Gleason Score Upgrading Research Articles

A single-center long-term experience of active surveillance for prostate cancer: 15 years of follow-up.

PurposeTo describe a single-center 15-year experience of active surveillance (AS) for prostate cancer (PCa).Materials and MethodsWe retrospectively reviewed patients who underwent AS between 2003 and 2018. One hundred fifty-three patients were selected according to the following criteria: (1) biopsy Gleason pattern ≤3+4 with (2) ≤two positive core(s) and (3) ≤50% core involvement, clinical-stage ≤T2a, and prostate-specific antigen (PSA) ≤20 ng/mL. Follow-up included PSA measurement every six months, prostate biopsies at one year and then every 2–3 years, and MRI every year. Intervention was triggered by (1) Gleason score (GS) upgrading, (2) >two positive cores, or (3) PSA doubling-time in <3 years.ResultsMean (±standard deviation) follow-up was 36.4 (±31.9) months. Ninety-three (60.8%) and 20 (13.1%) patients received second and third biopsies, respectively. Seventy-two patients (47.1%) discontinued AS for various reasons (59, intervention; 13, follow-up loss). Reasons for intervention consisted of GS upgrading (42.4%), >two positive cores (8.5%), abnormal PSA kinetics (11.9%), and patient preference (37.3%). Notably, 12 (25.5%) patients had pathologic GS ≥4+3 (unfavorable disease) and 3 (6.4%) patients had pathologic stage ≥T3a at radical prostatectomy. Median time to treatment-free survival was 19.5 months. Of the 59 patients who switched to intervention, biochemical recurrence was reported in only one (0.7%) patient.ConclusionsAS is an available option for low-risk PCa in carefully selected patients. Further larger prospective studies are needed to determine the optimal criteria for AS, especially in Korean PCa patients.

Impact of surgical wait times during summer months on the oncological outcomes following robotic-assisted radical prostatectomy: 10years' experience from a large Canadian academic center.

Most Canadian hospitals face significant reductions in operating room access during the summer. We sought to assess the impact of longer wait times on the oncological outcomes of localized prostate cancer patients following robotic-assisted radical prostatectomy (RARP). We conducted a retrospective review of a prospectively maintained RARP database in two high-volume academic centers, between 2010 and 2019. Assessed outcomes included the difference between post-biopsy UCSF-CAPRA and post-surgical CAPRA-S scores, Gleason score upgrade and biochemical recurrence rates (BCR). Multivariable regression analyses (MVA) were used to evaluate the effect of wait times. A total of 1057 men were included for analysis. Consistent over a 10year period, summer months had the lowest surgical volumes despite above average booking volumes. The lowest surgical volume occurred during the month of July (7.1 cases on average), which was 35% less than the cohort average. The longest average wait times occurred for patients booked in June (93 ± 69days, p < 0.001). On MVA, patients booked in June had significantly more chance of having an increase in CAPRA score [HR (95% CI) 1.64 (1.02-2.63); p = 0.04] and in CAPRA risk group [HR (95% CI) 1.82 (1.04-3.19); p = 0.03]. Cohort analysis showed fair correlation between CAPRA-score difference and wait time (Pearson correlation: r = - 0.062; p = 0.044). Our cohort results demonstrate that conventional RARP wait times are significantly and consistently prolonged during summer months over the past 10years, with worse post-RARP oncological outcomes in terms of CAPRA scores. Other compensatory mechanisms to sustain consistent yearly operative output should be considered.

Yield of concurrent systemic biopsy during MRI-targeted biopsy according to Prostate Imaging Reporting and Data System version 2 in patients with suspected prostate cancer

To investigate the yield of concurrent systemic biopsy (SB) during MRI-targeted biopsy (MRTB) as Prostate Imaging Reporting and Data System (PI-RADS) version 2 (v2) interpretations in patients with suspected prostate cancer (PCa). A total of 285 patients with suspected PCa underwent prebiopsy 3-T MRI, followed by MRI-transrectal ultrasound fusion targeted biopsy and concurrent standard SB for lesions with PI-RADS v2 scores 3-5. Detection rates and positive core rates of PCa and clinically significant cancer (CSC) were evaluated. In concurrent MRTB and SB, PCa and CSC detection rates were 18.9% and 9.4% for PI-RADS score 3, 45.9% and 32.4% for PI-RADS score 4, and 82.1% and 72.6% for PI-RADS score 5, respectively. Overall detection rate of CSCs (40.0%) for concurrent MRTB and SB was significantly higher than that of MRTB (34.4%, p = 0.004) or SB alone (27.7%, p < 0.001): an increase of 5.6% (16 patients) compared with MRTB alone. For patients with PI-RADS score 4 or 5, the CSC detection rate of concurrent MRTB and SB was 47.0%, an increase of 6.1% when compared with MRTB (40.9%) only (p < 0.001). Of the 110 patients with both MRTB- and SB-positive findings, 22 (20.0%) had the highest Gleason score in SB compared with that in MRTB. In 9.5% (27/285) patients including 12 patients with CSCs, only SB was positive, with negative MRTB. Concurrent SB with MRTB based on PI-RADS v2 can yield a higher CSC detection rate compared with MRTB alone in patients with suspected PCa. • Concurrent SB with MRTB yields an increase of 5.6% CSC detection compared with MRTB alone. • Of both MRTB- and SB-positive findings, 20.0% patients have upgraded Gleason score in SB. • In 18.4% patients, only SB was positive, with negative MRTB. Adding MRTB to SB is helpful for adequate risk stratification, reducing diagnostic uncertainty of PCa.

