of PSA-D remains mostly unclear. The aim of our study is to investigate the PSA-D predictive value of CS-PCa detection at different prostate volumes. Using our local radical prostatectomy registry, patients were divided into three prostate size subgroups based on preoperative sonographic prostate volume assessment: less than 50, 50-75, and more than 75 cc. Patients' and PCa characteristics were recorded, including age, body mass index, PSA at diagnosis, prostate volume, PSA-D, D'Amico risk classification, Gleason grade group, and pathological staging following surgery. The study cohort included 364 patients who underwent Robotic Radical prostatectomy for biopsy-proven clinically localized PCa. 221 (61%) and 143 (39%) patients had PSA-D less than 0.15 and PSA-D more than 0.15, respectively. ISUP GG 1-2 PCa (CS-PCa) was observed in 220 patients (60%), while 144 (40%) had ISUP GG 3-5 PCa at final pathology. PSA-D correlated with CS-PCa only in small and medium-size prostates, but not in large glands (p = .03, p = .01, and p = .36, respectively). The highest sensitivity (72.7%) was observed in small prostates, compared to 3.2% in large prostates. The highest specificity (89.4%) was noted in large prostates. Positive predictive value in small and medium-size prostates was similar (~50%), compared to 20% in large glands. The negative predictive value was slightly better for small and medium-size prostates compared with large glands (68.9%, 73.7%, and 53.1%, respectively). An association between PSA-D and harboring CS-PCa was detected only in small and medium-size glands (72.7% and 43%, respectively). PSA-D is associated with CS-PCa detection in radical prostatectomy specimens in small and medium-size prostates. The level of PSA-D is directly associated with the ISUP PCa grade group. Therefore, PSA-D is a beneficial, available, and cost-effective tool during decision-making in patients with small and medium-size prostate when considering treatment for PCa.

MP58-11 GLEASON GRADE GROUP 1 PROSTATE CANCER VOLUME AT BIOPSY IS ASSOCIATED WITH UNFAVORABLE PATHOLOGY BUT NOT UPGRADING AFTER RADICAL PROSTATECTOMY

BackgroundThe present study aimed to develop three nomograms by incorporating multiple clinical characteristics to identify those prostate cancer (PCa) patients with high probability of incorrect biopsy Gleason grade group (GG) before making treatment decisions. MethodsWe retrospectively collected data from PCa patients who underwent systematic biopsy and radical prostatectomy from January 2015 to December 2019 at Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology. Univariable and multivariable logistic regression analyses were preformed to identify independent risk factors associated with upgrading, upstaging and downgrading. By incorporating selected clinical parameters with high predictive value, we constructed three nomograms to predict the probability of upgrading, upstaging and downgrading. Discrimination of nomograms was evaluated by receiver operating characteristic (ROC) analysis with corresponding area under the curve (AUC). Decision curve analysis (DCA) and calibration curves were performed to evaluate calibration and the clinical usefulness of nomograms. Performance of the three nomograms was validated in the testing dataset. ResultsThere were 585 PCa patients in total enrolled in this study who met the inclusion criteria. Of the 585 patients, the disease of 262 (44.8 %) was upgraded and 68 (11.6 %) was downgraded, and the disease of 67 (11.5 %) was upstaged. With regard to findings of multivariable analyses, patients’ age and biopsy GG (GG 2, GG 3, GG 4 versus GG 1) were significantly associated with upgrading. Moreover, maximum diameter of the index lesion (D-max), clinical T stage (cT3a, cT3b versus cT1−2), number of positive cores and total tumor length were significantly associated with upstaging. Furthermore, d-max, %fPSA (> 0.16 versus ≤ 0.16) and biopsy GG (GG 3, GG 4, GG 5 versus GG 2) were independent predictors of downgrading. The three nomograms displayed good calibration in respective calibration plots. ROC analyses showed good discrimination with satisfactory AUC values and DCA plots demonstrated that the upgrading-risk nomogram, upstaging-risk nomogram and downgrading-risk nomogram were all clinically useful. ConclusionsThe upgrading-risk nomogram, upstaging-risk nomogram, and downgrading-risk nomogram were developed and correctly predicted the probability of incorrect Gleason grade group assigned to patients undergoing systematic biopsy.

