Predictors for clinically relevant Gleason score upgrade in patients undergoing radical prostatectomy

Determination of Whether Apex or Non-Apex Prostate Cancer Is the Best Candidate for the Use of Prostate-Specific Antigen Density to Predict Pathological Grade Group Upgrading and Upstaging after Radical Prostatectomy

Objective: Previous studies have demonstrated that prostate-specific antigen density (PSAD) may aid in predicting Gleason grade group (GG) upgrading and pathological upstaging in patients with prostate cancer (PCa). However, the differences and associations between patients with apex prostate cancer (APCa) and non-apex prostate cancer (NAPCa) have not been described. The aim of this study was to explore the different roles of PSAD in predicting GG upgrading and pathological upstaging between APCa and NAPCa. Patients and Methods: Five hundred and thirty-five patients who underwent prostate biopsy followed by radical prostatectomy (RP) were enrolled. All patients were diagnosed with PCa and classified as either APCa or NAPCa. Clinical and pathological variables were collected. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were performed. Results: Of the entire cohort, 245 patients (45.8%) had GG upgrading. Multivariate analysis revealed that only PSAD (odds ratio [OR]: 4.149, p < 0.001) was an independent, significant predictor of upgrading. A total of 262 patients (49.0%) had pathological upstaging. Both PSAD (OR: 4.750, p < 0.001) and percentage of positive cores (OR: 5.108, p = 0.002) were independently significant predictors of upstaging. Of the 374 patients with NAPCa, 168 (44.9%) displayed GG upgrading. Multivariate analysis also showed PSAD (OR: 8.176, p < 0.001) was an independent predictor of upgrading. Upstaging occurred in 159 (42.5%) patients with NAPCa, and PSAD (OR: 4.973, p < 0.001) and percentage of positive cores (OR: 3.994, p = 0.034) were independently predictive of pathological upstaging. Conversely, of the 161 patients with APCa, 77 (47.8%) were identified with GG upgrading, and 103 (64.0%) patients with pathological upstaging. Multivariate analysis demonstrated that there were no significant predictors, including PSAD, for predicting GG upgrading (p = 0.462) and pathological upstaging (p = 0.100). Conclusions: PSAD may aid in the prediction of GG upgrading and pathological upstaging in patients with PCa. However, this may only be practical in patients with NAPCa but not with APCa. Additional biopsy cores taken from the prostatic apex region may help improve the accuracy of PSAD in predicting GG upgrading and pathological upstaging after RP.

Clinical significance and risk factors of International Society of Urological Pathology (ISUP) grade upgrading in prostate cancer patients undergoing robot-assisted radical prostatectomy

BACKGROUND

The objective of this study is to investigate the clinical significance and risk factors of upgrading in the International Society of Urological Pathology (ISUP) Grade Group System in men undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer.

METHODS

A total of 583 patients diagnosed with prostate cancer by systematic biopsy were treated with RARP without neoadjuvant therapy from November 2011 to December 2018. Clinicopathological data were obtained from our clinical records. ISUP grade upgrading (IGU) was defined as 'ISUP grade in prostatectomy specimen determined to be higher than that in the biopsy specimen'. Clinicopathological factors, including age, PSA, prostate volume at biopsy (PV), PSA density, clinical stage, body mass index (BMI), interval from biopsy to prostatectomy, maximum percentage of cancer involvement per core (%CI), total number of biopsy cores, percentage of cancer positive biopsy cores (%PC), and sampling density were analyzed to detect potential risk factors of IGU. Biochemical recurrence (BCR) rates were calculated to analyze the effect of IGU on cancer prognosis.

RESULTS

In univariate analysis, BMI was a positive predictor of IGU, while %CI, %PC, and sampling density were negative predictors of IGU. BMI and %PC were statistically significant predictors of IGU in multivariate analysis. For cases diagnosed as ISUP grade group 2 or higher at biopsy, there was a significant difference in BCR rates between cases with and without IGU.

CONCLUSIONS

The results from our cohort showed that elements of both high-grade cancer risk (such as BMI) and sampling efficiency (such as %PC) contribute to IGU. Excluding cases diagnosed as ISUP grade group 1 at biopsy, BCR-free rates were significantly worse in cases with IGU, highlighting the need for more accurate pathological diagnosis at biopsy.

