Predictors Of Upgrading Research Articles

Detecting lower in addition to the highest Gleason score prostate cancer on core biopsy and the odds of upgrading at radical prostatectomy.

e16026 Background: We evaluated the odds of upgrading at radical prostatectomy when a biopsy core with a lower Gleason score (GS) compared to the core with the highest GS was present (ComboGS) versus not at diagnosis and in a concurrent submission, test ComboGS in a validation data set on the endpoint of prostate cancer-specific mortality. Methods: The study cohort consisted of 134 men with clinically localized PC diagnosed between 4/08 and 9/11 using a 12-core prostate needle biopsy. GS at biopsy and RP were assigned by an expert genitourinary pathologist. Logistic regression multivariable analysis (Table) was performed to assess the impact that ComboGShad on the odds of upgrading at RP adjusting for known predictors of upgrading. Results: Of 134 patients, 46 (34%) were upgraded. Both increasing percent positive biopsies (ppb) (p < 0.001) and PSA level (p=0.001) were associated with an increased odds of upgrading, whereas ComboGSwas associated with a decreased odds of upgrading (0.18 [95% CI: 0.04-0.76); p = 0.02). Men whose ppb was ≥ 33% (median) were upgraded in 47% (28 of 60) versus 14% (3 of 21) of cases (p = 0.009) when ComboGSwas absent versus present. These respective estimates in men with a PSA ≥ 5.2 ng/ml (median) were 43% and 12% (p = 0.019). Conclusions: In men with clinical factors associated with upgrading namely, increasing ppb and PSA, ComboGSis a favorable prognostic factor associated with a high rate of downgrading (> 40%) and a low rate (< 15%) of upgrading. Adjusted odds ratios and associated 95% confidence intervals and p values representing the impact of clinical factors at diagnosis on upgrading at radical prostatectomy. [Table: see text]

Clinical and pathological variables that predict changes in tumour grade after radical prostatectomy in patients with prostate cancer

Preoperative Gleason score is crucial, in combination with other preoperative parameters, in selecting the appropriate treatment for patients with clinically localized prostate cancer. The aim of the present study is to determine the clinical and pathological variables that can predict differences in Gleason score between biopsy and radical prostatectomy. We retrospectively analyzed the medical records of 302 patients who had a radical prostatectomy between January 2005 and September 2010. The association between grade changes and preoperative Gleason score, age, prostate volume, prostate-specific antigen (PSA), PSA density, number of biopsy cores, presence of prostatitis and high-grade prostatic intraepithelial neoplasia was analyzed. We also conducted a secondary analysis of the factors that influence upgrading in patients with preoperative Gleason score ≤6 (group 1) and downgrading in patients with Gleason score ≤7 (group 2). No difference in Gleason score was noted in 44.3% of patients, while a downgrade was noted in 13.7% and upgrade in 42.1%. About 2/3 of patients with a Gleason score of ≤6 upgraded after radical prostatectomy. PSA density (p = 0.008) and prostate volume (p = 0.032) were significantly correlated with upgrade. No significant predictors were found for patients with Gleason score ≤7 who downgraded postoperatively. Smaller prostate volume and higher values of PSA density are predictors for upgrade in patients with biopsy Gleason score ≤6 and this should be considered when deferred treatment modalities are planned.

Abstract P4-14-10: Atypical Ductal Hyperplasia diagnosed on directional vacuum-assisted biopsy: is surgical excision mandatory?

Abstract Background: The incidence of atypical ductal hyperplasia (ADH) is increasing due to mass screening. Because of the underestimation risk of malignancy, the management remains controversial. Our goal was to analyze clinicopathologic features of patients with ADH diagnosed on directional vacuum-assisted biopsy (DVAB). The objectives of this continuous retrospective study were to evaluate the underestimation rate of malignancy and to identify predictors of upgrade to carcinoma. Methods: Between 2003 and 2010, 3159 patients underwent stereotactic DVAB in our institute. We retrospectively evaluate clinical, mammographic and pathological features of 298 cases of ADH who underwent surgical excision in our center (93.1%). Patients with concurrent history of breast cancer, intraductal carcinoma (DCIS) associated, or with no follow-up or surgical excision on place were excluded. Histological scar of macrobiopsy was systematically searched in surgical specimens. A pathologic upgrade was defined by presence of invasive cancer or DCIS on surgical specimen. Statistical tests used were the chi-square or Fisher's exact test. Results: Among the 298 studied DVAB, 224 ADH were isolated (75.2%), 46 associated to flat epithelial atypia (15.4%) and 28 to lobular neoplasia (9.4%). 98.4% patients presented microcalcifications at diagnosis. In 52 cases, lesions were upgraded to DCIS (n = 38) or invasive cancer (n = 14). The underestimated rate was 17.5%. In 67.3% cases, upgrade lesions were low or intermediate grade DCIS. Only the history of contralateral breast cancer was significantly correlated with the underestimated rate (p = 0.04). There was no statistical difference between these 52 cases and the 246 others for: family history, size of calcification, sampling number, histological lesion, and quality of calcifications removal. Conclusions: In this study, DVAB may not be considered a therapeutic procedure in case of ADH, even in the case of complete removal of microcalcifications. It is still challenging to identify a subgroup of ADH cases with a low upgrade rate. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-10.

Are We Overtreating Papillomas Diagnosed on Core Needle Biopsy?