PurposeTo determine whether additional systematic biopsy is necessary in all biopsy naïve patients with MRI visible lesions by taking PI-RADS score and prostate volume into consideration.Materials and MethodsPatients who underwent combined systematic biopsy (SB) and cognitive MRI-targeted biopsy (TB) in our hospital between May 2018 and June 2020 were retrospectively reviewed. The detection rate of clinical significant prostate cancer (csPCa), biopsy grade group (GG) concordance, and disease upgrading rate on radical prostatectomy were compared between SB and TB and further stratified by PI-RADS v2.0 category and prostate volume.ResultsA total of 234 patients were analyzed in this study. TB alone detected more csPCa and less clinically insignificant prostate cancer (cisPCa) than SB alone in the whole cohort (57.3 vs 53%, P = 0.041; 3.8 vs 7.7%, P = 0.049 respectively). The additional SB indicated only a marginal increase of csPCa detection but a remarkable increase of cisPCa detection compared with targeted biopsy (59.4 vs 57.3%, P = 0.064; 3.8 vs 7.7%, P = 0.012). As stratified by PI-RADS category, the difference of csPCa detection rate between TB and SB was not significant either in PI-RADS 5 subgroup (83.8 vs 76.3%, P = 0.07) or in PI-RADS 3–4 subgroup (43.5 vs 40.9%, P = 1.0). Additional SB decreased the rate of disease upgrading on radical prostatectomy (RP) than TB alone in PI-RADS 3–4 subgroup (14.5 vs 25.5%, P = 0.031) other than PI-RADS 5 subgroup (6 vs 6%, P = 1.0). When stratified by prostate volume (PV), TB alone detected more csPCa than SB in small prostate (PV < 30 ml) group (81.0 vs 71.0%, P = 0.021) but not in large prostate (PV ≥ 30 ml) group (44.0 vs 42.7%, P = 0.754). The additional SB did not significantly decrease the rate of disease upgrading on RP than TB alone in either small or large prostate (6.4 vs 8.5%, P = 1.0; 13.8 vs 22.4%, P = 0.063).ConclusionThe combination biopsy method was no superior than targeted biopsy alone in PI-RADS 5 or in small volume prostate subgroup.

Introduction: The relationship between prostate cancer (PCa) and benign prostatic hyperplasia is unclear. Reduction in androgenicity and lower intraprostatic growth factor concentrations in smaller prostates may serve a more ideal environment for the development of aggressive tumors. We determined if prostate volume was associated with adverse pathological features, tumor volume, and biochemical recurrence (BCR) in men undergoing radical prostatectomy (RP) for PCa. Materials and Methods: We retrospectively identified 192 men who underwent RP at our institution for PCa from 2010 to 2016 years. Prostate volume was based on RP specimen weight, and cumulative tumor volume was calculated. Means were compared with one-way ANOVA test and proportions with Chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of BCR after RP. Results: Patients with prostate volume &gt;60 g were less likely to have high-risk PCa (Gleason grade group &gt;4) (7.1% vs. 13.4%; P = 0.042), node-positive disease (7.1% vs. 13.4%, P = 0.042), and BCR (10.7% vs. 25.0%, P = 0.002) after surgery. Linear regression showed an inverse relationship between prostate and tumor volume (R = 0.267; P &lt; 0.05). On multivariate logistic regression, prostate volume &gt;30 g (odds ratio [OR]: 0.21, 95% confidence interval [CI]: 0.09–0.88; P = 0.015) and &gt;60 g (OR: 0.14, 95% CI: 0.03–0.74; P = 0.002) were independent predictors of reduced BCR at mean follow-up of 24 months.Conclusions: Smaller prostate volume was associated with adverse pathological features, increased tumor volume, higher incidence of pathological node-positive disease, and increased rates of BCR. Prostate volume should be considered as a prognostic feature when counseling patients with both elevated prostate-specific antigen and newly diagnosed PCa.

Gleason Grade 1 Prostate Cancer Volume at Biopsy Is Associated With Upgrading but Not Adverse Pathology or Recurrence After Radical Prostatectomy: Results From a Large Institutional Cohort.

Purpose To access the incidence and predictors of Gleason grade group upgrading from cognitive MR-targeted fusion prostate biopsy to radical prostatectomy in a Chinese cohort. Materials and Methods We included 199 patients in our institution between January 2016 and June 2021. Multivariable logistic regression model and nomograms were utilized to analyze the collected data. Results The concordance rate of biopsy Gleason grade group and radical prostatectomy was 50.3% (100 in 199). Upgrading occurred in 80 (40.2%) patients and 37 (68.5%) patients have an upgrading Gleason grade group when the biopsy Gleason grade group was 1. Multivariable logistic regression models were established to analyze the incidence and predictors of Gleason grade group upgrading from cognitive MR-targeted fusion prostate biopsy to radical prostatectomy. Biopsy Gleason grade group, prostate volume, and patient year were confirmed to be individual predictors of upgrading. Based on the logistic regression models, nomograms for predicting probability of prostate Gleason grade group upgrading were generated. Conclusions We established a logistic regression model to predict the accuracy of prostate biopsy GG and provide the probability of upgrading. Clinicians should be more cautious when deciding the treatment strategy especially for prostate cancer biopsy GG1 patients. Future studies should expand the sample size and include more variables to improve the accuracy of predicting upgrading and prostate cancer early screening program is urgently needed in our city in China.