Radiologist-like artificial intelligence for grade group prediction of radical prostatectomy for reducing upgrading and downgrading from biopsy

Rationale: To reduce upgrading and downgrading between needle biopsy (NB) and radical prostatectomy (RP) by predicting patient-level Gleason grade groups (GGs) of RP to avoid over- and under-treatment. Methods: In this study, we retrospectively enrolled 575 patients from two medical institutions. All patients received prebiopsy magnetic resonance (MR) examinations, and pathological evaluations of NB and RP were available. A total of 12,708 slices of original male pelvic MR images (T2-weighted sequences with fat suppression, T2WI-FS) containing 5405 slices of prostate tissue, and 2,753 tumor annotations (only T2WI-FS were annotated using RP pathological sections as ground truth) were analyzed for the prediction of patient-level RP GGs. We present a prostate cancer (PCa) framework, PCa-GGNet, that mimics radiologist behavior based on deep reinforcement learning (DRL). We developed and validated it using a multi-center format. Results: Accuracy (ACC) of our model outweighed NB results (0.815 [95% confidence interval (CI): 0.773-0.857] vs. 0.437 [95% CI: 0.335-0.539]). The PCa-GGNet scored higher (kappa value: 0.761) than NB (kappa value: 0.289). Our model significantly reduced the upgrading rate by 27.9% (P < 0.001) and downgrading rate by 6.4% (P = 0.029). Conclusions: DRL using MRI can be applied to the prediction of patient-level RP GGs to reduce upgrading and downgrading from biopsy, potentially improving the clinical benefits of prostate cancer oncologic controls.

How to Pick Out the "Unreal" Gleason 3 + 3 Patients: A Nomogram for More Precise Active Surveillance Protocol in Low-Risk Prostate Cancer in a Chinese Population

OBJECTIVE

To develop a nomogram for selecting the "unreal" Gleason score (GS) 3 + 3 patients in biopsy GS 3 + 3 prostate cancer (PCa) patients.

METHODS

Patients who were newly diagnosed with PCa by biopsy and underwent radical prostatectomy in the First Affiliated Hospital of Nanjing Medical University from January 2009 to October 2018 were enrolled. Comparisons were made between GS 3 + 3 and higher grade PCa patients. Logistic regression analysis was performed to determine the risk factors for the "unreal" GS 3 + 3 PCa in biopsy GS 3 + 3 patients. Then, a nomogram was developed to predict the probability of "unreal" GS 3 + 3 PCa according to the results of multivariate analysis. Finally, receiver operating characteristic and decision curve analysis (DCA) curves were structured to identify the efficiency of the predictive model.

RESULTS

Compared to higher GS grade, biopsy GS 3 + 3 had greater upgrade risk (P < 0.05) while a lower proportion of positive surgical margins, seminal vesicle invasion, extra-prostatic extension, lymph node invasion, and nerve invasion (all P < 0.05). Multivariate analysis showed that age, PSAD, prostate imaging reporting and data system (PI-RADS) score and biopsy positive cores were significant risk factors for "unreal" GS 3 + 3. A nomogram was developed utilizing these factors with high prediction performance (area under curve = 0.924). Furthermore, DCA curve suggested that this predictive model was effective.

CONCLUSIONS

The nomogram identified the probability of "unreal" GS 3 + 3 PCa in biopsy GS 3 + 3 PCa patients, which was of great value for clinical guidance in low risk PCa therapy.

Oncological Outcomes of Open Radical Retropubic Prostatectomy in Ireland: A Single Surgeon's 5-Year Experience

Objectives  There is a little published data on the outcomes of radical prostatectomy in the Irish context. We aimed to determine the 5-year oncological results of open radical retropubic prostatectomy (RRP) performed by a single surgeon following appointment. Methods  A retrospective review of RRPs performed between 2011 and 2016 was conducted. Patient demographics, preoperative parameters (clinical stage on digital rectal exam, prostate-specific antigen (PSA) levels, biopsy Gleason's score and MRI [magnetic resonance imaging] findings), pathological variables (T-stage, Gleason's score, nodal status, and surgical margin status), and treatment decisions (lymphadenectomy or adjuvant radiotherapy) were recorded. Oncological outcome at last follow-up was ascertained. Results  265 patients underwent RRP between 2011 and 2016. Median age was 62 years (range: 41-74). Mean follow-up was 32.24 months (range: 8-72) months. Pathological disease stage was T2 in 170/265 (64.15%), T3a in 65/265 (24.53%), and T3b in 30/265 (11.32%). Final Gleason's score was upgraded from diagnostic biopsy in 16.35% (43/263) and downgraded in 27% (71/263). Pelvic lymph node dissection was performed in 44.25% (118/265) patients. A positive surgical margin (PSM) was seen in 26/170 (15.2%) patients with T2 disease and in 45/95 (47.37%) patients with T3 disease. Of the 265 patients, 238 (89.81%) were disease-free at last follow-up, of whom 24/238 (10.08%) had received adjuvant and 17/238 (7.14%) received salvage radiotherapy. Adjuvant/salvage treatment was ongoing in 19/265 (7.17%) of patients. Conclusion  Good oncological outcomes of RRP in the Irish context are seen in this 5-year review, with the vast majority of patients experiencing biochemical-free survival at most recent follow-up.