Preoperative prostate health index predicts adverse pathology and Gleason score upgrading after radical prostatectomy for prostate cancer

BackgroundWe aimed to explore the utility of prostate specific antigen (PSA) isoform [− 2] proPSA and its derivatives for prediction of pathological outcome after radical prostatectomy (RP).MethodsPreoperative blood samples were prospectively and consecutivelyanalyzed from 472 patients treated with RP for clinically localized prostate cancerat four medical centers. Measured parameters were PSA, free PSA (fPSA), fPSA/PSA ratio, [− 2] proPSA (p2PSA), p2PSA/fPSA ratio and Prostate Health Index (PHI)(p2PSA/fPSA)*√PSA]. Logistic regression models were fitted to determine the accuracy of markers for prediction of pathological Gleason score (GS) ≥7, Gleason score upgrading, extracapsular extension of the tumor (pT3) and the presence of positive surgical margin (PSM). The accuracy of predictive models was compared using area under the receiver operating curve (AUC).ResultsOf 472 patients undergoing RP, 339 (72%) were found to have pathologic GS ≥ 7, out of them 178 (53%) experienced an upgrade from their preoperative GS = 6. The findings of pT3 and PSM were present in 132 (28%) and 133 (28%) cases, respectively. At univariable analysis of all the preoperative parameters, PHI was the most accurate predictor of pathological GS ≥7 (OR 1.02, 95% CI 1.01–1.03, p<0.001), GS upgrading (OR 1.02, 95% CI 1.01–1.03, p<0.003), pT3 disease (OR 1.01, 95% CI 1.00–1.02, p<0.007) and the presence of PSM (OR 1.01, 95% CI 1.00–1.02, p<0.002). Adding of PHI into the base multivariable model increased significantly the accuracy for prediction of pathological GS by 4.4% to AUC = 66.6 (p = 0.015) and GS upgrading by 5.0% to AUC = 65.9 (p = 0.025), respectively.ConclusionsPreoperative PHI levels may contribute significantly to prediction of prostate cancer aggressiveness and expansion of the tumor detected at final pathology.

Role of multiparametric magnetic resonance imaging to predict postoperative Gleason score upgrading in prostate cancer with Gleason score 3 + 4.

To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) in Gleason score (GS) 3 + 4 prostate cancer (PCa) and evaluate independent factors in mpMRI that can predict GS upgrading, we compared the outcomes of GS upgrading group and GS non-upgrading group. We analyzed the data of 539 patients undergoing radical prostatectomy (RP) for biopsy GS 3 + 4 PCa from two tertiary referral centers. Univariate and multivariate analyses were performed to determine significant predictors of GS upgrading. GS upgrading, the study outcome, was defined as GS ≥ 4 + 3 at definitive pathology at RP specimen. GS upgrading rate was 35.3% and biochemical recurrence (BCR) rate was 8.0%. GS upgrading group was significantly older (p = 0.015), had significantly higher prebiopsy serum prostate-specific antigen (PSA) level (p = 0.001) and PSA density (p = 0.003), had a higher number of prostate biopsy (p = 0.026). There were 413 lesions (76.6%) of PI-RADS lesion ≥ 4, 236 (57.1%) for PI-RADS 4 and 177 (42.9%) for PI-RADS 5 lesion. Multivariate logistic regression analysis revealed that age (p = 0.045), initial prebiopsy PSA level (p = 0.002) and presence of PI-RADS lesion ≥ 4 (p = 0.044) are independent predictors of GS upgrading. MpMRI can predict postoperative Gleason score upgrading in prostate cancer with Gleason score 3 + 4. Especially, presence of clinically significant PI-RADS lesion ≥ 4, the significant predictor of GS upgrading, in preoperative mpMRI needs to be paid attention and can be helpful for patient counseling on prostate cancer treatment.

