Upgrading of Gleason score and prostate volume: a clinicopathological analysis

Risk factors for Gleason score upgrade from prostate biopsy to radical prostatectomy

Accurate identification of prostate cancer Gleason grade group remains an important component of the initial management of clinically localized disease. However, Gleason score upgrading (GSU) from biopsy to radical prostatectomy can occur in up to a third of patients treated with surgery. Concern for disease undergrading remains a source of diagnostic uncertainty, contributing to both over-treatment of low-risk disease as well as under-treatment of higher-risk prostate cancer. This review examines the published literature concerning risk factors for GSU from time of biopsy to prostatectomy final pathology. Risk factors identified for Gleason upgrading include patient demographic and clinical factors including age, body mass index, race, prostate volume, and biomarker based assays, including prostate-specific antigen (PSA) density, and testosterone values. In addition, prostate magnetic resonance imaging (MRI) findings have also been associated with GSU. Biopsy-specific characteristics associated with GSU include lower number of biopsy cores and lack of targeted methodology, and possibly increasing percent biopsy core positivity. Recognition of risk factors for disease undergrading may prompt confirmatory testing including repeat sampling or imaging. Continued refinements in imaging guided biopsy techniques may also reduce sampling error contributing to undergrading.

The factors impacting on Gleason score upgrading in prostate cancer with initial low Gleason scores

BACKGROUND

This study aims to investigate the factors contributing to the discrepancy in between biopsy Gleason score (GS) and radical prostatectomy GS in patients diagnosed with prostate cancer.

METHODS

341 patients who underwent radical prostatectomy from 2011/04 to 2020/12 were identified. 102 Patients with initial GS of six after biopsy were enrolled. Preoperative clinical variables and pathological variables were also obtained and assessed. The optimal cut-off points for significant continuous variables were identified by the area under the receiver operating characteristic curve.

RESULTS

Upgrading was observed in 63 patients and non-upgrading in 39 patients. In the multiple variables assessed, smaller prostate volume (PV) (p value = 0.0007), prostate specific antigen density (PSAD) (p value = 0.0055), positive surgical margins (p value = 0.0062) and pathological perineural invasion (p value = 0.0038) were significant predictors of GS upgrading. To further explore preclinical variables, a cut-off value for PV (≤ 38 ml, p value = 0.0017) and PSAD (≥ 0.26 ng/ml2, p value = 0.0013) were identified to be associated with GS upgrading.

CONCLUSIONS

Smaller PV and elevated PSAD are associated with increased risk of GS upgrading, whereas lead-time bias is not. A cut-off value of PV < 38 ml and PSAD > 0.26 ng/ml2 were further identified to be associated with pathological GS upgrading.

A contemporary analysis of disease upstaging of Gleason 3 + 3 prostate cancer patients after robot-assisted laparoscopic prostatectomy

BACKGROUND

Risk of biochemical recurrence (BCR) in localised prostate cancer can be stratified using the 5-tier Cambridge Prognostic Group (CPG) or 3-tier European Association of Urology (EAU) model. Active surveillance is the current recommendation if CPG1 or EAU low-risk criteria are met. We aimed to determine the contemporary rates of upgrading, upstaging and BCR after radical prostatectomy for CPG1 or EAU low-risk disease.

METHODS

A database of all robotic-assisted laparoscopic prostatectomies (RALPs) performed in Glasgow between 12/2015 and 05/2022 was analysed. Rates of upgrading, upstaging and BCR post-RALP for CPG1 or EAU low-risk disease were defined. Univariate and multivariate analysis were performed to assess the relationship between patient factors and outcomes.

RESULTS

A total of 1223 RALP cases were identified. A total of 12.6% met CPG1 criteria with 70.1% and 25.3% upgraded and upstaged to extraprostatic disease post-operatively respectively. A total of 5.8% met EAU low-risk criteria with 60.6% upgraded and 25.4% upstaged to extraprostatic disease post-operatively respectively. CPG1 (p < 0.0001) and EAU low-risk (p = 0.02) patients were at a significantly higher risk of BCR if upstaged.

DISCUSSION

Many patients who met CPG1 or EAU low-risk criteria were upgraded post-RALP and approximately 25% were upstaged due to extraprostatic disease. Upstaging puts patients at a significantly higher risk of BCR.

