Discrepancies between Gleason scores of needle biopsy and radical prostatectomy specimens

Discrepancies in Gleason score between needle core biopsy and radical prostatectomy specimens with correlation between clinical and pathological staging

BACKGROUND

The studies have shown that GS given after assessment of the entire prostate gland on the radical prostatectomy specimen may differ from GS given after examination of a small sample from needle core biopsy. We conducted this study to assess discrepancies in the Gleason score between NCB and RP specimens and to find out the correlation between the clinical stage and pathological stage.

METHODS

The study included 174 patients with carcinoma prostate which underwent robotic-assisted radical prostatectomy (RARP). Pre-operative Gleason score was determined on 12-core biopsy samples under trans-rectal ultrasound (TRUS) guidance. The Gleason score obtained from the radical prostatectomy specimen was compared with that of the NCB Gleason score to find out differences.

RESULTS

The preoperative Gleason score (GS) ranges from 6 to 9 with a mean GS of 6.97 ± 1.02. The post-operative GS ranges between 6 and 10 with mean and GS of 7.5 ± 1.10. On the pre-operative assessment of biopsy specimens, 70 (43.2%) patients had a GS of 6, while 44 patients had a GS of 7 (27.1%) and 48 (29.8%) patients had a GS of more than 7. On the postoperative assessment of specimens, 31 (19.1%) patients had post-operative GS of 6, while 66 (41%) patients had GS of 7 and 74 (41.1%) patients had GS of more than 7. When pre-operative GS and post-operative GS were compared, no changes were observed in the GS of 79 patients, whereas 83 patients showed the difference in GS, with 75 patients showing up-gradation and eight patients marked as down-graded.

CONCLUSION

concordance between biopsy and the pathology results directly affects the prognosis of the patient. The results of our study demonstrated the rate of discordance between Gleason scores obtained from transrectal prostate biopsy and RP surgical specimens. This rate brings into question the accuracy of the chosen treatment.

Propensity score matching analysis comparing radical prostatectomy and radiotherapy with androgen deprivation therapy in locally advanced prostate cancer

To compare clinical outcomes between the use of robotic-assisted laparoscopic radical prostatectomy (RP) and radiotherapy (RT) with long-term androgen deprivation therapy (ADT) in locally advanced prostate cancer (PC), 315 patients with locally advanced PC (clinical T-stage 3/4) were considered for analysis retrospectively. Propensity score-matching at a 1:1 ratio was performed. The median follow-up period was 59.2 months (IQR 39.8–87.4). There were 117 (37.1%) patients in the RP group and 198 (62.9%) patients in the RT group. RT patients were older and had higher PSA at diagnosis, higher Gleason score grade group and more advanced T-stage (all p < 0.001). After propensity score-matching, there were 68 patients in each group. Among locally advanced PC patients, treatment with RP had a higher risk of biochemical recurrence compared to the RT group. In multivariate Cox regression analysis, treatment with RT plus ADT significantly decreased the risk of biochemical failure (HR 0.162, p < 0.001), but there was no significant difference in local recurrence, distant metastasis and overall survival (p = 0.470, p = 0.268 and p = 0.509, respectively). This information supported a clinical benefit in BCR control for patients undergoing RT plus long-term ADT compared to RP.

Low serum total testosterone level as a predictor of upgrading in low-risk prostate cancer patients after radical prostatectomy: A systematic review and meta-analysis

Purpose

To investigated the association between serum total testosterone and Gleason score upgrading of low-risk prostate cancer after radical prostatectomy (RP).

Materials and Methods

Medline, Web of Science, Embase, and Cochrane Library databases were searched to identify eligible studies published before October 2021. Multivariate adjusted odds ratios (ORs) and associated 95% confidence intervals (CIs) were calculated using random or fixed effects models.

Results

Five studies comprising 1,203 low-risk prostate cancer patients were included. The results showed that low serum total testosterone (<300 ng/dL) is associated with a high rate of Gleason score upgrading after RP (OR, 2.3; 95% CI, 1.38–3.83; p<0.001; I², 92.2%). Notably, sensitivity and meta-regression analyses further strengthen the reliability of our results.

Conclusions

Our results support the idea that low serum total testosterone is associated with a high rate of Gleason score upgrading in prostate cancer patients after RP. It is beneficial for urologist to ensure close monitoring of prostate-specific antigen levels and imaging examination when choosing non-RP treatment for low-risk prostate cancer patients.

Learning a Triplet Embedding Distance to Represent Gleason Patterns

Gleason grade stratification is the main histological standard to determine the severity and progression of prostate cancer. Nonetheless, there is a high variability on disease diagnosis among expert pathologists (kappa lower than 0.44). End-to-end deep representations have recently deal with the automatic classification of Gleason grades, where each grade is limited to namely code high-visual-variability sharing patterns among classes. Such limitation on models may be attributed to the relatively few labels to train the representation, as well as, to the natural imbalanced sets, available in clinical scenarios. To overcome such limitation, this work introduces a new embedding representation that learns intra and inter-Gleason relationships from more challenging class samples (grades tree and fourth). The proposed strategy implements a triplet loss scheme building a hidden embedding space that correctly differentiates close Gleason levels. The proposed approach shows promising results achieving an average accuracy of 74% to differentiate between degrees three and four. For classification of all degrees, the proposed approach achieves an average accuracy of 62%.

The role of artificial intelligence in medical imaging research

Without doubt, artificial intelligence (AI) is the most discussed topic today in medical imaging research, both in diagnostic and therapeutic. For diagnostic imaging alone, the number of publications on AI has increased from about 100-150 per year in 2007-2008 to 1000-1100 per year in 2017-2018. Researchers have applied AI to automatically recognizing complex patterns in imaging data and providing quantitative assessments of radiographic characteristics. In radiation oncology, AI has been applied on different image modalities that are used at different stages of the treatment. i.e. tumor delineation and treatment assessment. Radiomics, the extraction of a large number of image features from radiation images with a high-throughput approach, is one of the most popular research topics today in medical imaging research. AI is the essential boosting power of processing massive number of medical images and therefore uncovers disease characteristics that fail to be appreciated by the naked eyes. The objectives of this paper are to review the history of AI in medical imaging research, the current role, the challenges need to be resolved before AI can be adopted widely in the clinic, and the potential future.

Does the Time Interval from Biopsy to Radical Prostatectomy Affect the Postoperative Oncologic Outcomes in Korean Men?

