Abstract
BackgroundAccurate grading at the time of diagnosis if fundamental to risk stratification and treatment decision making in patients with prostate cancer. Whilst previous studies have demonstrated significant pathological upgrading and downgrading following radical prostatectomy (RP), these were based on historical cohorts and do not reflect contemporary patient selection and management practices. The aim of this national, multicentre observational study was to characterise contemporary rates and risk factors for pathological upgrading after RP in the United Kingdom (UK).MethodsAll RP entries on the British Association of Urological Surgeons (BAUS) Radical Prostatectomy Registry database of prospectively entered cases undertaken between January 2011 and December 2016 were extracted. Those patients with full preoperative PSA, clinical stage, needle biopsy and subsequent RP pathological grade information were included. Upgrade was defined as any increase in Gleason grade from initial needle biopsy to pathological assessment of the entire surgical specimen. Statistical analysis and multivariate logistic regression were undertaken using R version 3.5 (R Foundation for Statistical Computing, Vienna, Austria).ResultsA total of 17,598 patients met full inclusion criteria. Absolute concordance between initial biopsy and pathological grade was 58.9% (n = 10,364), whilst upgrade and downgrade rates were 25.5% (n = 4489) and 15.6% (n = 2745) respectively. Upgrade rate was highest in those with D’Amico low risk compared with intermediate and high-risk disease (55.7% versus 19.1 and 24.3% respectively, P < 0.001). Although rates varied between year of surgery and geographical regions, these differences were not significant after adjusting for other preoperative diagnostic variables using multivariate logistic regression.ConclusionsPathological upgrading after RP in the UK is lower than expected when compared with other large contemporary series, despite operating on a generally higher risk patient cohort. As new diagnostic techniques that may reduce rates of pathological upgrading become more widely utilised, this study provides an important benchmark against which to measure future performance.
Highlights
Accurate grading at the time of diagnosis if fundamental to risk stratification and treatment decision making in patients with prostate cancer
Despite advances in recent years, conventional diagnostic pathways employ transrectal ultrasound (TRUS) guided prostate biopsy to acquire systematic needle biopsies of the prostate, which has recently been shown to have a sensitivity of only 48% for the diagnosis of ‘clinically significant’ cancer, defined as Gleason score of at least 4 + 3 or a maximum core length of at least 6 mm [8]
Despite apparent regional differences, almost all failed to reach significance. This is the largest study to date exploring pathological upgrading after radical prostatectomy, as well as the first of its kind conducted within a large contemporary United Kingdom (UK) patient cohort
Summary
Accurate grading at the time of diagnosis if fundamental to risk stratification and treatment decision making in patients with prostate cancer. Whilst previous studies have demonstrated significant pathological upgrading and downgrading following radical prostatectomy (RP), these were based on historical cohorts and do not reflect contemporary patient selection and management practices. The aim of this national, multicentre observational study was to characterise contemporary rates and risk factors for pathological upgrading after RP in the United Kingdom (UK). Given the heterogeneity of disease it is not surprising that a significant proportion of cases are upgraded following radical prostatectomy (RP) compared with the initial TRUS biopsy [9,10,11] This has wide ranging implications, as it may potentially lead to undertreatment of those that are undergraded by the initial biopsy, or overtreatment of those that have been overgraded. Upgrading has been associated with adverse pathological outcomes, such as positive surgical margin status and biochemical recurrence [12, 13]
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