Role of inflammatory factors in prediction of Gleason score and its upgrading in localized prostate cancer patients after radical prostatectomy

Purpose

To investigate the role of inflammatory factors including systemic immune-inflammation index (SII) and neutrophil to lymphocyte ratio (NLR) in predicting Gleason Score (GS) and Gleason Score upgrading (GSU) in localized prostate cancer (PCa) after radical prostatectomy (RP).

Methods

The data of 297 patients who underwent prostate biopsy and RP in our center from January 2014 to March 2020 were retrospectively analyzed. Preoperative clinical characteristics including age, values of tPSA, total prostate volume (TPV), f/t PSA ratio, body mass index (BMI), biopsy GS and inflammatory factors including SII, NLR, lymphocyte to monocyte (LMR), neutrophil ratio (NR), platelet to lymphocyte ratio (PLR), lymphocyte ratio (LR), mean platelet volume (MPV) and red cell distribution (RDW) as well as pathological T (pT) stage were collected and compared according to the grades of RP GS (GS ≤ 6 and GS≥7), respectively. ROC curve analysis was used to confirm the discriminative ability of inflammatory factors including SII, NLR and their combination with tPSA for predicting GS and GSU. By using univariate and multivariate logistic regression analysis, the association between significant inflammatory markers and grades of GS were evaluated.

Results

Patients enrolled were divided into low (GS ≤ 6) and high (GS≥7) groups by the grades of GS. The median values of clinical factors were 66.08 ± 6.04 years for age, 36.62 ± 23.15 mL for TPV, 26.16 ± 33.59 ng/mL for tPSA and 0.15 ± 0.25 for f/t PSA ratio, 22.34 ± 3.14 kg/m² for BMI, 15 (5.1%) were pT1, 116 (39.1%) were pT2 and 166 (55.9%) were pT3. According to the student's t test, patients in high GS group had a greater proportion of patients with pT3 (P<0.001), and higher NLR (P=0.04), SII (P=0.037) and tPSA (P=0.015) compared with low GS group, the distribution of age, TPV, f/t PSA ratio, BMI, LMR, NR, PLR, LR, MPV and RDW did not show any significantly statistical differences. The AUC for SII, NLR and tPSA was 0.732 (P=0.007), 0.649 (P=0.045) and 0.711 (P=0.015), with threshold values of 51l.08, 2.3 and 10.31ng/mL, respectively. According to the multivariable logistic regression models, NLR ≥ 2.3 (OR, 2.463; 95% CI, 0.679-10.469, P=0.042), SII ≥ 511.08 (OR, 3.519; 95% CI 0.891-12.488; P=0.003) and tPSA ≥ 10.31 ng/mL (OR, 4.146; 95% CI, 1.12-15.35; P=0.033) were all independent risk factors associated with higher GS. The AUC for combination of SII, NLR with tPSA was 0.758 (P=0.003) and 0.756 (P=0.003), respectively. GSU was observed in a total of 48 patients with GS ≤ 6 (55.17%). Then patients were divided into 2 groups (high and low) according to the threshold value of SII, NLR, tPSA, SII+tPSA and NLR+tPSA, respectively, when the GSU rates were compared with regard to these factors, GSU rate in high level group was significantly higher than that in low level group, P=0.001, 0.044, 0.017, <0.001 and <0.001, respectively.

Conclusion

High SII, NLR and tPSA were associated with higher GS and higher GSU rate. SII was likely to be a more favorable biomarker for it had the largest AUC area compared with tPSA and NLR; the combination of SII or NLR with tPSA had greater values for predicting GS and GSU compared with NLR, SII or tPSA alone, since the AUC area of combination was much higher. SII, NLR were all useful inflammatory biomarkers for predicting GS and detecting GSU among localized PCa patients with biopsy GS ≤ 6.

Percentage Gleason pattern 4 and PI-RADS score predict upgrading in biopsy Grade Group 2 prostate cancer patients without cribriform pattern

PURPOSE

To identify parameters to predict upgrading in biopsy Grade Group (GG) 2 prostate cancer patients without cribriform and intraductal carcinoma (CR/IDC) on biopsy.

METHODS

Preoperative biopsies from 657 men undergoing radical prostatectomy (RP) for prostate cancer were reviewed for GG, presence of CR/IDC, percentage Gleason pattern 4, and tumor length. In men with biopsy GG2 without CR/IDC (n = 196), clinicopathologic features were compared between those with GG1 or GG2 without CR/IDC on RP (GG ≤ 2-) and those with GG2 with CR/IDC or any GG > 2 (GG ≥ 2+). Logistic regression analysis was used to predict upgrading in the biopsy cohort.