Multiparametric magnetic resonance imaging can exclude prostate cancer progression in patients on active surveillance: a retrospective cohort study

ObjectivesTo assess the ability of multiparametric MRI (mp-MRI) of the prostate to exclude prostate cancer (PCa) progression during monitoring patients on active surveillance (AS).MethodsOne hundred forty-seven consecutive patients on AS with mp-MRI (T2WI, DWI, DCE-MRI) at 3T were initially enrolled. Fifty-five received follow-up mp-MRI after a minimum interval of 12 months and subsequent targeted MR/US fusion-guided biopsy (FUS-GB) plus concurrent systematic transrectal ultrasound-guided (TRUS-GB) biopsy as reference standard. Primary endpoint was the negative predictive value (NPV) of the follow-up mp-MRI to exclude histopathologic tumor progression using PRECISE recommendations. Secondary endpoints were the positive predictive value (PPV), sensitivity, specificity, Gleason score (GS) upgrades, and comparison of biopsy method.ResultsOf 55 patients, 29 (53%) had a GS upgrade on re-biopsy. All 29 patients showed a tumor progression on follow-up mp-MRI. Fifteen of 55 patients (27%) displayed signs of tumor progression, but had stable GS on re-biopsy. None of the 11 patients (20%) without signs of progression on follow-up mp-MRI had a GS upgrade on re-biopsy. The NPV was 100%, PPV was 66%, sensitivity was 100%, and specificity 42%. FUS-GB resulted in GS upgrade significantly more often (n = 28; 51%) compared with TRUS-GB (n = 12; 22%; p < 0.001).Conclusions(Follow-up) Mp-MRI can reliably exclude PCa progression in patients on AS. Standard serial re-biopsies might be waived if follow-up mp-MRIs are stable. Over 60% of patients with signs of tumor progression on mp-MRI during AS had a GS upgrade on re-biopsy. Targeted re-biopsies should be performed if cancer progression or higher-grade PCa is suspected on mp-MRI.Key Points• None of the patients with unsuspicious mp-MRI had a GS upgrade in re-biopsy and mp-MRI might replace serial biopsies in these cases• More than 60% of patients with mp-MRI signs of tumor progression had subsequent Gleason score (GS) upgrades• Targeted re-biopsies should be performed in case of higher GS cancer suspicion on mp-MRI

Prediction of prostate cancer Gleason score upgrading from biopsy to radical prostatectomy using pre-biopsy multiparametric MRI PIRADS scoring system

An increase or ‘upgrade’ in Gleason Score (GS) in prostate cancer following Transrectal Ultrasound (TRUS) guided biopsies remains a significant challenge to overcome. to evaluate whether MRI has the potential to narrow the discrepancy of histopathological grades between biopsy and radical prostatectomy, three hundred and thirty men treated consecutively by laparoscopic radical prostatectomy (LRP) between July 2014 and January 2019 with localized prostate cancer were included in this study. Independent radiologists and pathologists assessed the MRI and histopathology of the biopsies and prostatectomy specimens respectively. A multivariate model was constructed using logistic regression analysis to assess the ability of MRI to predict upgrading in biopsy GS in a nomogram. A decision-analysis curve was constructed assessing impact of nomogram using different thresholds for probabilities of upgrading. PIRADS scores were obtained from MRI scans in all the included cases. In a multivariate analysis, the PIRADS v2.0 score significantly improved prediction ability of MRI scans for upgrading of biopsy GS (p = 0.001, 95% CI [0.06–0.034]), which improved the C-index of predictive nomogram significantly (0.90 vs. 0.64, p < 0.05). PIRADS v2.0 score was an independent predictor of postoperative GS upgrading and this should be taken into consideration while offering treatment options to men with localized prostate cancer.

Interval from transurethral resection of prostate to laparoscopic radical prostatectomy does not affect outcomes for incidental prostate cancer.

Laparoscopic radical prostatectomy (LRP) has become a common option for the treatment of prostate cancer. The aim of our study was to examine whether LRP performed within 12 weeks of transurethral resection of the prostate (TURP) is associated with surgical difficulty or outcomes. A single-institutional retrospective analysis was performed on patients who underwent LRP for incidental prostate cancer after TURP between July 2009 and December 2017. The interval between TURP and LRP was determined and patients with intervals of ≤ 12 weeks were compared to those with intervals of > 12 weeks. Patient characteristics, perioperative, pathological, and postoperative functional outcomes were analyzed to determine statistically significant differences between the 2 groups. Multivariable analyses were performed to determine whether the interval between TURP and LRP was a significant independent predictor of these outcomes. A total of 56 incidental prostate cancer patients detected by TURP were included in this study. No significant differences were detected in estimated blood loss, operative duration, postoperative length of stay, and rate of positive margin, Gleason score upgrading, major complications, incontinence and prostate-specific antigen (PSA) recurrence in patients with a TURP to LRP interval above and below 12 weeks. The TURP to LRP interval was not an independent predictor of outcomes during or after LRP. Our results showed that performing LRP within 12 weeks after TURP does not adversely influence surgical difficulty or outcomes.