Breast papillomas often are diagnosed with core needle biopsy (CNB). Most studies support excision for atypical papillomas, because as many as one half will be upgraded to malignancy on final pathology. The literature is less clear on the management of papillomas without atypia on CNB. Our goal was to determine factors associated with pathology upgrade on excision. Our pathology database was searched for breast papillomas diagnosed by CNB during the past 10 years. We identified 277 charts and excluded lesions associated with atypia or malignancy on CNB. Two groups were identified: papillomas that were surgically excised (group 1) and those that were not (group 2). Charts were reviewed for the subsequent diagnosis of cancer or high-risk lesions. Appropriate statistical tests were used to analyze the data. A total of 193 papillomas were identified. Eighty-two lesions were excised (42%). Caucasian women were more likely to undergo excision (p = 0.03). Twelve percent of excised lesions were upgraded to malignancy. Increasing age was a predictor of upgrading, but this was not significant. Clinical presentation, lesion location, biopsy technique, and breast cancer history were not associated with pathology upgrade. Two lesions in group 2 ultimately required excision due to enlargement, and both were upgraded to malignancy. Twenty-four percent of papillomas diagnosed on CNB have upgraded pathology on excision--half to malignancy. All of the cancers diagnosed were stage 0 or I. For patients in whom excision was not performed, 2 of 111 papillomas were later excised and upgraded to malignancy.

Prostate biopsy clinical and pathological variables that predict significant grading changes in patients with intermediate and high grade prostate cancer

To identify the clinical and pathological variables that predict pathological changes in the significant proportion of men with prostate cancer who have an intermediate- or high-grade biopsy Gleason score (GS) of >or=7 and who are upgraded or downgraded on interpretation of radical prostatectomy (RP) pathological specimens, as GS is critical in treatment decisions. We retrospectively evaluated 1129 patients who had RP after a biopsy showing a GS of >or=7, at our institution, from 2000 to 2007. Complete relevant clinical information was available for all patients. A multivariable logistic regression analysis was used to identify predictors of pathological grading changes. The overall mean age was 61 years, with median prostate-specific antigen (PSA) level of 6 ng/mL. Of the 1129 patients, the surgical GS was upgraded in 296 (26.2%), downgraded in 210 (18.6%), and remained the same in 623 (55.2%). Factors predicting a surgical GS upgrade were a higher PSA level (P = 0.005), presence of perineural invasion (P = 0.043), absence of inflammation (P < 0.001), and absence of associated high-grade prostatic intraepithelial neoplasia (P = 0.02). In an analysis of pathological variables the number of positive cores (P = 0.033) was predictor of upgrading. Large prostate volume (P = 0.004) and low maximum percentage cancer in any core (P = 0.001) were predictors of downgrading. Men with a higher PSA level, perineural invasion and high-volume cancer at biopsy are most likely to be upgraded, while men with a large prostate volume and low-volume cancer at biopsy are more likely to be downgraded. These findings have implications for men with prostate cancer managed without confirmation by RP of their true GS.

Prostate Cancers Scored as Gleason 6 on Prostate Biopsy are Frequently Gleason 7 Tumors at Radical Prostatectomy: Implication on Outcome

Differentiation between Gleason score 6 and 7 in prostate biopsy is important for treatment decision making. Nevertheless, under grading errors compared with the actual pathological grade at radical prostatectomy are common. We compared the characteristics and outcomes of tumors that were scored 6 on prostate biopsy but were 7 on subsequent radical prostatectomy pathological evaluation to those in tumors with a consistent rating of Gleason score 6 or 7 at biopsy and surgery. We performed a retrospective database analysis from our referral center (1989 to 2004). We compared pre-prostatectomy characteristics, radical prostatectomy pathological features and the post-radical prostatectomy prostate specific antigen failure rate, defined as any 2 consecutive detectable prostate specific antigen measurements, in 3 subgroups of patients, including 156 with matched Gleason score 6 in the prostate biopsy and radical prostatectomy, 205 with upgraded Gleason score 6/7, that is prostate biopsy Gleason score 6 and radical prostatectomy Gleason score 7, and 412 with matched Gleason score 7 in the prostate biopsy and radical prostatectomy. Radical prostatectomy Gleason score matched the prostate biopsy score in 38.2% of biopsy Gleason score 6 and 81.4% of biopsy Gleason score 7 cases. Higher prostate specific antigen was associated and an increased percent of cancer in the prostate biopsy was predictive of discordance between the prostate biopsy and radical prostatectomy Gleason scores (p <0.001). Margin (p = 0.0075) or seminal vesicle involvement (p = 0.0002), cancer volume (p <0.001) and the prostate specific antigen failures rate (p = 0.014) were significantly higher in under graded Gleason score 7 cancer compared to those in matched Gleason score 6 cases. However, they were comparable to those with a matched Gleason score 7 tumor grade (p = 0.66). Almost half of tumors graded Gleason score 6 at biopsy are Gleason score 7 at surgery. Upgraded Gleason score 6 to 7 tumors have outcomes similar to those of genuine Gleason score 7 cancer. For prostate biopsy Gleason score 6 tumors clinicians should consider the overall likelihood of tumor upgrading as well as specific patient characteristics, such as prostate specific antigen and the percent of tumor in the prostate biopsy, when contemplating treatments that are optimized for low grade tumors, including watchful waiting or brachytherapy.