RESULTS

In total 283 men had biopsy GG2 of whom 87 (30.7%) had CR/IDC and 196 (69.3%) did not. CR/IDC status in matched biopsy and RP specimens was concordant in 179 (63.3%) and discordant in 79 (27.9%) cases (sensitivity 45.1%; specificity 92.6%). Of 196 biopsy GG2 men without CR/IDC, 106 (54.1%) had GG ≥ 2+ on RP. Multivariable logistic regression analysis showed that age [odds ratio (OR): 1.85, 95% confidence interval (CI)1.09-3.20; p = 0.025], percentage Gleason pattern 4 (OR 1.54, 95% CI 1.17-2.07; p = 0.003), PI-RADS 5 lesion (OR 2.17, 95% CI 1.03-4.70; p = 0.045) and clinical stage T3 (OR 3.60; 95% CI 1.08-14.50; p = 0.049) were independent parameters to predict upgrading to GG ≥  2+ on RP in these men.

CONCLUSIONS

Age, clinical stage T3, percentage Gleason pattern 4 and presence of PI-RADS 5 lesions are independent predictors for upgrading in men with biopsy GG2 without CR/IDC. These findings allow for improved clinical decision-making on surveillance eligibility in intermediate-risk prostate cancer patients.

Old men with prostate cancer have higher risk of Gleason score upgrading and pathological upstaging after initial diagnosis: a systematic review and meta-analysis

BACKGROUND

To evaluate the predictive performance of age for the risk of Gleason score change and pathologic upstaging.

EVIDENCE ACQUISITION

Ovid MEDLINE, Ovid Embase, and the Cochrane Library were searched from inception until May 2020. Quality of included studies was appraised utilizing the Newcastle-Ottawa Quality Assessment Scale for case-control studies. The publication bias was evaluated by funnel plots and Egger's tests.

EVIDENCE SYNTHESIS

Our search yielded 27 studies with moderate-to-high quality including 84296 patients with mean age of 62.1 years. From biopsy to prostatectomy, upgrading and upstaging occurred in 32.3% and 9.8% of patients, respectively. Upgrading from diagnostic biopsy to confirmatory biopsy was found in 16.8%. Older age was associated with a significant increased risk of upgrading (OR 1.04, 95% CI 1.03-1.05), and similar direction of effect was found in studies focused on upgrading from diagnostic biopsy to confirmatory biopsy (OR 1.06, 95% CI 1.04-1.08). For pathologic upstaging within older men compared with younger, the pooled odds was 1.03 (95% CI 1.01-1.04).

CONCLUSION

Thorough consideration of age in the context of effect sizes for other factors not only prompts more accurate risk stratification but also helps providers to select optimal therapies for patients with prostate cancer.

How accurately can multiparametric magnetic resonance imaging measure the tumour volume of a prostate cancer? Results of a systematic review

The tumour volume of a cancer within the prostate gland is commonly measured with multiparametric MRI. The measurement has a role in many clinical scenarios including focal therapy, but the accuracy of it has never been systematically reviewed. We included articles if they compared tumour volume measurements obtained by mpMRI with a reference volume measurement obtained after radical prostatectomy. Correlation and concordance statistics were summarised. A simple accuracy score was derived by dividing the given mean or median mpMRI volume by the histopathological reference volume. Factors affecting the accuracy were noted. Scores for potential bias and quality were calculated for each article. A total of 18 articles describing 1438 patients were identified. Nine articles gave Pearson's correlation scores, with a median value of 0.75 but the range was wide (0.42-0.97). A total of 11 articles reported mean values for volume while 9 reported median values. For all 18 articles, the mean or median values for MRI volumes were lower than the corresponding reference values suggesting consistent underestimation. For articles reporting mean and median values for volume, the median accuracy scores were 0.83 and 0.80, respectively. The accuracy was higher for tumours of greater volume, higher grade and when an endorectal coil was used. Accuracy did not seem to improve over time, with a 3 Tesla magnet or by applying a shrinkage factor to the reference measurement. Most studies showed evidence of at least moderate bias, and their quality was highly variable, but neither of these appeared to affect accuracy.

Concordance of cribriform architecture in matched prostate cancer biopsy and radical prostatectomy specimens

Aims

Invasive cribriform and/or intraductal carcinoma have been identified as independent adverse parameters for prostate cancer outcome. Little is known on biopsy undersampling of cribriform architecture. Our aim was to determine the extent of cribriform architecture undersampling and to find predictive factors for identifying false cribriform‐negative cases.