MP13-09 PRE-BIOPSY MULTIPARAMTRIC MR IMAGING USING PI-RADS SCORING SYSTEM SIGNIFICANTLY PREDICT UPGRADING OF RANDOM TRANSRECTAL PROSTATE BIOPSIES GRADING FOLLOWING RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVE: An increase or ‘upgrade’ in Gleason Score (GS) in prostate cancer following Transrectal Ultrasound (TRUS) guided biopsies remains a significant challenge to overcome. To evaluate whether pre-biopsy magnetic resonance imaging (MRI) has the potential to narrow the discrepancy of histopathological grades between TRUS biopsy and radical prostatectomy using Prostate Imaging Reporting and Data System version 2 (PIRADS v2.0). METHODS: Three hundred and thirty men treated consecutively by laparoscopic radical prostatectomy (LRP) between July 2013 and January 2019 with localised prostate cancer were included in this study. All the participants had a pre-biopsy 3T-MRI scan followed by TRUS biopsies. An independent radiologist and pathologist assessed the PIRADS scoring of the MRI and histopathology of the biopsies and prostatectomy specimens respectively. An improved orientation between imaging and histopathology was achieved by using 3-D fabricated moulds to direct histopathological grossing. A multivariate model was constructed using logistic regression analysis to assess the ability of PIRADS v2.0 score to predict upgrading in TRUS biopsy GS in a nomogram. A decision-analysis curve was constructed assessing impact of nomogram using different thresholds for probabilities of upgrading. RESULTS: Eight men were excluded for analysis for various reasons. PIRADS scores were obtained from MRI scans in all the included cases. Of the remaining 322 patients, 101/322 (31%) experienced histopathological upgrading on LRP from TRUS biopsies. Most of the participants with upgrading had high (≥ 4) PIRADS score (91/101; 90%). In a multivariate analysis, the PIRADS score significantly improved prediction ability of pre-biopsy MRI scans for upgrading of TRUS biopsy GS (p=0.001, 95% CI [0.06-0.034]), which improved the C-index of predictive nomogram significantly (0.90 vs. 0.64, p<0.05). CONCLUSIONS: PIRADS v2.0 score is an independent predictor of postoperative GS upgrading and this should be taken into consideration while offering treatment options to men with localised prostate cancer. Source of Funding: No Funding

MP23-04 THE EXPANSION OF ACTIVE SURVEILLANCE: REFLECTIONS ON ONCOLOGIC OUTCOMES OF THOSE FAILING THIS INCREASINGLY ACCEPTED MANAGEMENT STRATEGY