BACKGROUND

Prostate cancer (PC) is the second most common type of cancer in men worldwide and the fifth most common cancer among Korean men. Although most PCs grow slowly, it is unclear whether a longer time interval from diagnosis to treatment causes worse outcomes. This study aimed to investigate whether the time interval from diagnosis to radical prostatectomy (RP) in men with clinically localized PC affects postoperative oncologic outcomes.

METHODS

We retrospectively analyzed data of 427 men who underwent RP for localized PC between January 2005 and June 2016. The patients were divided into two groups based on the cutoff median time interval (100 days) from biopsy to surgery. The associations between time interval from biopsy to surgery (< 100 vs. ≥ 100 days) and adverse pathologic outcomes such as positive surgical margin, pathologic upgrading, and upstaging were evaluated. Biochemical recurrence (BCR)-free survival rates were analyzed and compared based on the time interval from biopsy to surgery.

RESULTS

Pathologic upgrading of Gleason score in surgical specimens was more frequent in the longer time interval group and showed marginal significance (38.8% vs. 30.0%; P = 0.057). Based on multivariable analysis, an association was observed between time interval from biopsy to surgery and pathologic upgrading (odds ratio, 2.211; 95% confidence interval [CI], 1.342-3.645; P = 0.002). BCR-free survival did not differ based on time interval from biopsy to surgery, and significant association was not observed between time interval from biopsy to surgery and BCR on multivariable analysis (hazard ratio, 1.285; 95% CI, 0.795-2.077; P = 0.305).

CONCLUSION

Time interval ≥ 100 days from biopsy to RP in clinically localized PC increased the risk of pathologic upgrading but did not affect long-term BCR-free survival rates in Korean men.

Advancing Age and the Odds of Upgrading and Upstaging at Radical Prostatectomy in Men with Gleason Score 6 Prostate Cancer

PURPOSE

To identify a subset of men with Gleason score (GS) 6 prostate cancer who are at high risk for upgrading/upstaging who should be recommended for multiparametric magnetic resonance imaging.

PATIENTS AND METHODS

Between 1992 and 2017, a total of 3571 men with GS6 prostate cancer were consecutively treated at a single institution with radical prostatectomy. Logistic regression multivariable analyses to determine the odds of upgrading and upstaging were performed, adjusting for age and year of diagnosis, clinical T category, prostate-specific antigen level, number of biopsy cores, and percentage of positive biopsy cores.

RESULTS

Of 3571 men, the disease of 115 (3.22%), 245 (6.86%), and 254 (7.11%) was upgraded, was upstaged, or had positive surgical margins (R1), respectively. Older age at diagnosis was associated with an increased risk of upgrading disease to GS7 or higher, prostatectomy T3/T4, and R1 with adjusted odds ratios (95% confidence intervals) of 1.05 (1.01-1.08; P = .005), 1.02 (1.00-1.05; P = .048), and 1.02 (1.002-1.05; P = .03), respectively. Older age was associated with an increasing proportion of men with disease upgraded to GS7 or higher (T1c: P = .002; T2 or higher: P = .04) or upstaged to pT3/4 or pT2R1 (T1c: P = .02; T2 or higher: P = .02) among men with ≥ 33% but not < 33% positive biopsy cores.

CONCLUSION

Before initiating active surveillance, performing multiparametric magnetic resonance imaging in otherwise healthy older men with GS6 prostate cancer and ≥ 33% positive biopsy cores should be considered.

False positives in PIRADS (V2) 3, 4, and 5 lesions: relationship with reader experience and zonal location

PURPOSE

To investigate the effect of reader experience and zonal location on the occurrence of false positives (FPs) in PIRADS (V2) 3, 4, and 5 lesions on multiparametric (MP)-MRI of the prostate.

MATERIALS AND METHODS

This retrospective study included 139 patients who had consecutively undergone an MP-MRI of the prostate in combination with a transrectal ultrasound MRI fusion-guided biopsy between 2014 and 2017. MRI exams were prospectively read by a group of inexperienced radiologists (cohort 1; 54 patients) and an experienced radiologist (cohort 2; 85 patients). Multivariable logistic regression analysis was performed to determine the association of experience of the radiologist and zonal location with a FP reading. FP rates were compared between readings by inexperienced and experienced radiologists according to zonal location, using Chi-square (χ²) tests.

RESULTS

A total of 168 lesions in 139 patients were detected. Median patient age was 68 years (Interquartile range (IQR) 62.5-73), and median PSA was 10.9 ng/mL (IQR 7.6-15.9) for the entire patient cohort. According to multivariable logistic regression, inexperience of the radiologist was significantly (P = 0.044, odds ratio 1.927, 95% confidence interval [CI] 1.017-3.651) and independently associated with a FP reading, while zonal location was not (P = 0.202, odds ratio 1.444, 95% CI 0.820-2.539). In the transition zone (TZ), the FP rate of the inexperienced radiologists 59% (17/29) was significantly higher (χ²P = 0.033) than that of the experienced radiologist 33% (13/40).

CONCLUSION

Inexperience of the radiologist is significantly and independently associated with a FP reading, while zonal location is not. Inexperienced radiologists have a significantly higher FP rate in the TZ.

Radiomics with artificial intelligence for precision medicine in radiation therapy

Recently, the concept of radiomics has emerged from radiation oncology. It is a novel approach for solving the issues of precision medicine and how it can be performed, based on multimodality medical images that are non-invasive, fast and low in cost. Radiomics is the comprehensive analysis of massive numbers of medical images in order to extract a large number of phenotypic features (radiomic biomarkers) reflecting cancer traits, and it explores the associations between the features and patients' prognoses in order to improve decision-making in precision medicine. Individual patients can be stratified into subtypes based on radiomic biomarkers that contain information about cancer traits that determine the patient's prognosis. Machine-learning algorithms of AI are boosting the powers of radiomics for prediction of prognoses or factors associated with treatment strategies, such as survival time, recurrence, adverse events, and subtypes. Therefore, radiomic approaches, in combination with AI, may potentially enable practical use of precision medicine in radiation therapy by predicting outcomes and toxicity for individual patients.

Prostate-specific antigen levels and proportion of biopsy positive cores are independent predictors of upgrading patterns in low-risk prostate cancer

BACKGROUND

The aim of this study is to evaluate clinical factors associated with the risk of tumor upgrading patterns in low risk prostate cancer (PCA) patients undergoing radical prostatectomy.

METHODS

In a period running from January 2013 to December 2016, 245 low risk patients underwent RP. Patients were classified into three groups, which included case with pathology grade group one (no upgrading pattern), two-three (intermediate upgrading pattern), and four-five (high upgrading pattern). The association of factors with the upgrading risk was evaluated by the multinomial logistic regression model. It was used a receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis to assess the efficacy of predictors.