Methods and results

We reviewed 186 matched prostate biopsies and radical prostatectomy specimens. Of 97 biopsy grade group 2 (Gleason score 3 + 4 = 7) patients, 22 (23%) had true cribriform‐negative (TN), 39 (40%) false‐negative (FN) and 36 (37%) true‐positive (TP) biopsies. Patients with FN biopsies had higher, although not statistically significant (P = 0.06), median PSA levels than patients with TP biopsies (12 versus 8 ng/ml). A PI‐RADS 5 lesion was present in nine of 16 (54%) FN and three of 11 (27%) TN biopsies (P = 0.05). Positive biopsy rate (P = 0.47), percentage Gleason pattern 4 (P = 0.55) and glomeruloid architecture (P = 1.0) were not different. Logistic regression identified PSA as an independent predictor (odds ratio = 3.5; 95% confidence interval = 1.2–9.4, P = 0.02) for cribriform architecture on radical prostatectomy, but not PI‐RADS score. The FN rate for large cribriform architecture at radical prostatectomy was 27%, which was lower than for any cribriform architecture (P = 0.01). During follow‐up (median 27 months), biochemical recurrence‐free survival of patients with TP biopsies was significantly shorter than that of those with FN biopsies (P = 0.03).

Conclusion

In conclusion, 40% of grade group 2 prostate cancer biopsies were FN for cribriform architecture. These patients had higher PSA levels and more frequent PI‐RADS score 5 lesions than men with TN biopsies.

Cumulative Cancer Locations is a Novel Metric for Predicting Active Surveillance Outcomes: A Multicenter Study

BACKGROUND

Active surveillance (AS) of prostate cancer (PC) has increased in popularity to address overtreatment.

OBJECTIVE

To determine whether a novel metric, cumulative cancer locations (CCLO), can predict AS outcomes in a group of AS patients with low and very low risk.

DESIGN, SETTING, AND PARTICIPANTS

CCLO is obtained by summing the total number of histological cancer-positive locations in both diagnostic and confirmatory biopsies (Bx). The retrospective study cohort comprised three prospective AS cohorts (Helsinki University Hospital: n=316; European Institute of Oncology: n=204; and University of Münster: n=89).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We analyzed whether risk stratification based on CCLO predicts different AS outcomes: protocol-based discontinuation (PBD), Gleason upgrading (GU) during AS, and adverse findings in radical prostatectomy (RP) specimens.

RESULTS

In Kaplan Meier analyses, patients in the CCLO high-risk group experienced significantly shorter event-free survival for all outcomes (PBD, GU, and adverse RP findings; all p<0.002). In multivariable Cox regression analysis, patients in the CCLO high-risk group had a significantly higher risk of experiencing PBD (hazard ratio [HR] 12.15, 95% confidence interval [CI] 6.18-23.9; p<0.001), GU (HR 6.01, 95% CI 2.16-16.8; p=0.002), and adverse RP findings (HR 9.144, 95% CI 2.27-36.9; p=0.006). In receiver operating characteristic analyses, the area under the curve for CCLO outperformed the number of cancer-positive Bxs in confirmatory Bx in predicting PBD (0.734 vs 0.682), GU (0.655 vs 0.576) and adverse RP findings (0.662 vs 0.561) and the added value was supported by decision curve analysis.

CONCLUSIONS

CCLO is distinct from the number of positive Bx cores. Higher CCLO predicts AS outcomes and may aid in selection of patients for AS.

PATIENT SUMMARY

For patients on active surveillance for prostate cancer, the cumulative number of cancer-positive locations in diagnostic and confirmatory biopsies is a predictor of active surveillance outcomes.

Prostate Cancers Detected by Magnetic Resonance Imaging–Targeted Biopsies Have a Higher Percentage of Gleason Pattern 4 Component and Are Less Likely to Be Upgraded in Radical Prostatectomies

Context.—

In Gleason score (GS) 7 prostate cancers, the quantity of Gleason pattern 4 (GP 4) is an important prognostic factor and influences treatment decisions. Magnetic resonance imaging (MRI)–targeted biopsy has been increasingly used in clinical practice.

Objective.—

To investigate whether MRI-targeted biopsy may detect GS 7 prostate cancer with greater GP 4 quantity, and whether it improves biopsy/radical prostatectomy GS concordance.