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I (MP23)1 Apr 2020MP23-04 THE EXPANSION OF ACTIVE SURVEILLANCE: REFLECTIONS ON ONCOLOGIC OUTCOMES OF THOSE FAILING THIS INCREASINGLY ACCEPTED MANAGEMENT STRATEGY Brennan Timm*, Peter Liodakis, Damien Bolton, Greg Jack, and Nathan Lawrentschuk Brennan Timm*Brennan Timm* More articles by this author , Peter LiodakisPeter Liodakis More articles by this author , Damien BoltonDamien Bolton More articles by this author , Greg JackGreg Jack More articles by this author , and Nathan LawrentschukNathan Lawrentschuk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000856.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Active surveillance has become the preferred choice of management when compared with surgery or radiotherapy amongst those patients with low volume, low grade prostate cancer. Expansion upon PRIAS criteria defining the appropriate active surveillance population has become commonplace. This change in thinking has ensued as large prospective randomized trials such as PROTECT mature, with 10 year follow up suggesting there is no overall mortality benefit to aggressive therapy versus active surveillance. We sought to ascertain whether those men who fail active surveillance have worse oncologic outcomes than matched peers undergoing immediate radical prostatectomy. METHODS: An audit was undertaken of a prospectively collected database capturing patients with prostate cancer identified by transperineal biopsy between January 2012 and December 2017. Patients were divided into those initially managed by active surveillance vs those with who were treated with surgery primarily. Histologic and oncologic outcomes were compared for time and disease burden matched populations of men with low and low- intermediate risk prostate cancer defined as ISUP 1 and 2 (Gleason pattern 4 component <10%) low volume disease respectively. 128 patients over the 5 year period were captured, where 88 were initially placed on active surveillance, and 40 elected to proceed to radical prostatectomy without a preliminary period of Active Surveillance. RESULTS: Mean patient age was 60.6 vs 61 years in the active surveillance and immediate surgery groups, mean PSA at diagnosis was 5.2 vs 5.6 respectively, and pre biopsy MRI was performed in 71% vs 73% of the AS vs immediate surgery groups. Surgical specimens had a gland volume of 52ml vs 50 ml. 71% of patients had one or more MRI scans during their period of active surveillance. Pathological stage of pT3a was 45% vs 32%, 21% vs 0% had pathological upgrading of Gleason score and 25% vs 17.5% had involved margins in the AS vs immediate treatment groups. Biochemical recurrence with a minimum of 18 months of follow up has been 13% in the AS group vs 0% in the immediate treatment groups. Mean time on active surveillance to failure was 29.1 months. CONCLUSIONS: Those men who fail AS appear to have worse outcomes compared to matched peers undergoing immediate radical prostatectomy. These results are possibly reflective of an increasing trend to put patients on active surveillance who do not meet the strict PRIAS criteria for active surveillance in an effort to delay or avoid potential side effects of treatment of their prostate cancer. Source of Funding: nil © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e338-e339 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brennan Timm* More articles by this author Peter Liodakis More articles by this author Damien Bolton More articles by this author Greg Jack More articles by this author Nathan Lawrentschuk More articles by this author Expand All Advertisement PDF downloadLoading ...

Investigating association of perineural invasion on prostate biopsy with Gleason score upgrading at prostatectomy: A multi-institutional analysis.

BackgroundThe significance of perineural invasion (PNI) in prostate cancer (PC) is unclear. A recent report of patients with pT2N0R0 PC found that PNI at prostatectomy was independently associated with higher Gleason score and more diffuse prostatic disease. We aimed to test our hypothesis that PNI on prostate biopsy in pT2N0R0 patients is associated with increased Gleason score upgrading at prostatectomy.MethodsWe identified 2892 patients status post prostatectomy with pT2N0R0 PC from three institutions, diagnosed between 1 January 2008 and 31 December 2014. Multivariable logistic regression (MVA) was used to evaluate the association between prostate biopsy PNI status and surgical Gleason upgrading, while controlling for potential confounders.ResultsOf the 2892 patients identified, 14% had PNI on biopsy, of whom 21% had surgical Gleason upgrading, while 28% without PNI on biopsy had such upgrading (P < .01). On MVA, the odds ratio (OR) of surgical Gleason upgrading for patients with biopsy PNI relative to patients without biopsy PNI was 0.69 (P < .01). The variables associated with surgical Gleason upgrading were age ≤60 years (OR 1.22, P = .02) and preoperative PSA >4 ng/mL (OR 1.26, P = .02).ConclusionsIn post‐prostatectomy patients with favorable‐risk PC, PNI on prostate biopsy was not associated with surgical Gleason score upgrading. This may be due to the association of PNI with more diffuse disease, leading to increased biopsy tumor yield and grading accuracy. These findings suggest that in this setting, biopsy PNI alone should not be a concern for more aggressive disease requiring pathologic confirmation or intervention. This may help guide treatment decision‐making for men debating active surveillance, radiation, and surgery.

Pathological Association Between Radical Prostatectomy and Needle Biopsy Specimen in Prostate Cancer Patients

Background: Prostate cancer (PCa) is the second most common cancer in men worldwide. The accuracy of Gleason score (GS), as a useful system for histopathological assessment, is important because any fault in the assessment and calculation leads to inappropriate approaches and complications. Multifocality is common in PCa and it is expected that different grading of cancer would be seen in different areas. This is one of the sources of diversity in pathologic reports of transrectal ultrasound guided biopsy (TRUS BX) and radical prostatectomy, which is obtained in 41% to 43% of samples with exact accordance; so, when choosing the treatment plan is based on of the needle biopsy sample, the accuracy of TRUS BX GS is bolded. Objectives: In this study, we compared the pathology reports of initial biopsy and final pathology of the prostate after radical prostatectomy to determine the discrepancy among the Iranian population. Methods: In this retrospective study, 105 of 127 patients that underwent both TRUS Bx and radical prostatectomy in Shohada-e-Tajrish Hospital from August 2009 to October 2017 enrolled in the study. Results: In the current study, 55% of the patients were without change and 36% were upgraded. The rate of abnormal digital rectal examination and the increase of prostate-specific antigene levels have a statistically significant correlation with the upgrading of GS, respectively (P = 0.001 and 0.02). Conclusions: It is generally concluded that the initial biopsy with the final pathology of radical prostatectomy is similar in our investigation.