RESULTS

Overall, tumor upgrading was detected in 158 patients (67.3%). Tumor upgrading patterns were absent in 80 patients (32.7%), intermediate in 152 cases (62%) and high in 13 subjects (5.3%). Median prostate specific (PSA) levels and proportion of biopsy positive core (BPC) were higher in patients with intermediate (PSA=6 ng/mL; BPC=0.28) and high (PSA=8.9 ng/mL; BPC=0.33) than those without (PSA=5.7 ng/mL; BPC=0.17) and the difference was significant (PSA: P=0.002; BPC: P=0.001). When compared to not upgraded cases, higher BPC proportions were independent predictors of intermediate upgrading patterns (odds ratio, OR=36.711; P<0.0001; AUC=0.613) while higher PSA values were independent predictors of high upgrading patterns (OR=2.033, P<0.0001; AUC=0.779).

CONCLUSIONS

PSA and BPC were both independent predictors of tumor upgrading in low risk PCA. BPC associated with the risk of intermediate tumor upgrading patterns, but showed a low discrimination power. PSA associated with high upgrading patterns and showed a fair discrimination power in the model. Tumor upgrading risk patterns should be evaluated in low risk PCA patients before treatment.

Clinical factors stratifying the risk of tumor upgrading to high-grade disease in low-risk prostate cancer

PURPOSE

To identify clinical factors stratifying the risk of tumor upgrading to increasing patterns of the tumor grading system in low-risk prostate cancer (PCa).

METHODS

We evaluated the records of 438 patients who underwent radical prostatectomy. Associations between clinical factors and tumor upgrading were assessed by the univariate and multivariate multinomial logistic regression model.

RESULTS

Low-risk PCa included 170 cases (38.8%) and tumor upgrading was detected in 111 patients (65.3%): 72 (42.4%) had pathology Gleason pattern (pGP) 3 + 4, 27 (15.9%) pGP 4 + 3, and 12 (7.1%) pGP 4 + 4. Prostate- specific antigen (PSA) and proportion of positive cores (P+) were independent predictors of upgrading to high-risk disease. These factors also stratified the risk of tumor upgrading to the increasing patterns of the tumor grading system. The model allowed the identification of pGP 4 + 4. The main difference between high-risk PCa and other upgraded tumors related to PSA load (odds ratio 2.4) that associated with high volume disease in the specimen.

CONCLUSIONS

Low-risk PCa is a heterogeneous population with significant rates of tumor upgrading. Significant clinical predictors stratifying the risk of tumor upgrading to increasing patterns of the grading system included PSA and P+. These factors allowed the identification of the subset hiding high-grade disease requiring further investigations before delivering active treatments.

Risk of Upgrading from Prostate Biopsy to Radical Prostatectomy Pathology-Does Saturation Biopsy of Index Lesion during Multiparametric Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy Help?

PURPOSE

We sought to determine whether saturation of the index lesion during magnetic resonance imaging-transrectal ultrasound fusion guided biopsy would decrease the rate of pathological upgrading from biopsy to radical prostatectomy.

MATERIALS AND METHODS

We analyzed a prospectively maintained, single institution database for patients who underwent fusion and systematic biopsy followed by radical prostatectomy in 2010 to 2016. Index lesion was defined as the lesion with largest diameter on T2-weighted magnetic resonance imaging. In patients with a saturated index lesion transrectal fusion biopsy targets were obtained at 6 mm intervals along the long axis of the index lesion. In patients with a nonsaturated index lesion only 1 target was obtained from the lesion. Gleason 6, 7 and 8-10 were defined as low, intermediate and high risk, respectively.

RESULTS

Included in the study were 208 consecutive patients, including 86 with a saturated and 122 with a nonsaturated lesion. Median patient age was 62.0 years (IQR 10.0) and median prostate specific antigen was 7.1 ng/ml (IQR 8.0). The median number of biopsy cores per index lesion was higher in the saturated lesion group (4 vs 2, p <0.001). The risk category upgrade rate from systematic only, fusion only, and combined fusion and systematic biopsy results to prostatectomy was 40.9%, 23.6% and 13.8%, respectively. The risk category upgrade from combined fusion and systematic biopsy results was lower in the saturated than in the nonsaturated lesion group (7% vs 18%, p = 0.021). There was no difference in the upgrade rate based on systematic biopsy between the 2 groups. However, fusion biopsy results were significantly less upgraded in the saturated lesion group (Gleason upgrade 20.9% vs 36.9%, p = 0.014 and risk category upgrade 14% vs 30.3%, p = 0.006).

CONCLUSIONS

Our results demonstrate that saturation of the index lesion significantly decreases the risk of upgrading on radical prostatectomy by minimizing the impact of tumor heterogeneity.

Low-Risk Prostate Cancer and Tumor Upgrading in the Surgical Specimen: Analysis of Clinical Factors Predicting Tumor Upgrading in a Contemporary Series of Patients Who were Evaluated According to the Modified Gleason Score Grading System

OBJECTIVE

To identify significant clinical factors associated with prostate cancer (PCa) upgrading the low-risk PCa patients graded according to the modified Gleason score system.

MATERIALS AND METHODS

The logistic regression model was used to evaluate the records of 438 patients.

RESULTS

There were 170 cases (38.8%) of low-risk PCa and tumors were upgraded in 111 patients (65.3%). Only prostate specific antigen (PSA) and the proportion of positive cores (P+) were independent predictors of tumor upgrading. Further exploration was investigated by categorizing and regressing PSA (≤ 5.0 vs. > 5.0 ng/ml) and P+ (≤ 0.20 vs. > 0.20). The odds ratio of PSA > 5 ng/ml was 1.32 and of P+ > 0.20 was 2.71. The population was stratified into very low-risk with PSA ≤ 5 ng/ml and P+ ≤ 0.20 (class A), low-risk with PSA > 5 ng/ml and P+ ≤ 0.20 (class B), intermediate risk with PSA ≤ 5 ng/ml and P+ > 0.20 (class C), and high risk with PSA > 5 ng/ml and P+ 0.20 (class D). Upgrading rates were extremely low in class A (9%), extremely high in D (50.5%), and moderate (20%) in B and C.

CONCLUSION

Patients diagnosed with low-risk PCa at biopsy are a heterogeneous population because they include subsets with undetected high-grade disease. Significant clinical predictors of upgrading include the PSA value and P+. In low-risk PCa, we identified a high-risk upgrading subgroup that needed repeat biopsies in order to reclassify the tumor grade and to reassess the clinical risk category.