Design.—

A total of 243 patients with paired standard and MRI-targeted biopsies with cancer in either standard or targeted or both were studied, 65 of whom had subsequent radical prostatectomy. The biopsy findings, including GS and tumor volume, were correlated with the radical prostatectomy findings.

Results.—

More prostate cancers detected by MRI-targeted biopsy were GS 7 or higher. Mean GP 4 percentage in GS 7 cancers was 31.0% ± 29.3% by MRI-targeted biopsy versus 25.1% ± 29.5% by standard biopsy. A total of 122 of 218 (56.0%) and 96 of 217 (44.2%) prostate cancers diagnosed on targeted biopsy and standard biopsy, respectively, had a GP 4 of 10% or greater (P = .01). Gleason upgrading was seen in 12 of 59 cases (20.3%) from MRI-targeted biopsy and in 24 of 57 cases (42.1%) from standard biopsy (P = .01). Gleason upgrading correlated with the biopsy cancer volume inversely and GP 4 of 30% or less in standard biopsy. Such correlation was not found in MRI-targeted biopsy.

Conclusions.—

Magnetic resonance imaging–targeted biopsy may detect more aggressive prostate cancers and reduce the risk of Gleason upgrading in radical prostatectomy. This study supports a potential role for MRI-targeted biopsy in the workup of prostate cancer and inclusion of percentage of GP 4 in prostate biopsy reports.

Concordance of Gleason grading with three-dimensional ultrasound systematic biopsy and biopsy core pre-embedding

PURPOSE

To determine the value of a three-dimensional (3D) greyscale transrectal ultrasound (TRUS)-guided prostate biopsy system and biopsy core pre-embedding method on concordance between Gleason scores of needle biopsies and radical prostatectomy (RP) specimens.

METHODS

Retrospective analysis of prostate biopsies and subsequent RP for PCa in the Jeroen Bosch Hospital, the Netherlands, from 2007 to 2016. Two cohorts were analysed: conventional 2D TRUS-guided biopsies and RP (2007-2013, n = 266) versus 3D TRUS-guided biopsies with pre-embedding (2013-2016, n = 129). The impact of 3D TRUS-guidance with pre-embedding on Gleason score (GS) concordance between biopsy and RP was evaluated using the κ-coefficient. Predictors of biopsy GS 6 upgrading were assessed using logistic regression models.

RESULTS

Gleason concordance was comparable between the two cohorts with a κ = 0.44 for the 3D cohort, compared to κ = 0.42 for the 2D cohort. 3D TRUS-guidance with pre-embedding, did not significantly affect the risk of biopsy GS 6 upgrading in univariate and multivariate analysis.

CONCLUSIONS

3D TRUS-guidance with biopsy core pre-embedding did not improve Gleason concordance. Improved detection techniques are needed for recognition of low-grade disease upgrading.

The Modulating Effects of Benign Prostate Enlargement Medications on Upgrading Predictors in Patients with Gleason 6 at Biopsy

BACKGROUND

Upgrading following prostate biopsy is very common in clinical practice. This study investigated whether the use of 5-alpha reductase inhibitors (ARI) and alpha blockers affect known clinical predictors of Gleason score upgrading or not.

MATERIALS AND METHODS

A retrospective study on 998 patients treated with robotic assisted laparoscopic prostatectomy for clinically localized biopsy Gleason score 6 prostate cancer were studied. The logarithm of prostate specific antigen concentration, prostate size and tumor volume were compared on the basis of the medication history of 5-ARIs and alpha blockers in the cohort of biopsy Gleason 6 patients with benign prostatic hyperplasia history, and patients whose prostate sizes fall in the top quartile. We compared known clinical and pathologic characteristics associated with upgrading in regression models with and without the addition of medications.

RESULTS

Alpha blockers, but not 5-ARI were associated with a bigger prostate. Upgrading was associated with older age (OR 1.03, 95% CI 1.01-1.06), higher BMI (OR 1.00 CI 1.01-1.08), higher log prostate specific antigen (OR 7.32, CI 3.546-15.52), smaller prostate size (OR 0.97, CI 0.96-0.98), fewer biopsy cores (OR 0.96 CI 0.92-0.99), more positive cores (OR 1.20, CI 1.08-1.34), and higher percentage of tumor at biopsy (OR 1.02, CI 1.01-1.03). Neither of the two medication classes were a significant predictor of upgrading. Medications made minimal changes in the multivariate predictive models.