MRI-Based Prostate-Specific Antigen Density Predicts Gleason Score Upgrade in an Active Surveillance Cohort.

OBJECTIVE. Elevated prostate-specific antigen density (PSAD) based on transrectal ultrasound (TRUS) measurements has been shown to be strongly associated with clinically significant disease and to predict progression on active surveillance (AS) for men with disease that is at a low stage or grade. We hypothesized that elevated MRI PSAD is similarly associated with increased risk of progression on subsequent biopsy. MATERIALS AND METHODS. In this retrospective study, men with Gleason score of 3+3 on diagnostic TRUS-guided biopsy who were managed with AS, had undergone MRI, and had at least one additional biopsy were included. MRI PSAD was calculated using prostate volume on MRI and prostate-specific antigen level temporally closest to the MRI. Multivariable logistics regression models were used to evaluate the association between MRI PSAD and predictors of upgrade on serial biopsy. RESULTS. A total of 166 patients were identified, of whom 74 (44.6%) were upgraded to a Gleason score of 7 or higher on subsequent biopsy. Lesions with Prostate Imaging Reporting and Data System (PI-RADS) scores of 4 and 5 more commonly had MRI PSAD of 0.15 ng/mL2 or higher (51.93% vs 22.22%, p = 0.01) than lesions with PI-RADS scores of 1-3. Median MRI PSAD was significantly higher in the upgraded group compared with the group that was not upgraded (0.15 ng/mL2 vs 0.11 ng/mL2, p = 0.01). MRI PSAD was significantly associated with increased odds of upgrading on subsequent biopsy (log transformation; odds ratio, 1.9 [95% CI, 1.2-2.8]; p = 0.01) after adjusting for age and length of follow-up. CONCLUSION. MRI PSAD was significantly associated with Gleason score upgrading on subsequent biopsy for men initially diagnosed with Gleason 3+3 disease. Although this result is intuitive, to our knowledge it has not been previously shown. As MRI utilization increases, MRI PSAD can aid in risk stratification for men managed with AS.

Prediction of pathologic upgrading in Gleason score 3+4 prostate cancer: Who is a candidate for active surveillance?

PurposeWhether active surveillance (AS) can be safely extended to patients with Gleason score (GS) 3+4 prostate cancer is highly debated. We examined the incidence and predictors of upgrading among patients with GS 3+4 disease.Materials and MethodsThe study involved 377 patients with biopsy GS 3+4 who underwent robot-assisted laparoscopic radical prostatectomy (RP) from 2014 to 2018 at a single institution. We analyzed the rate of GS upgrading and used logistic regression to determine the predictors of upgrading.ResultsA total of 168 (44.6%) patients with GS 3+4 experienced an upgrade in GS. In multivariable analysis, advanced age, prostate-specific antigen (PSA) level, PSA density (PSAD) and Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score were significant predictors of GS upgrading. When structured into a predictive model that included age ≥65 years, PSA ≥7.7 ng/mL, PSAD ≥0.475 ng/mL2 and PI-RADS v2 score 4–5, the probability of GS upgrading ranged from 36.4% to 65.7% when one to four of these factors were included.ConclusionsA substantial proportion of patients with GS 3+4 prostate cancer were upgraded after RP. However, according to our model combining clinical and imaging predictors, patients with a low risk of GS upgrading may be eligible candidates for AS.

Does extent of prostate-specific antigen fluctuation can predict Gleason score upgrading in low-risk prostate cancer patients?

To evaluate the effect of prostate-specific antigen (PSA) fluctuation on Gleason score (GS) upgrading, disease upstaging, oncological outcomes in low-risk prostate cancer (PCa) patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP) and met the inclusion criteria for active surveillance (AS). Data of 354 low-risk PCa patients who underwent RARP were retrospectively evaluated. Patients were divided into two groups: PSA fluctuation rate<9.5%/month (Group 1, n=192) and >9.5%/month (Group 2, n=162). Mainly compared parameters were GS upgrading, disease upstaging, biochemical recurrence (BCR) and surgical margin positivity (SMP) rates. GS upgrading, disease upstaging and SMP were detected in 128 (36.2%), 56 (15.8%) and 42 (11.9%) patients, respectively. After a median follow-up of 46 months, BCR was observed in 40 (11.3%) patients. GS upgrading (41.1% vs. 30.2%, p=0.033), disease upstaging (19.8% vs. 11.1%, p=0.028), SMP (15.1% vs. 8%, p=0.035) and BCR development (15.6% vs. 6.2%, p=0.005) rates were statistically significantly higher in Group 1 than Group 2. In multivariate analysis, digital rectal examination positivity, the presence of two positive cores and low PSA fluctuation rate were found to be significant predictors of GS upgrading. Low PSA fluctuation rate is associated with higher GS upgrading.