Low serum testosterone predicts upgrading and upstaging of prostate cancer after radical prostatectomy

Often, pathological Gleason Score (GS) and stage of prostate cancer (PCa) were inconsistent with biopsy GS and clinical stage. However, there were no widely accepted methods predicting upgrading and upstaging PCa. In our study, we investigated the association between serum testosterone and upgrading or upstaging of PCa after radical prostatectomy (RP). We enrolled 167 patients with PCa with biopsy GS ≤6, clinical stage ≤T2c, and prostate-specific antigen (PSA) <10 ng ml⁻¹ from April 2009 to April 2015. Data including age, body mass index, preoperative PSA level, comorbidity, clinical presentation, and preoperative serum total testosterone level were collected. Upgrading occurred in 62 (37.1%) patients, and upstaging occurred in 73 (43.7%) patients. Preoperative testosterone was lower in the upgrading than nonupgrading group (3.72 vs 4.56, P< 0.01). Patients in the upstaging group had lower preoperative testosterone than those in the nonupstaging group (3.84 vs 4.57, P= 0.01). In multivariate logistic regression analysis, as both continuous and categorical variables, low serum testosterone was confirmed to be an independent predictor of pathological upgrading (P = 0.01 and P= 0.01) and upstaging (P = 0.01 and P = 0.02) after RP. We suggest that low serum testosterone (<3 ng ml⁻¹) is associated with a high rate of upgrading and upstaging after RP. It is better for surgeons to ensure close monitoring of PSA levels and imaging examination when selecting non-RP treatment, to be cautious in proceeding with nerve-sparing surgery, and to be enthusiastic in performing extended lymph node dissection when selecting RP treatment for patients with low serum testosterone.

Low-Risk Prostate Cancer and Tumor Upgrading to Higher Patterns in the Surgical Specimen. Analysis of Clinical Factors Predicting Tumor Upgrading to Higher Gleason Patterns in a Contemporary Series of Patients Who Have Been Evaluated According to the Modified Gleason Score Grading System

OBJECTIVE

To identify clinical factors associated with prostate cancer (PCA) upgrading to higher patterns of the surgical specimen in low-risk PCA.

MATERIALS AND METHODS

We evaluated the records of 438 patients. The multinomial logistic regression model was used.

RESULTS

Low-risk PCA included 170 cases (38.8%) and tumor upgrading was detected in 111 patients (65.3%) of whom 72 (42.4%) had pathological Gleason patterns (pGP) = 3 + 4 and 39 (22.9%) pGP >3 + 4. Prostate-specific antigen (PSA) and proportion of positive cores (P+) were independent predictors of tumor upgrading to higher patterns. The main difference between upgraded cancers related to PSA and to P+ >0.20. The population was stratified into risk classes by PSA ≤5 μg/l and P+ ≤0.20 (class A), PSA >5 μg/l and P+ ≤0.20 (class B), PSA ≤5 μg/l and P+ >0.20 (class C) and PSA >5 μg/l and P+ 0.20 (class D). Upgrading rates to pGP >3 + 4 were extremely low in class A (5.1%), extremely high in D (53.8%).

CONCLUSIONS

Low-risk PCA is a heterogeneous population with significant rates of undetected high-grade disease. Significant clinical predictors of upgrading to higher patterns include PSA and P+, which identify a very high-risk class that needs repeat biopsies in order to reclassify tumor grade.

Does the time from biopsy to radical prostatectomy affect Gleason score upgrading in patients with clinical t1c prostate cancer?

PURPOSE

It is debated whether treatment delay worsens oncologic results in localized prostate cancer (PCa). Few studies have focused on the role of a delay between the time of biopsy and the time of surgery. Thus, we aimed to investigate the effect of the time period between biopsy and surgery on Gleason score upgrading (GSU).

MATERIALS AND METHODS

A total of 290 patients who underwent radical retropubic prostatectomy in Ankara Training and Research Hospital were included in the study. The biopsy Gleason score, age, total prostate-specific antigen (PSA) value, prostate volumes, and PSA density (PSAD) were analyzed in all patients. The patients were divided into two groups: patients with GSU (group 1) and patients without GSU (group 2). Variables having a p-value of ≤0.05 in the univariate analysis were selected and then evaluated by use of multivariate logistic regression models. Results were considered significant at p<0.05.

RESULTS

GSU occurred in 121 of 290 patients (41.7%). The mean age of the patients was 66.0±7.2 years in group 1 and 65.05±5.60 years in group 2 (p=0.18). The mean PSA values of groups 1 and 2 were 8.6±4.1 and 8.8±4.3 ng/dL, respectively. The mean prostate volumes of groups 1 and 2 were 43.8±14.1 and 59.5±29.8 mL, respectively. The PSAD of group 1 was significantly higher than that of group 2 (0.20 vs. 0.17, p=0.003). The mean time to surgery was shorter in group 2 (group 1, 52.2±22.6 days; group 2, 45.3±15.5 days; p=0.004). According to the logistic regression, time from biopsy to surgery is important in the prediction of GSU.

CONCLUSIONS

We suggest that the time period between biopsy and surgery is a significant factor that affects GSU in patients with clinically localized PCa.

How reliable is 12-core prostate biopsy procedure in the detection of prostate cancer?

INTRODUCTION

Prostate biopsies incur the risk of being false-negative and this risk has not yet been evaluated for 12-core prostate biopsy. We calculated the false-negative rate of 12-core prostate biopsy and determined the patient characteristics which might affect detection rate.

METHODS

We included 90 prostate cancer patients (mean age of 64, range: 49-77) diagnosed with transrectal ultrasound guided 12-core prostate biopsy between December 2005 and April 2008. All patients underwent radical retropubic prostatectomy and the 12-core prostate biopsy procedure was repeated on surgical specimen ex-vivo. Results of preoperative and postoperative prostate biopsies were compared. We analyzed the influence of patient age, prostate weight, serum prostate-specific antigen (PSA) level, free/total PSA ratio, PSA density and Gleason score on detection rate.

RESULTS

In 67.8% of patients, prostate cancer was detected with repeated ex-vivo biopsies using the same mapping postoperatively. We found an increase in PSA level, PSA density and biopsy Gleason score; patient age, decreases in prostate weight and free/total PSA ratio yielded higher detection rates. All cores, except the left-lateral cores, showed mild-moderate or moderate internal consistency. Preoperative in-vivo biopsy Gleason scores remained the same, decreased and increased in 43.3%, 8.9% and 47.8% of patients, respectively, on final specimen pathology.