CONCLUSION

Although, alpha blockers were associate with bigger prostate size, the modulating effects of alpha blockers and 5-ARIs on common predictors of Gleason score upgrading was not significant.

Prostate-specific antigen 10-20 ng/mL: A predictor of degree of upgrading to ≥8 among patients with biopsy Gleason score 6

PURPOSE

This study aimed to identify the predictors of upgrading and degree of upgrading among patients who have initial Gleason score (GS) 6 treated with robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

A retrospective review of the data of 359 men with an initial biopsy GS 6, localized prostate cancer who underwent RARP between July 2005 to June 2010 was performed. They were grouped into group 1 (nonupgrade) and group 2 (upgraded) based on their prostatectomy specimen GS. Logistic regression analysis of studied cases identified significant predictors of upgrading and the degree of upgrading after RARP.

RESULTS

The mean age and prostate-specific antigen (PSA) was 63±7.5 years, 8.9±8.77 ng/mL, respectively. Median follow-up was 59 months (interquartile range, 47-70 months). On multivariable analysis, age, PSA, PSA density and ≥2 cores positive were predictors of upgrading with (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06; p=0.003; OR, 1.006; 95% CI, 1.01-1.11; p=0.018; OR, 0.65; 95% CI, 0.43-0.98, p=0.04), respectively. On subanalysis, only PSA level of 10-20 ng/mL is associated with upgrading into GS ≥8. They also had lower biochemical recurrence free survival, cancer specific survival, and overall survival (p≤0.001, p=0.003, and p=0.01, respectively).

CONCLUSIONS

Gleason score 6 patients with PSA (10-20 ng/mL) have an increased risk of upgrading to pathologic GS (≥8), subsequently poorer oncological outcome thus require a stricter follow-up. These patients should be carefully counseled in making an optimal treatment decision.

Extreme Gleason Upgrading From Biopsy to Radical Prostatectomy: A Population-based Analysis

OBJECTIVE

To examine the risk factors associated with the odds of extreme Gleason upgrading at radical prostatectomy (RP) (defined as a Gleason prognostic group score increase of ≥2), we utilized a large, population-based cancer registry.

MATERIALS AND METHODS

The Surveillance, Epidemiologic, and End Results database was queried (2010-2011) for all patients diagnosed with Gleason 3 + 3 or 3 + 4 on prostate needle biopsy. Available clinicopathologic factors and the odds of upgrading and extreme upgrading at RP were evaluated using multivariate logistic regression.

RESULTS

A total of 12,459 patients were identified, with a median age of 61 (interquartile range: 56-65) and a diagnostic prostate-specific antigen (PSA) of 5.5 ng/mL (interquartile range: 4.3-7.5). Upgrading was observed in 34% of men, including 44% of 7402 patients with Gleason 3 + 3 and 19% of 5057 patients with Gleason 3 + 4 disease. Age, clinical stage, diagnostic PSA, and % prostate needle biopsy cores positive were independently associated with odds of any upgrading at RP. In baseline Gleason 3 + 3 disease, extreme upgrading was observed in 6%, with increasing age, diagnostic PSA, and >50% core positivity associated with increased odds. In baseline Gleason 3 + 4 disease, extreme upgrading was observed in 4%, with diagnostic PSA and palpable disease remaining predictive. Positive surgical margins were significantly higher in patients with extreme upgrading at RP (P < .001).

CONCLUSION

Gleason upgrading at RP is common in this large population-based cohort, including extreme upgrading in a clinically significant portion.

Gleason Misclassification Rate Is Independent of Number of Biopsy Cores in Systematic Biopsy

OBJECTIVE

To compare the utility of saturation core biopsy and 12-core biopsy in detecting true Gleason grades, using final pathology in prostatectomy specimens as outcome measures, with a particular interest in Gleason upgrading.

PATIENTS AND METHODS

We compared the concordance rates of Gleason grades diagnosed on biopsies and prostatectomy specimens in 375 consecutive patients, including 106 saturation biopsies (18-33 cores, median = 20 cores) and 269 12-core biopsies. Grading bias was addressed by a central rereview of all cases that had discordance in reporting high Gleason grades (Gleason grade ≥ 4) on biopsies and prostatectomy specimens.