The factors predicting upgrading of prostate cancer by using International Society for Urological Pathology (ISUP) 2014 Gleason grading system.

To investigate the factors to predict Gleason score upgrading (GSU) of patients with prostate cancer who were evaluated by using the International Society for Urological Pathology (ISUP) 2014 Gleason grading system. Between January 2008 and December 2015, we retrospectively investigated patients who had undergone radical prostatectomy and followed up in the uro-oncology outpatient clinic. The pathologic specimens of the patients were evaluated based on the ISUP 2014 classification system. The patients were divided into two groups with or without upgraded Gleason scores. Factors that could be effective in predicting upgrading such as age, prostate-specific antigen (PSA), prostate volume, D'Amico risk classification, PSA density, cancer of the prostate risk assessment (CAPRA) scores, biopsy tumor percentage, body mass index, and clinical stage parameters were compared between both groups. Of the 265 patients who could be evaluated and followed up regularly, Gleason score upgrades were observed in 110 (41.5%) patients. Advanced age (p=0.009), PSA >20 ng/mL (p=0.036), PSA density >0.35 (p=0.005), high CAPRA score (p=0.031), and high biopsy tumor percentage (p=0.009) were discovered to be correlated with Gleason score upgrade in univariate logistic regression analysis. Advanced age alone was a predictor for GSU in multivariate logistic regression analysis (p=0.002). Five-year biochemical recurrence-free survival rate was 86% in the non-GSU group and 55% in the GSU group (p<0.001). GSU risk should be taken into consideration in making therapeutic decisions for older patients with prostate cancer, and precautions should be taken against development of aggressive disease.

Investigating Association of PNI on Prostate Biopsy with Gleason Score Upgrading at Prostatectomy: a Multi-Institutional Study

Perineural invasion (PNI) is a histologic finding observed in up to 84% of patients with prostate cancer (PC), but with conflicting data regarding its prognostic significance. A recent, large, multi-institutional study of PC patients with pT2N0R0 disease found that PNI on histology was not an independent prognostic indicator of biochemical recurrence, but that PNI was associated with higher Gleason score and more diffuse disease within the prostate. We aim to assess whether PNI noted on prostate biopsy in apparently favorable-risk patients is associated with an increased risk of Gleason score upgrading at prostatectomy in patients found to have stage pT2N0M0 disease. We hypothesized that the presence of PNI on prostate biopsy would be associated with an increased risk of surgical Gleason score upgrading in this population. We identified 2,892 patients status post prostatectomy with pT2N0M0 PC from three different institutions diagnosed between 1/1/2008 and 12/31/2014. The electronic medical record was used to obtain age, biopsy and surgical PNI status, biopsy and surgical Gleason score, pre-operative PSA, surgical margin status, clinical and pathological staging, ethnicity, and year of diagnosis for each patient. Multivariable logistic regression (MVA) was used to evaluate for an association between PNI on prostate biopsy and Gleason score upgrading at surgery. Of the 2,892 patients studied, 14.5% (419/2,892) had PNI on biopsy. Of patients with PNI on biopsy, 21.5% (90/419) had Gleason score upgrading at resection, while 28.2% (699/2,473) of patients without PNI on biopsy had Gleason score upgrading at resection (p= 0.0047). On MVA, the odds ratio (OR) of Gleason upgrading at resection for patients with PNI on biopsy relative to patients without PNI on biopsy was 0.69 (p= 0.003, 95% confidence interval (CI) 0.53-0.87). The variables that were statistically significantly associated with Gleason upgrading at resection on MVA were age less than or equal to 60 years (p= 0.018, OR= 1.22, 95% CI 1.03-1.44), and pre-operative PSA greater than 4 ng/mL (p=0.015, OR 1.26, 95% CI 1.05-1.53). In post-prostatectomy patients with favorable-risk PC presence of PNI on initial prostate biopsy was not associated with Gleason score upgrading on resection. This may be due to the association of PNI with more diffuse disease, leading to increased tumor yield on biopsy, and thus more accurate overall grading on biopsy. These findings suggest that for patients with favorable-risk, clinically localized PC, biopsy PNI alone should not be a concern for more aggressive disease requiring pathologic confirmation or intervention. This may help guide treatment decision-making for men debating active surveillance, radiation, and surgery.