CONCLUSIONS

The detection rate of prostate cancer with 12-core biopsy in patients (all of whom had prostate cancer) was considerably low. Effectively, repeat biopsies can still be negative despite the patient's reality of having prostate cancer. The detection rate is higher if 12-core biopsies are repeated in younger patients, patients with high PSA levels, PSA density and Gleason scores, in addition in patients with smaller prostates, lower free/total PSA ratios.

How reliable is 12-core prostate biopsy procedure in the detection of prostate cancer?

INTRODUCTION

Prostate biopsies incur the risk of being false-negative and this risk has not yet been evaluated for 12-core prostate biopsy. We calculated the false-negative rate of 12-core prostate biopsy and determined the patient characteristics which might affect detection rate.

METHODS

We included 90 prostate cancer patients (mean age of 64, range: 49-77) diagnosed with transrectal ultrasound guided 12-core prostate biopsy between December 2005 and April 2008. All patients underwent radical retropubic prostatectomy and the 12-core prostate biopsy procedure was repeated on surgical specimen ex-vivo. Results of preoperative and postoperative prostate biopsies were compared. We analyzed the influence of patient age, prostate weight, serum prostate-specific antigen (PSA) level, free/total PSA ratio, PSA density and Gleason score on detection rate.

RESULTS

In 67.8% of patients, prostate cancer was detected with repeated ex-vivo biopsies using the same mapping postoperatively. We found an increase in PSA level, PSA density and biopsy Gleason score; patient age, decreases in prostate weight and free/total PSA ratio yielded higher detection rates. All cores, except the left-lateral cores, showed mild-moderate or moderate internal consistency. Preoperative in-vivo biopsy Gleason scores remained the same, decreased and increased in 43.3%, 8.9% and 47.8% of patients, respectively, on final specimen pathology.

CONCLUSIONS

The detection rate of prostate cancer with 12-core biopsy in patients (all of whom had prostate cancer) was considerably low. Effectively, repeat biopsies can still be negative despite the patient's reality of having prostate cancer. The detection rate is higher if 12-core biopsies are repeated in younger patients, patients with high PSA levels, PSA density and Gleason scores, in addition in patients with smaller prostates, lower free/total PSA ratios.

Frequency and determinants of disagreement and error in gleason scores: a population-based study of prostate cancer

BACKGROUND

To examine factors that affect accuracy and reliability of prostate cancer grade we compared Gleason scores documented in pathology reports and those assigned by urologic pathologists in a population-based study.

METHODS

A stratified random sample of 318 prostate cancer cases was selected to ensure representation of whites and African-Americans and to include facilities of various types. The slides borrowed from reporting facilities were scanned and the resulting digital images were re-reviewed by two urologic pathologists. If the two urologic pathologists disagreed, a third urologic pathologist was asked to help arrive at a final "gold standard" result. The agreements between reviewers and between the pathology reports and the "gold standard" were examined by calculating kappa statistics. The determinants of discordance in Gleason scores were evaluated using multivariate models with results expressed as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The kappa values (95% CI) reflecting agreement between the pathology reports and the "gold standard," were 0.61 (95% CI: 0.54, 0.68) for biopsies, and 0.37 (0.23, 0.51) for prostatectomies. Sixty three percent of discordant biopsies and 72% of discordant prostatectomies showed only minimal differences. Using freestanding laboratories as reference, the likelihood of discordance between pathology reports and expert-assigned biopsy Gleason scores was particularly elevated for small community hospitals (OR = 2.98; 95% CI: 1.73, 5.14).

CONCLUSIONS

The level of agreement between pathology reports and expert review depends on the type of diagnosing facility, but may also depend on the level of expertise and specialization of individual pathologists.

Association between percentage of tumor involvement and Gleason score upgrading in low-risk prostate cancer

To find the predictors of Gleason score upgrading in a cohort of low-risk prostate cancer patients, data were analyzed comprising 1,632 consecutive men with low-risk prostate cancer who underwent radical prostatectomy between 1993 and 2009. Assessment focused on preoperative parameters including patient age, race, diagnostic prostate-specific antigen (PSA) levels, clinical stage and biopsy Gleason score, along with pathological parameters including percentage of tumor involvement (PTI), tumor laterality, pathological stage, extra-capsular extension, seminal vesicle invasion, and surgical margins. These parameters were analyzed using univariate and multivariate methods. Kaplan-Meier curves compared differences in biochemical disease-free survival in men having cancers with and without Gleason score upgrading. Cases involving pathological Gleason score upgrading were identified in 723 (44.3 %) of 1,632 patients. Kaplan-Meier PSA recurrence-free survival curves showed a difference in outcome between men with and without Gleason score upgrading (p < 0.001). Of Gleason score upgraded patients, 35 (4.8 %) men had PTI of <5 %, 237 (32.8 %) had PTI of 5-9.9 %, 177 (24.5 %) had PTI of 10-14.9 %, and 274 (37.9 %) had PTI ≥ 15 % (p < 0.001). PTI (p < 0.001) along with diagnostic PSA, patient age, diagnostic biopsy Gleason score, pathologic stage, and surgical margin status were independent predictors of pathological Gleason score upgrading on multivariate logistic regression. PTI correlates closely with Gleason score upgrading in a low-risk prostate cancer cohort. Low-risk prostate cancer patients with clinical findings suggestive of high PTI or large volume cancers should not benefit from active surveillance strategies.

The association between pre-operative PSA and prostate cancer-specific mortality in patients with long-term follow-up after radical prostatectomy

BACKGROUND

The clinical and pathologic predictors of prostate cancer-specific mortality (PCSM) many years after radical prostatectomy (RP) remain to be fully elucidated. We explored the association between pre-operative prostate-specific antigen (PSA) and other pathologic predictors and PCSM in men who have undergone (RP).

METHODS

We report on 459 patients with PCSM data after RP who were followed prospectively over a 23-year period between 1987 and 1997. Cox regression and Kaplan-Meier analysis were used to evaluate pre-operative PSA, pathologic Gleason sum, pathologic stage, and surgical margin status as predictors of PCSM.

RESULTS

The median PSA was 6.6 ng/ml (± 9.9) and the median follow-up time was 9.4 (± 4.9) years. Fourteen patients (3.1%) died of PC. On multivariate analysis, only PSA (HR: 1.050; P = 0.001) and binary Gleason sum (HR: 3.402; P = 0.043) remained significant predictors of PCSM. The predicted 10-year PCSM was significantly worse in those patients in the highest PSA tertile compared to those in other tertiles [PSA > 9.9: 87% (82-92%) vs. PSA = 4-9.9: 95% (93.0-97.0%) vs. PSA = 0-3.9: 100.0% (100.0-100.0%)].