The impact of the 2005 International Society of Urological Pathology Gleason grading consensus on active surveillance for prostate cancer

Introduction

Current treatment plans for localized prostate carcinoma (PC) are based on core needle biopsies (CNB) classified using the Gleason score (GS). Recently, many institutions have started using the latest version of International Society of Urological Pathology (ISUP) guideline revision from 2014 for PC grading. Interestingly, this adoption is occurring without first understanding whether the 2005 ISUP revisions had a positive clinical impact. CNB-based GS may underestimate tumor aggressiveness and, therefore, critically impact patient eligibility for active surveillance (AS). The 2005 ISUP recommendations bore a significant impact on the grading of Gleason 6 and 7 PCs - a range that is meaningful for AS. The objective of this study was to compare the concordance between GS in CNB and radical prostatectomy (RP) before and after the 2005 ISUP guideline revisions, with an emphasis on its clinical impact on AS.

Material and methods

This was a single-center, prospective observational study. CNB were performed in a standardized manner. GS of CNB and RP specimens were compared across three time periods: 1999-2005 (pre-revision), 2006-2007 (transitional period), and 2008-2015 (post-revision). AS is usually employed in patients with GS 6 or GS 7 PC. Thus, we therefore focused on the analysis of patients with CNBs of GS ≤7.

Results

Between 1999 and 2015, 380 men with GS ≤7 PC underwent RP at our institution (median age: 62y; median PSA: 5.8 ng/ml). Of these, 231 CNB specimens were classified as GS ≤6, while 149 were GS 7.46% (pre-revision), 43% (transitional), and 54% (post-revision) of CNB with original scores ≤6 were later upgraded in corresponding RP specimens (p <0.001).

Conclusions

The 2005 ISUP GS revisions did not lower the rates of GS upgrades in RP specimens when compared to corresponding initial CNBs. Thus, these revisions did not improve AS selection. Future advances in molecular diagnostics may provide additional valuable information that facilitates patient enrollment in AS programs.

Nicotinamide phosphoribosyltransferase in malignancy: a review

Nicotinamide phosphoribosyltransferase (Nampt) catalyzes the rate-limiting step of nicotinamide adenine dinucleotide (NAD) synthesis. Both intracellular and extracellular Nampt (iNampt and eNampt) levels are increased in several human malignancies and some studies demonstrate increased iNampt in more aggressive/invasive tumors and in tumor metastases. Several different molecular targets have been identified that promote carcinogenesis following iNampt overexpression, including SirT1, CtBP, and PARP-1. Additionally, eNampt is elevated in several human cancers and is often associated with a higher tumor stage and worse prognoses. Here we review the roles of Nampt in malignancy, some of the known mechanisms by which it promotes carcinogenesis, and discuss the possibility of employing Nampt inhibitors in cancer treatment.

Increased fatty acid synthase expression in prostate biopsy cores predicts higher Gleason score in radical prostatectomy specimen

BACKGROUND

Fatty acid synthase (FAS) is highly expressed in various types of cancer, and elevated expression of FAS has been suggested to be a predictor of tumor aggressiveness and poor prognosis. We examined whether FAS expression in prostate biopsy cores could predict the pathological characteristics of radical prostatectomy (RP) specimens.

METHODS

Paraffin-embedded prostate biopsy cores, obtained from 102 patients who subsequently underwent RP, were immunostained with polyclonal anti-FAS antibody. The staining intensity was categorized into non-staining, weak, moderate, and strong. Tumors with moderate or strong immunostaining were considered to show high FAS expression, and other tumors were considered to show low FAS expression. The relation between the FAS expression status in biopsy cores and pathological parameters in RP specimens was analyzed.

RESULTS

The FAS expression in the biopsy cores of 64 of the 102 tumors (63%) was high, whereas it was low in the biopsy cores of the other 38 tumors (37%). High FAS expression was significantly associated with Gleason Score (GS) ≥ 7 in RP specimens (p< 0.0001). In multivariable logistic regression analyses, GS ≥7 in biopsy cores (p <0.0001), higher preoperative PSA (p = 0.0194), and high FAS expression (p = 0.0004) were independent predictors of GS ≥ 7 in the RP specimen.

CONCLUSIONS

Increased FAS expression in prostate biopsy cores could be a novel parameter for predicting higher GS in RP specimens. The treatment strategy for patients with high FAS expression in prostate biopsy cores should be carefully determined.

Elevated fatty acid synthase expression in prostate needle biopsy cores predicts upgraded Gleason score in radical prostatectomy specimens

BACKGROUND

We examined whether fatty acid synthase (FAS) expression in prostate biopsy cores had valuable information and could predict a Gleason score (GS) upgraded from biopsy to radical prostatectomy (RP) specimens.