A trend towards inverse stage migration in prostate cancer (PCa) was reported. However, previous analyses did not take into account potential differences in sampling strategies (number of biopsy cores), which might have confounded these reports. Within our single-institutional database we identified PCa patients treated with radical prostatectomy (RP) between 2000 and 2020 (n = 21,646). We calculated the estimated annual percentage change (EAPC) for D'Amico risk groups, biopsy Gleason Grade Group (GGG), PSA and cT stage as well as postoperative RP GGG and pT stage relying on log linear regression methodology. Subsequently, we repeated the analyses after adjustment for number of cores obtained at biopsy. Absolute rates of D'Amico low risk decreased (-30.1%), while intermediate and high risk increased (+21.2% and +9.0%, respectively). Rates of GGG I decreased (-50.0%), while GGG II-V increased, with the largest increase in GGG II (+22.5%). This trend, albeit less pronounced, was also recorded after adjusted EAPC analyses (p < .05). Specifically, EAPC values for D'Amico low vs intermediate vs high risk were -1.07%, +0.37%, +0.45%, respectively, and EAPC values for GGG ranged between -0.71% (GGG I) and +0.80% (GGG IV). Finally, an increase in ≥cT2 (EAPC: +3.16%) was displayed (all p < .001). These trends were confirmed in EAPC calculations in RP GGG and pT stages (p < .001). Our findings confirm the trend towards less frequent treatment of low risk PCa and more frequent treatment of high risk PCa, also after adjustment for number of biopsy cores.

MP49-09 DECIPHER® PREDICTS CLINICALLY SIGNIFICANT UPGRADING ON FINAL RADICAL PROSTATECTOMY PATHOLOGY

Prostate Size Does Not Predict High Grade Cancer

BackgroundActive surveillance (AS) is generally recognized as the preferred option for men with low-risk prostate cancer. Current guidelines use prostate-specific antigen (PSA) of 10–20 ng/mL or low-volume biopsy Gleason grade group (GG) 2 as features that, in part, define the favorable intermediate-risk disease and suggest that AS may be considered for some men in this risk category.MethodsWe identified 26,548 men initially managed with AS aged <80 years, with clinically localized prostate cancer (cT1-2cN0M0), PSA ≤ 20 ng/mL, biopsy GG ≤ 2 with percent positive cores ≤33% and who converted to treatment with radical prostatectomy from the surveillance, epidemiology, and end results prostate with the watchful waiting database. Multivariable logistic regression was performed to determine predictors of adverse pathology at RP according to PSA level (<10 vs 10–20 ng/mL) and GG (1 vs 2).ResultsOf 1731 men with GG 1 disease and PSA 10–20 ng/mL, 382 (22.1%) harbored adverse pathology compared to 2340 (28%) of 8,367 men with GG 2 and a PSA < 10 ng/mL who had adverse pathology at RP. On multivariable analysis, the odds of harboring adverse pathology with a PSA 10–20 ng/mL (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.71–2.05, p < 0.001) was less than that of GG 2 (OR 2.56, 95%CI 2.40–2.73, p < 0.001) after adjustment.ConclusionsOur results support extending AS criteria more permissively to carefully selected men with PSA 10–20 ng/mL and GG 1 disease.