RESULTS

For patients with high Gleason grades on final pathology, saturation and 12-core biopsy schemes had a comparable sensitivity, specificity, negative and positive predictive values (72.5% vs 69.5%, 91.9% vs 97.6%, 64.2% vs 58.4%, and 94.3% vs 98.5%, respectively) in detecting high Gleason grades. On multivariate analysis, prebiopsy serum prostate-specific antigen and clinical T stage independently predicted Gleason upgrading; saturation biopsy was not a significant predictor. Approximately one-third of cases where high Gleason grade was not present in the biopsy were attributed to the confinement of high-grade tumors to unusual anatomic locations such as anterior lobes, apex, bladder neck, and parasagittal zones.

CONCLUSION

Our study showed that Gleason misclassification rate is independent of the number of biopsy cores in systematic biopsy. One of the reasons for missing high Gleason grade tumors on systematic biopsy was unusual tumor location outside of the biopsy grid, supporting the need for improved detection technique such as magnetic resonance imaging-guided targeted biopsies.

Developing a Correct System to Evaluate the Accuracy of Gleason Score in Prostate Cancer of Chinese Population

INTRODUCTION

A study was conducted to develop a new correct system to improve the overall rate of Gleason sum concordance between biopsy and final pathology.

MATERIALS AND METHODS

A total of 592 consecutive patients who had undergone transrectal ultrasound-guided prostate biopsy and radical prostatectomy were evaluated during the first stage. Age, PSA, PSA density (PSAD), biopsy cores, positive cores, prostate volume, positive core rate (PCR), core volume rate (CVR) and digital rectal examination findings were considered predictive factors. A multiple logistic regression analysis involving a backward elimination selection procedure and linear regression analysis involving a stepwise procedure were applied to select independent predictors.

RESULTS

Positive cores, PCR, CVR and PSAD were included in our assessing credibility model in the first stage. A significantly higher area under the receiver-operating curve was obtained in our model compared with CVR alone (0.641 vs. 0.517). In the second stage, patients with credibility of pre-operative Gleason score <0.388 were subjected to further evaluation. Compared with the 2 statuses, the rate of overall concordance was significantly increased (60.3 vs. 50.2%, p = 0.002).

CONCLUSIONS

We developed a follow-up strategy based on the new and correct system, which represents an important consideration procedure when clinicians make decisions with regard to treatment plans.

Analysis of topographical distribution of prostate cancer and related pathological findings in prostatectomy specimens using cMDX document architecture

INTRODUCTION

Understanding the topographical distribution of prostate cancer (PCa) foci is necessary to optimize the biopsy strategy. This study was done to develop a technical approach that facilitates the analysis of the topographical distribution of PCa foci and related pathological findings (i.e., Gleason score and foci dimensions) in prostatectomy specimens.

MATERIAL & METHODS

The topographical distribution of PCa foci and related pathologic evaluations were documented using the cMDX documentation system. The project was performed in three steps. First, we analyzed the document architecture of cMDX, including textual and graphical information. Second, we developed a data model supporting the topographic analysis of PCa foci and related pathologic parameters. Finally, we retrospectively evaluated the analysis model in 168 consecutive prostatectomy specimens of men diagnosed with PCa who underwent total prostate removal. The distribution of PCa foci were analyzed and visualized in a heat map. The color depth of the heat map was reduced to 6 colors representing the PCa foci frequencies, using an image posterization effect. We randomly defined 9 regions in which the frequency of PCa foci and related pathologic findings were estimated.

RESULTS

Evaluation of the spatial distribution of tumor foci according to Gleason score was enabled by using a filter function for the score, as defined by the user. PCa foci with Gleason score (Gls) 6 were identified in 67.3% of the patients, of which 55 (48.2%) also had PCa foci with Gls between 7 and 10. Of 1173 PCa foci, 557 had Gls 6, whereas 616 PCa foci had Gls>6. PCa foci with Gls 6 were mostly concentrated in the posterior part of the peripheral zone of the prostate, whereas PCa foci with Gls>6 extended toward the basal and anterior parts of the prostate. The mean size of PCa foci with Gls 6 was significantly lower than that of PCa with Gls>6 (P<0.0001).

CONCLUSION

The cMDX-based technical approach facilitates analysis of the topographical distribution of PCa foci and related pathologic findings in prostatectomy specimens.

Factors effective on survival after radical prostatectomy: To what extent is pre-operative biopsy Gleason scoring is confident in predicting the prognosis?