CONCLUSIONS

We have highlighted the importance of pre-operative PSA in predicting PCSM many years after RP. It is a more significant predictor than Gleason sum and pathologic stage. Thus, PSA may help identify patients with life-threatening PC at a time when their disease is curable with definitive therapy.

Prostate size as a predictor of Gleason score upgrading in patients with low risk prostate cancer

PURPOSE

Gleason score upgrading between biopsy and surgical pathological specimens occurs in 30% to 50% of cases. Predicting upgrading in men with low risk prostate cancer may be particularly important since high grade disease influences management decisions and impacts prognosis. We determined whether prostate size predicts Gleason score upgrading in patients with low risk prostate cancer.

MATERIALS AND METHODS

A total of 1,251 consecutive patients with D'Amico low risk disease and complete data available underwent radical prostatectomy at our institution between January 2000 and June 2008. Patients were divided into 3 groups by pathological Gleason score, including no, minor (3 + 4 = 7) and major (4 + 3 = 7 or greater) Gleason score upgrading. We developed bivariate and multivariate models to determine whether prostate size was an important predictor of upgrading while controlling for clinical and biopsy characteristics.

RESULTS

Of 1,251 cases 387 (31.0%) were upgraded, including 324 (26%) and 63 (5%) with minor and major upgrading, respectively. As expected, Gleason score upgrading was associated with worse pathological and cancer control outcomes. On multivariate analysis smaller prostate size was an independent predictor of any and major upgrading (OR 0.58, 95% CI 0.48-0.69, p <0.01 and OR 0.67, 95% CI 0.49-0.96, p = 0.03, respectively). Men with prostate volume at the 25th percentile (36 cm(3)) were 50% more likely to experience upgrading than men with prostate volume at the 75th percentile (58 cm(3)).

CONCLUSIONS

Of low risk cases 31% were upgraded at final pathology. Smaller prostate size predicts Gleason score upgrading in men with clinically low risk prostate cancer. This is important information when counseling patients on management and prognosis.

The long-term outcomes after radical prostatectomy of patients with pathologic Gleason 8-10 disease

Background. We explored the long-term clinical outcomes including metastases-free survival and prostate cancer-specific survival (PCSS) in patients with pathologic Gleason 8–10 disease after radical prostatectomy (RP). Methods. We report on 91 patients with PCSS data with a median followup of 8.2 years after RP performed between 1988 and 1997. Cox regression and Kaplan-Meier analysis were used to evaluate year of surgery, pathologic stage, and surgical margin status as predictors of PCSM. Results. Median age was 65 years (IQR: 61–9), and median PSA was 9.7 ng/ml (IQR: 6.1–13.4). Of all patients, 62 (68.9%) had stage T3 disease or higher, and 48 (52.7%) had a positive surgical margin. On multivariate analysis, none of the predictors were statistically significant. Of all patients, the predicted 10-year BCR-free survival, mets-free survival, and PCSS were 59% (CI: 53%–65%), 88% (CI: 84%–92%), and 94% (CI: 91%–97%), respectively. Conclusions. We have demonstrated that cancer control is durable even 10 years after RP in those with pathologic Gleason 8–10 disease. Although 40% will succumb to BCR, only 6% of patients died of their disease. These results support the use of RP for patients with high-risk localized prostate cancer.

Predictive models for worsening prognosis in potential candidates for active surveillance of presumed low-risk prostate cancer

PURPOSE

Low-risk prostate cancer patients clinically eligible for active surveillance can also be managed surgically. We evaluated the pathologic outcomes for this cohort that was treated by radical prostatectomy and devised nomograms to predict patients at risk of upgrading and/or upstaging.

MATERIALS AND METHODS

Seven hundred and fifty patients treated by radical prostatectomy from Jan 2005 to the present fulfilled conventional active surveillance criteria and formed the study cohort. Preoperative data on standard clinicopathologic parameters were available. The radical prostatectomy specimens were graded and staged, and any upgrading to Gleason sum >6 or upstaging to ≥pT3 ('worsening prognosis') were noted. Multivariable logistic regression models were used to develop predictive nomograms.

RESULTS

Of the 750 patients, 303 (40.4%) patients were either upgraded or upstaged. Multivariable analysis found that preoperative PSA, number of positive cores, and prostate volume were significantly predictive of worsening prognosis and formed the nomogram criteria.

CONCLUSIONS

Of patients deemed eligible for active surveillance based on conventional criteria, 40.4% have worse prognostic factors after radical prostatectomy. Current active surveillance criteria may be too relaxed, and the use of nomograms which we have devised, may aid in counseling primary prostate cancer patients considering active surveillance as their therapy of choice.

Clinicopathological Strategies to Identify Contralateral Prostate Cancer Involvement in Potential Candidates for Focal Therapy

Objective: To identify the magnitude and possible predictors of contralateral lobe involvement and contralateral extraprostatic extension (EPE) in prostatic biopsy—defined localized unilateral cancers. Patients and Methods: Between January 2005 and August 2009, 1861 patients underwent robotic-assisted radical prostatectomy at the authors’ institution. A total of 1114 had unilateral disease on preoperative biopsy. Final histopathology reports of these patients were reviewed. Results: Of the 1114 patients with unilateral disease on biopsy, 867 (77.9%) had contralateral or bilateral disease on final histopathology. EPE was found in 132 patients (11.9%). Twenty patients (1.8%) had contralateral EPE involvement. High-grade prostatic intraepithelial neoplasm (HGPIN) on biopsy was the significant predictor of contralateral lobe involvement on both univariate ( P = .02; odds ratio [OR] = 1.791) and multivariate analysis ( P = .004; OR = 2.677). Clinical stage T2 was the significant predictor of contralateral EPE on both univariate ( P = .012; OR = 5.250) and multivariate analysis ( P = .007; OR = 8.656). Conclusion: HGPIN on biopsy significantly predicts for contralateral lobe involvement and should be considered an exclusion criterion for focal therapy in prostate cancer patients. Patients with palpable tumor on digital rectal examination should be advised in favor of radical treatment as these patients may harbor more aggressive tumors involving the contralateral side despite the biopsy findings.