Cancer Location in Upgrading and Detection after Transperineal Template-Guided Mapping Biopsy for Patients in Active Surveillance and Negative Transrectal Ultrasonography-Guided Prostate Biopsy

Objectives: We investigated the efficacy of transperineal template-guided mapping biopsy (TTMB) for patients on active surveillance (AS) or those with previous negative transrectal ultrasound-guided biopsy (TRUS-Bx). Methods: We retrospectively analyzed 99 patients on AS and 60 patients with previous negative TRUS-Bx, which is a total of 159 patients who underwent TTMB from May 2017 to January 2019. Cancer location was analyzed with focus on the anterior and apex lesions of the prostate after TTMB. Multiparametric magnetic resonance imaging was performed before TTMB. Cancer location after TTMB in 138 patients, excluding 21 patients who were not eligible for analysis (4 patients on AS and 17 patients with previous negative TRUS-Bx) was compared with Prostate Imaging-Reporting and Data System version 2 (PI-RADS^TM v2) score. Factors that may affect detecting cancer after TTMB with previous negative TRUS-Bx was analyzed using a logistic regression model. Results: In AS patients, 29 patients (29.3%) exhibited an upgrade in Gleason score (GS) after TTMB. Among them, 22 patients (75.9%) showed at the anterior or apex lesions. In patients with previous negative TRUS-Bx, 18 patients (30.0%) were diagnosed with prostate cancer. Among them, 13 patients (72.2%) exhibited cancer at the anterior or apex lesion. Among the 25 AS patients with PI-RADS^TM score 1–2, 5 patients (20.0%) showed an upgrade in GS. Among the 26 patients with previous negative TRUS-Bx and PI-RADS^TM score 1–2, 6 patients (23.1%) had cancer. In multivariate regression model, prostate volume (OR 0.951) was identified as the predictor for a positive biopsy result after TTMB with previous negative TRUS-Bx. Conclusions: TTMB is efficient for patients on AS in the detection of upgraded cancer located in anterior or apex or those with previous negative TRUS-Bx in the detection of anterior or apex cancer. In PI-RADS^TM score 1–2, a substantial proportion of patients after experienced upgrade in GS on AS patients or cancer detection on previous negative TRUS-Bx. Moreover, we identified prostate volume is the independent predictor for a positive biopsy result after TTMB with previous negative TRUS-Bx.

Prostate volume effect on Gleason score upgrading in active surveillance appropriate patients.

Gleason Score (GS) upgrading rates in the literature are reported to be around 33-45%. The relationship between prostate volume and GS upgrading should be defined, aiming to reduce upgrading rates in patients with low risk groups who are eligible for active surveillance (AS) or minimally invasive treatment, by varying biopsy cores, or lengths of cores according to prostate volumes. In this regard, the aim of our study was to establish the relationship between prostate volume and GS upgrading. We retrospectively analyzed the medical records of 78 patients, who were appropriate for AS between 2011-2016 at our hospital. Inclusion criteria were patient age under 65 years, PSA level under 10 ng/ml, GS (3 + 3) or (3 + 4), and 3 or less positive cores, clinical stages ≤ T2. GS increase in radical prostatectomy specimen was considered as 'upgrading' and in addition, score reported by biopsy as 3 + 4 but in surgical specimen as 4 + 3 were also considered as 'upgrading'. The effect of prostate volume on Gleason grade upgrading was examined by calculating upgrading rates separately for patients with prostate volume 30 ml or less, those with 30 to 60 ml, and those over 60 ml. As a result of the analysis of the data, upgrading was seen in 35 (44.8%) of 78 patients included in the study. In the cohort mean prostate volume was 49.8 (± 26.3) ml. Twenty-two patients (28.2%) had prostate volume 30 ml or less, 34 (43.6%) 30 to 60 ml, and 22 (28.2%) 60 ml or more. The patients were divided into two groups as those with and without GS upgrading. Between the groups prostate volume and prostate volume range (0-30/31-60/> 60) were not significantly different (p value > 0.05). Gleason grade upgrading causes patients to be classified in a lower risk group than they actually are, and may lead to inappropriate treatment. This condition has a direct effect on the decision of active surveillance. Therefore, it is important to define the factors that can predict GS upgrading in active surveillance appropriate patients. In this study, we found that prostate volume has no significant effect on upgrading in active surveillance appropriate patients.

Correlation between trans rectal ultrasound guided prostate biopsy and radical prostatectomy specimen and risk factors for upgraded Gleason score in prostate cancer

Correlation between trans rectal ultrasound guided prostate biopsy and radical prostatectomy specimen and risk factors for upgraded Gleason score in prostate cancer