412 Background: Nguyen et al recently proposed an outcome-based radical prostatectomy (RP) histologic classifier (PMID 38828674, “Canary histology risk group”), combining all high-risk carcinoma histology patterns into “unfavorable histology,” versus absence as “favorable histology.” We examine whether this classifier, with additional stratification of favorable, is applicable to prostate biopsies for risk stratification. Methods: Archival databases of one single institution were searched for patients with long term clinical follow-up after RP and available prostate biopsy slides. Most recent biopsies underwent blinded re-review. Canary risk group was assigned based on highest risk patterns in any core. Unfavorable histology encompasses all Gleason pattern 5, large cribriform/intraductal carcinoma (&gt;0.25 mm), anastomosing cords of carcinoma, grade 3 stromogenic carcinoma, and complex intraluminal papillary architecture. To capture patterns potentially predictive of unsampled unfavorable histology, “biopsy borderline” combines small cribriform/glomeruloid (≤0.25 mm), simple glomerulations, predominance of extensive poorly formed glands, equivocal small anastomosing cords, grade 2 stromal response, and epithelial complexity associated with mucin (beyond mucinous fibroplasia). “Biopsy favorable” is defined as void of any unfavorable or biopsy borderline histology. Biopsy and RP Gleason Grade Group (GG), pT stage, and pN stage were recorded from original reports. Biochemical recurrence (BCR) was defined as consecutive PSA of ≥0.2 ng/mL 8 weeks after RP or receipt of salvage treatment. RP stage and GG were analyzed using chi-square. BCR-free survival was analyzed using Kaplan-Meier curve. Results: 360 patients were identified (median, IQR): Age at diagnosis 61 years (56, 66), PSA at diagnosis 5.38 ng/mL (4.2, 7.6), post-RP follow-up 9 years, (7, 12). The patients were classified as histologically unfavorable (n=63; 17.8%), biopsy borderline (n=92; 25.6%), and biopsy favorable (n=205; 56.9%). The three-tiered classification is significantly associated with earlier BCR (log-rank p-value &lt;.01), RP GG (&lt;.01), pT stage (&lt;.01), and pN stage (&lt;.01) (Table). Conclusions: Unfavorable histology on biopsy was associated with highest risk of BCR after RP, compared to “biopsy borderline” and “biopsy favorable” groups. This proof-of-principle study demonstrates the three-tiered histology-based classifier could be applicable in biopsies for risk stratification. Canary Histology Risk Group N (%) GG3+ at RP pT3a at RP pT3b at RP pN1 BCR event within 7 years of RP Unfavorable 63 (18%) 46 (73%) 30 (48%) 11 (17%) 11 (17%) 53 (84%) Biopsy Borderline 92 (26%) 21 (23%) 32 (35%) 5 (5%) 1 (1%) 60 (63%) Biopsy Favorable 205 (57%) 22 (11%) 69 (34%) 3 (1%) 0 (0%) 110 (54%) All patients 360 (100%) 89 (25%) 131 (36%) 19 (5%) 12 (3%) 223 (62%)

Accurate assessment of the clinical staging is crucial for determining the need for radical prostatectomy (RP) in prostate cancer (PCa). However, the current methods for PCa staging may yield incorrect results. This study aimed to comprehensively analyze independent predictors of postoperative upstaging of intraprostatic cancer. We conducted a retrospective analysis of data from intraprostatic cancer patients who underwent radical surgery between March 2019 and December 2022. Intraprostatic cancer was defined as a lesion confined to the prostate, excluding cases where multiparameter magnetic resonance imaging (mpMRI) showed the lesion in contact with the prostatic capsule. We assessed independent predictors of extraprostatic extension (EPE) and analyzed their association with positive surgical margin (PSM) status. In addition, based on the distance of the lesion from the capsule on mpMRI, we divided the patients into non-transition zone and transition zone groups for further analysis. A total of 500 patients were included in our study. Logistic regression analysis revealed that biopsy Gleason grade group (GG) (odds ratio, OR: 1.370, 95% confidence interval, CI: 1.093-1.718) and perineural invasion (PNI) (OR: 2.746, 95% CI: 1.420-5.309) were predictive factors for postoperative EPE. Both biopsy GG and PNI were associated with lateral (GG: OR: 1.270, 95% CI: 1.074-1.501; PNI: OR: 2.733, 95% CI: 1.521-4.911) and basal (GG: OR: 1.491, 95% CI: 1.194-1.862; PNI: OR: 3.730, 95% CI: 1.929-7.214) PSM but not with apex PSM (GG: OR: 1.176, 95% CI: 0.989-1.399; PNI: OR: 1.204, 95% CI: 0.609-2.381) after RP. Finally, PNI was an independent predictor of EPE in the transition zone (OR: 11.235, 95% CI: 2.779-45.428) but not in the non-transition zone (OR: 1.942, 95% CI: 0.920-4.098). PNI and higher GG may indicate upstaging of tumors in patients with intraprostatic carcinoma. These two factors are associated with PSM in locations other than the apex of the prostate. Importantly, cancer in the transition zone of the prostate is more likely to spread externally through nerve invasion than cancer in the non-transition zone.

P1091 - Radical prostatectomy for localized prostate cancer: 20-year oncological outcomes from a German high-volume center

Radical prostatectomy for localized prostate cancer: 20-year oncological outcomes from a German high-volume center