Technologies for localization and diagnosis of prostate cancer

The gold standard for detecting prostate cancer (PCa), systematic biopsy, lacks sensitivity as well as grading accuracy. PSA screening leads to over-treatment of many men, and it is unclear whether screening reduces PCa mortality. This review provides an understanding of the difficulties of localizing and diagnosing PCa. It summarizes recent developments of ultrasound (including elastography) and MRI, and discusses some alternative experimental techniques, such as resonance sensor technology and vibrational spectroscopy. A comparison between the different methods is presented. It is concluded that new ultrasound techniques are promising for targeted biopsy procedures, in order to detect more clinically significant cancers while reducing the number of cores. MRI advances are very promising, but MRI remains expensive and MR-guided biopsy is complex. Resonance sensor technology and vibrational spectroscopy have shown promising results in vitro. There is a need for large prospective multicentre trials that unambiguously prove the clinical benefits of these new techniques.

Upgrading of Gleason score 6 prostate cancers on biopsy after prostatectomy in the low and intermediate tPSA range

When offering watchful waiting or active monitoring protocols to prostate cancer (PCa) patients, differentiation between Gleason scores (GS) 6 and 7 at biopsy is important. However, upgrading after prostatectomy is common. We investigated the impact of different PSA levels on misclassification in the PSA range of 2-3.9 and 4-10 ng ml(-1). A total of 448 patients with GS 6 PCa on prostate biopsy were evaluated by comparing biopsy and prostatectomy GS. Possible over diagnosis was defined as GS <7, pathological stage pT2a and negative surgical margins, and possible under diagnosis was defined as pT3a or greater, or positive surgical margins; the percentage of over- or under diagnosis was determined for correctly and upgraded tumors after prostatectomy. A match between biopsy and prostatectomy GS was found in 210 patients (46.9%). Patients in the PSA range of 2.0-3.9 and 4.0-10.0 ng ml(-1) were upgraded in 32.6 and 44.0%, respectively. Over diagnosis was more common than under diagnosis (23.2% vs 15.6%). When upgraded there was a significant increase in under diagnosis. As almost 40% of GS 6 tumors on biopsy are GS 7 or higher after surgery with a significant rise in under diagnosis there is a risk of misclassification and subsequent delayed or even insufficient treatment, when relying on favorable biopsy GS.

Saturation biopsy improves preoperative Gleason scoring of prostate cancer

We evaluated the differences between conventional needle biopsy (CB) and saturation biopsy (SB) techniques with regard to the prediction of Gleason score, tumor stage, and insignificant prostate cancer. Data from a total number of 240 patients were analyzed. The main group, consisting of 185 patients, was diagnosed according to a saturation prostate needle biopsy protocol (SB), by which more than 12 cores were taken per biopsy. The control group was diagnosed using CB, by which 12 or less than 12 cores were taken per biopsy (n=55). In the main group, the Gleason score of the biopsy was confirmed in 19.5%, in the control group in 23.5% according to the prostatectomy specimen (p=0.50). Upgrading after the operation was found in 56.7% in the main group and in 60% in the control group (p=0.24). Downgrading after the operation was found in 23.9% in the main group and in 16.3% in the control group (p=0.24). If the Gleason score of the postoperative specimens differed by only one point from the biopsy, we considered this a minor deviation. In the main group, 59% of the carcinomas were preoperatively classified correctly or revealed minor deviation in Gleason scores. In contrast, only 47% of the carcinomas in the control group were assessed correctly or with minor deviation in Gleason scores. Thus, the main group demonstrated a better rate of preoperative prediction in tumor grading assessed by Gleason score (p=0.05). In addition, the Gleason scores of both protocols were assigned to three groups (Gleason <7; Gleason 7; Gleason >7), and the group changes from the biopsy to the prostatectomy specimen were found to be significantly more frequent in the CB group (p=0.04). There was no significant difference between the two types of biopsy techniques regarding tumor stage or the detection of insignificant carcinomas. The advantage of the extensive prostate needle biopsy technique (SB) is a better preoperative prediction of the Gleason score as well as the risk groups with Gleason scores <7, equal to 7, or >7. Both techniques fail to detect insignificant prostate cancer.

Well-differentiated prostate cancer in core biopsy specimens may be associated with extraprostatic disease

CONTEXT AND OBJECTIVE

Accurate determination of the Gleason score in prostate core biopsy specimens is crucial in selecting the type of prostate cancer treatment, especially for patients with well-differentiated tumors (Gleason score 2 to 4). For such patients, an inaccurate biopsy score may result in a therapeutic intervention that is too conservative. We evaluate the role of Gleason score 2-4 in prostate core-needle biopsies for predicting the final pathological staging following radical prostatectomy.

DESIGN AND SETTING

Retrospective study at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo.

METHODS

We analyzed the medical records of 120 consecutive patients who underwent radical retropubic prostatectomy to treat clinical localized prostate cancer at our institution between December 2001 and July 2006. Thirty-two of these patients presented well-differentiated tumors (Gleason score 2 to 4) in biopsy specimens and were included in the study. The Gleason scores of the core-needle biopsies were compared with the pathological staging of the surgical specimens.

RESULTS

Sixteen of the 32 patients (50%) presented moderately differentiated tumors (Gleason score 5 to 7) in surgical specimens. Eighteen patients (56%) had tumors with involvement of the prostate capsule and ten (31%) had involvement of adjacent organs. Evaluating the 16 patients that maintained Gleason scores of 2 to 4 in the pathological staging of the surgical specimens, 11 (68.7%) had focal invasion of the prostate capsule and five (31.25%) had organ-confined disease.

CONCLUSION

Well-differentiated tumors (Gleason score 2 to 4) seen in biopsies are not predictive of organ-confined disease.

Trends in Gleason score: concordance between biopsy and prostatectomy over 15 years

OBJECTIVES

To assess the changes in the concordance rate of prostate biopsy and radical prostatectomy (RP) Gleason score (GS) over 15 years.

METHODS

We reviewed 1670 consecutive patients who underwent RP between 1992 and 2006. We excluded patients who underwent neoadjuvant hormone therapy or salvage RP, or who had incomplete data. Patients who had RP during 1992 through 1996, 1997 through 2001, and 2002 through 2006 were assigned to groups 1, 2, and 3, respectively. All clinical and pathological data were collected retrospectively. We defined overgrading as a biopsy GS higher than the RP Gleason score. Undergrading was a biopsy GS less than the RP Gleason score. The GS concordance between biopsy and RP was evaluated by kappa coefficient.

RESULTS

A total of 1363 patients satisfied the inclusion criteria. Biopsy and RP Gleason score categories correlated exactly in 937 (69%) men. Gleason undergrading occurred in 361 (26%) men and overgrading in 65 (5%). The exact correlation of GS between biopsy and RP was 58%, 66%, and 75% in groups 1, 2, and 3, respectively. The most common discordant finding was undergrading of the biopsy specimen. The number of cases with exact correlation was highest in GS 7 (78%). Undergrading was more in GS 6 or less (35%) and overgrading was more in the GS 8 through 10 (35%) category.