In the present study, the effect of different grades on independent survival from the biochemical relapse was investigated through comparison of the histological grades of the biopsy and prostatectomy materials in patients undergoing radical prostatectomy (RP). A total of 152 patients undergoing RP following biopsy were retrospectively investigated in an attempt to reveal the effect of discordance between needle biopsy Gleason score and RP Gleason score on prostate specific antigen relapse-free survival. Accordingly, while 58.3% (14/24) survival was seen in the patients in Group 1 (high-graded) with Gleason score 7, 93.7% (15/16) survival has been seen in the patients in Group 2 (low-graded) and Group 3 (same Gleason scores) with Gleason score 7. The difference in-between has been statically found significant (P < 0.001). Similarly, while a 10% (1/10) survival is seen in the patients in Group 1 with Gleason score 8 and above, 75% (3/4) survival has been observed in the patients in Group 2 and 3 with Gleason score 8 and above. Also in this comparison, the difference in-between has been statically found significant (P = 0.041). Eventually, different grading, particularly determination of Gleason score higher than the RP specimen biopsy also bring about bad pathologic parameters and shortened survival periods.

Prostate biopsy concordance in a large population-based sample: a Surveillance, Epidemiology and End Results study

AIMS

To use the Surveillance, Epidemiology and End Results database in order to evaluate prostate biopsy concordance in a large population-based sample.

METHODS

We identified 34 195 men who were diagnosed with prostate cancer and underwent a radical prostatectomy from 2010 to 2011. All patients also had to have both clinical and pathological Gleason scores available for analysis. The concordance of the biopsy Gleason score to the pathological Gleason score was analysed using the coefficient of agreement (κ). Univariate and multivariate logistic regression analyses were performed to determine potential factors that may impact concordance of Gleason score.

RESULTS

Overall, the clinical and pathological Gleason scores matched in 55.4% of patients. The concordance rates were 55.3% for Gleason 6, 66.9% for Gleason 3+4, 42.9% for Gleason 4+3 and 24.8% for Gleason 8, with frequent downgrading to Gleason 7. The κ for Gleason score concordance was 0.36 (95% CI 0.35 to 0.37), indicating fair agreement. The weighted κ for Gleason score concordance was 0.51 (95% CI 0.50 to 0.52), indicating moderate agreement. Additionally, the Bowker tests of symmetry were highly significant (p<0.001), indicating that when discordant findings were present, pathological upgrading was more common than downgrading.

CONCLUSIONS

This study is, to our knowledge, the largest contemporary study of prostate biopsy concordance. We found that there continues to be significant Gleason migration both upward from biopsy Gleason 6 or 3+4 and downgrading from biopsy Gleason ≥8. Further studies are needed to better determine other potential genomic or biologic factors that may help increase the biopsy Gleason concordance.

Shear wave elastography for localization of prostate cancer lesions and assessment of elasticity thresholds: implications for targeted biopsies and active surveillance protocols

PURPOSE

Shear wave elastography allows the detection of cancer by using focused ultrasound pulses for locally deforming tissue. The differences in tissue elasticity and stiffness have been used increasingly in breast cancer imaging and help detect potential tumor lesions in the prostate. In this study we localized prostate cancer lesions using shear wave elastography before radical prostatectomy and assessed the examiner independent elasticity threshold for cancer foci detection.

MATERIALS AND METHODS

Shear wave elastography scanning of the whole prostate was performed before radical prostatectomy in 60 consecutive patients with high, intermediate and low risk disease. Localization of suspected lesions and density threshold (kPa) were recorded in up to 12 areas and resulted in 703 different fields. Shear wave elastography findings were correlated with final pathology. Initially 381 areas were used to establish shear wave elastography cutoffs (development cohort 32 patients). Subsequently these cutoffs were validated in 322 areas (validation cohort 28 patients).

RESULTS

Using shear wave elastography significant differences were recorded for the elasticity of benign tissue vs prostate cancer nodules at 42 kPa (range 29 to 71.3) vs 88 kPa (range 54 to 132) (all p <0.001). Median cancer lesion diameter was 26 mm (range 18 to 41). Applying the most informative cutoff of 50 kPa to the validation cohort resulted in 80.9% and 69.1% sensitivity and specificity, respectively, and 74.2% accuracy for detecting cancer nodules based on final pathological finding. The corresponding positive and negative predictive values were 67.1% and 82.2%, respectively.

CONCLUSIONS

Shear wave elastography allows the identification of cancer foci based on shear wave elastography differences. Moreover, reliable cutoffs for this approach can be established, allowing examiner independent localization of prostate cancer foci.

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.