METHODS

Immunostaining with a FAS antibody was performed on paraffin-embedded prostate biopsy cores with GS 5-6 obtained from 80 patients who subsequently underwent RP. The correlations between FAS expression and clinicopathological parameters, upgrading group, and clinicopathological parameters including FAS expression were analyzed. Logistic regression analysis was performed to identify a significant set of independent predictors for upgrading GS.

RESULTS

A total of 46 patients (57.5%) with biopsy GS 5-6 were upgraded to GS ≥7 at RP. FAS expression was significantly associated with clinical T stage (P = 0.0232) and positive core rate (P = 0.0245). Upgrading from biopsy GS 5-6 to GS ≥7 at RP was significantly associated with clinical T stage (P = 0.0337), positive core rate (P = 0.0262), and FAS expression (P < 0.0001). FAS expression was a significant predictor for upgrading from biopsy GS 5-6 to GS ≥7 at RP in multivariate analysis (P < 0.0001; odds ratio, 12.35). FAS scores showed the largest area under the receiver-operating characteristic curve (AUC) in preoperative parameters (AUC = 0.753).

CONCLUSIONS

Increased FAS expression in prostate biopsy cores could be a novel parameter for upgrading from biopsy GS 5-6 to GS ≥7 at RP. If a biopsy GS is low, the treatment strategy for patients with high FAS expression in prostate biopsy cores should be carefully determined.

Agreement of Gleason score on prostate biopsy and radical prostatectomy specimen: is there improvement with increased number of biopsy cylinders and the 2005 revised Gleason scoring?

INTRODUCTION

The objectives of this study were to assess the agreement of GS on biopsy compared with RP specimens and to assess whether an increased number of biopsy cylinders and the 2005 International Society of Urological Pathology (ISUP) GS modification improved this agreement.

MATERIALS AND METHODS

Pathological data of biopsy and RP specimens were analyzed in 328 consecutive patients, before (group 1; n = 135) and after (group 2; n = 193) implementation of the 2005 ISUP modification. Additionally, patients had more biopsy cylinders taken in group 2 (mean 10 vs. 6.9). The agreement of GS between biopsy and RP specimens was evaluated using the kappa coefficient. GS was pooled into 3 grades: low- (GS ≤ 6), intermediate- (GS = 7), and high-grade (GS ≥ 8) prostate cancer.

RESULTS

Kappa coefficient for GS in group 1 and 2 was 0.261 and 0.341, respectively. For tumor grade, this was 0.308 and 0.359 for group 1 and 2, respectively. For RP specimens, there was more agreement between biopsy and RP GS in group 2 compared with group 1 (53.9% vs. 37.8%). Upgrading was almost exclusively (89.5%) seen in patients with biopsy GS ≤ 6 and was lower in group 2 (25.4% vs. 48.1%) because of classification of more intermediate- and high-grade tumors using the 2005 ISUP modification. Taking > 6 biopsy cylinders was associated with better GS and tumor grade agreement.

CONCLUSION

Extended biopsy template and the 2005 ISUP modification resulted in an improved agreement between biopsy GS and RP GS and a shift toward more aggressive tumors.

Predictors of Gleason score upgrading in a large African-American population

PURPOSE

Gleason score from biopsy specimens is important for prostate cancer (PCa) risk stratification and influences treatment decisions. Gleason score upgrading (GSU) between biopsy and surgical pathology specimens has been reported as high as 50 % and presents a challenge in counseling low-risk patients. While recent studies have investigated predictors of GSU, populations in these studies have been largely Caucasian. We report our analysis of predictors of GSU in a large urban African-American population.

METHODS

A total of 959 patients with D'Amico low-risk prostate cancer underwent radical prostatectomy at Georgetown University or Washington Hospital Center between January 2005 and July 2012. Race, age, PSA, body mass index (BMI), cancer of the prostate risk assessment (CAPRA) score, and transrectal ultrasound (TRUS) biopsy characteristics (percent of biopsy cores showing adenocarcinoma, highest percent of biopsy core involved with cancer, and measured TRUS prostate volume) were analyzed with both univariate and multivariate analyses to identify significant predictors of GSU while controlling for clinical parameters.

RESULTS

Of the 959 cases, 288 (30.0 %) were upgraded on final pathologic specimen with approximately 38 % (133/355) of African-American patients experiencing GSU. BMI (P = 0.02), percent positive biopsy cores (P < 0.01) and percent of core involved with cancer (P < 0.01), increasing CAPRA score, and serum PSA were independent predictors of GSU on both uni- and multivariate regression analyses. African Americans had a 73 % increase in the incidence of GSU over other races.

CONCLUSION

More than a quarter of low-risk prostate cancer patients were upgraded on final pathology in our series. Higher BMI, serum PSA, CAPRA score, percent of cores positive, and percent of cores involved were independent predictors of GSU. Individuals with those clinical parameters may harbor occult high-grade disease and should be carefully counseled on treatment decisions.