CONCLUSIONS

This large, single institutional study confirms increasing concordance of Gleason scores in prostate needle biopsies and surgical specimens. This is reassuring for patients assessing various treatment options for prostate cancer.

Increasing the number of biopsies increases the concordance of Gleason scores of needle biopsies and prostatectomy specimens

PURPOSE

To determine the importance of increasing the number of biopsy cores to decrease the discrepancy of Gleason scores of needle biopsy and radical prostatectomy specimens.

MATERIALS AND METHODS

Between May 1998 and July 2005, 392 patients with clinically localized prostate cancer diagnosed by 18-gauge transrectal needle biopsy underwent radical prostatectomy. We categorized the cohort into 2 groups according to the number of the cores. Group 1 consisted of 206 patients diagnosed by extended biopsies (> or =10 cores, range 10-14, median 11). The remaining 186 patients who were diagnosed by sextant biopsies were categorized as being in group 2. Preoperative clinical variables, including patient age, digital rectal examination findings, serum prostate-specific antigen, and the number of cores positive for cancer the parameters, were assessed in both groups. The concordance of Gleason scores in both groups were analyzed by both individual Gleason scores and clinical subgroups of Gleason scores: 2-4 (well differentiated), 5-6 (moderately differentiated), 7 (intermediate), and 8-10 (poorly differentiated).

RESULTS

Needle biopsies revealed moderately differentiated tumors (Gleason 5-6) for the 2 groups (55.3% and 60.2%). Gleason scores of the needle biopsies were identical to that of the prostatectomy specimen in 116 (56.31%) and 76 cases (40.86%) for each group (kappa: 0.432 and 0.216 for each group, respectively). Gleason score of the needle biopsy differed by 1 grade in 56 (27.18%) and 84 cases (45.16%), and by > or =2 units in 34 (16.50%) and 26 cases (15.05%) for each group, respectively. Of the specimens, 34% were undergraded, and 10% were overgraded in group 1. These rates were 38% and 22% in group 2, respectively. A total of 70% in group 1 and 56% in group 2 remained in the same categorical group, 28% and 32% of the specimens were undergraded, and 4% and 12% were overgraded in groups 1 and 2, respectively. In group 1, the number of patients with Gleason scores of 2-4, 5-6, 7, and 8 were 9.7%, 55.3%, 21.4%, 13.6%, and 1.9%, 47.6%, 32%, 18.4%, graded by needle biopsies and radical prostatectomy specimens, respectively. However, in the sextant group, the change was the number of patients with Gleason scores of 2-4, 5-6, 7, and 8-10 was 5.4% 60.2%, 24.7%, and 9.7%, detected by needle biopsies, respectively. Radical prostatectomy specimens revealed the same Gleason categories in 4.3%, 41.9%, 38.7%, and 15.1%, respectively. There was no correlation between categorized prostate-specific antigen levels and concordance of the Gleason grade. Age and digital rectal examination results did not affect Gleason correlation.

CONCLUSIONS

We have shown that an extended biopsy scheme beyond its superior diagnostic capability also improves the concordance of Gleason scores of needle biopsies and radical prostatectomy specimens.

Predicting unilateral prostate cancer based on biopsy features: implications for focal ablative therapy--results from the SEARCH database

PURPOSE

For men with low risk prostate cancer it was recently proposed that ablative treatment to the affected side may decrease morbidity, while maintaining good oncological outcomes. However, few studies have assessed the correlation between biopsy parameters and pathological outcome (unilateral vs bilateral disease).

MATERIALS AND METHODS

Using the Shared Equal Access Regional Cancer Hospital Database of men treated with radical prostatectomy at multiple equal access medical centers we retrospectively examined the records of 261 men with clinical stage T1c or T2a prostate cancer, prostate specific antigen less than 10 ng/ml, Gleason sum 6 or less and only 1 or 2 ipsilateral positive cores on at least sextant biopsy. We compared clinical characteristics between men with pathologically unilateral disease or less (pT2b or less) and men with pathologically bilateral disease or extraprostatic extension (pT2c or greater). To determine the significant predictors of pT2c or greater disease we used a multivariate logistic regression model.

RESULTS

Of the cohort of 261 men with low risk prostate cancer only 93 (35.1%) had unilateral or no evidence of disease following examination of radical prostatectomy specimens. Men with pathologically unilateral or less disease did not differ from those with bilateral or more advanced disease by age, prostate specific antigen, clinical stage, body mass index or number of positive biopsy cores (1 vs 2). On multivariate analysis no clinical feature was significantly related to pathologically unilateral or less vs bilateral or greater disease.

CONCLUSIONS

The majority of men with low risk prostate cancer and 1 or 2 ipsilateral positive biopsy cores have pathologically bilateral disease. Therefore, strategies for unilateral treatment of prostate cancer are unlikely to be curative for these men.

Clinical predictors of gleason score upgrading

BACKGROUND

Brachytherapy, active surveillance, and watchful waiting are increasingly being offered to men with low-risk prostate cancer. However, many of these men harbor undetected high-grade disease (Gleason pattern > or =4). The ability to identify those individuals with occult high-grade disease may help guide treatment decisions in this patient cohort.

METHODS

The authors identified 175 cases of low-risk prostate cancer treated with radical prostatectomy. By using logistic regression analysis, 11 a priori-defined preoperative risk factors were evaluated for their ability to predict upgrading from Gleason 6 at biopsy to Gleason > or =7 at radical prostatectomy. An internally validated nomogram using all clinical variables was subsequently created to help physicians identify patients who had undetected high-grade disease.

RESULTS

A total of 60 (34%) patients were upgraded to high-grade disease. On multivariate analyses, both prostate-specific antigen (PSA) level (P = .02) and the level of pathologist expertise (P = .007) were predictive of upgrading. The predictive nomogram contained these variables plus age, digital rectal examination, transrectal ultrasound results, biopsy scheme applied (sextant vs extended), presence of prostatic intraepithelial neoplasia, prostate gland volume, and percentage of cancer in the biopsy. The nomogram provided acceptable discrimination (C statistic 0.71).

CONCLUSIONS

The authors identified significant predictors of upgrading for patients diagnosed with low-risk prostate cancer. A nomogram based on these study findings could help physicians further risk-stratify patients with low-risk prostate cancer before embarking on treatment. Caution should be exercised in recommending nonradical therapy to individuals with a high probability of undetected high-grade disease.