Predictive Factors and Oncologic Outcome of Downgrade to Pathologic Gleason Score 6⁻7 after Radical Prostatectomy in Patients with Biopsy Gleason Score 8⁻10

Machine learning discrimination of Gleason scores below GG3 and above GG4 for HSPC patients diagnosis

This study aims to develop machine learning (ML)-assisted models for analyzing datasets related to Gleason scores in prostate cancer, conducting statistical analyses on the datasets, and identifying meaningful features. We retrospectively collected data from 717 hormone-sensitive prostate cancer (HSPC) patients at Yunnan Cancer Hospital. Of these, data from 526 patients were used for modeling. Seven auxiliary models were established using Logistic Regression (LR), Support Vector Machine (SVM), Random Forest (RF), Decision Tree (DT), Extreme gradient boosting tree (XGBoost), Adaptive Boosting (Adaboost), and artificial neural network (ANN) based on 21 clinical biochemical indicators and features. Evaluation metrics included accuracy (ACC), precision (PRE), specificity (SPE), sensitivity (SEN) or regression rate(Recall), and f1 score. Evaluation metrics for the models primarily included ACC, PRE, SPE, SEN or Recall, f1 score, and area under the curve(AUC). Evaluation metrics were visualized using confusion matrices and ROC curves. Among the ensemble learning methods, RF, XGBoost, and Adaboost performed the best. RF achieved a training dataset score of 0.769 (95% CI: 0.759-0.835) and a testing dataset score of 0.755 (95% CI: 0.660-0.760) (AUC: 0.786, 95%CI: 0.722-0.803), while XGBoost achieved a training dataset score of 0.755 (95% CI: 95%CI: 0.711-0.809) and a testing dataset score of 0.745 (95% CI: 0.660-0.764) (AUC: 0.777, 95% CI: 0.726-0.798). Adaboost scored 0.789 on the training dataset (95% CI: 0.782-0.857) and 0.774 on the testing dataset (95% CI: 0.651-0.774) (AUC: 0.799, 95% CI: 0.703-0.802). In terms of feature importance (FI) in ensemble learning, Bone metastases at first visit, prostatic volume, age, and T1-T2 have significant proportions in RF's FI. fPSA, TPSA, and tumor burden have significant proportions in Adaboost's FI, while f/TPSA, LDH, and testosterone have the highest proportions in XGBoost. Our findings indicate that ensemble learning methods demonstrate good performance in classifying HSPC patient data, with TNM staging and fPSA being important classification indicators. These discoveries provide valuable references for distinguishing different Gleason scores, facilitating more accurate patient assessments and personalized treatment plans.

Prostate cancer grade downgrading at time of prostatectomy provides risk-stratification insight into future tumor behavior after prostatectomy

BACKGROUND

Prostate biopsy (Bx) sampling-based diagnosis of prostate cancer (PCa) has well-described inaccuracy when compared against whole gland analysis upon prostatectomy. Although upgrading of PCa Grade Group (GG) is often described, the occurrence and prognostic implications of downgrading PCa GG at the time of radical prostatectomy (RP) is less understood. Our objective was to evaluate whether downgrading PCa GG at the time of RP was associated with future tumor behavior.

METHODS

The SEER database was searched from 2010 to 2017 and patients were included if they were assigned pathological grades on both Bx and RP specimen. Patients were stratified into Bx GG > RP GG and Bx GG ≤ RP GG groups, and tumor behavior after treatment was examined. Cox regression was used for the survival analysis.

RESULTS

Here, 99,835 patients were included in this study. A total of 18,516 (18.5%) patients encountered downgrading from Bx GG to RP GG. A downgrading of 1 grade occurred in 13,969 (75.4%) of these patients and of 2 or more grades occurred in 4547 (24.6%) patients. A history of higher Bx GG compared with RP GG increased the risk of cancer-specific mortality (CSM) for each given RP GG controlling for age, race, preop prostate-specific antigen level, percentage of positive biopsy cores, and pathologic TNM stages. Specifically, a history of high Bx GG conferred a 45% increased risk of CSM for any given RP GG (hazard ratio = 1.45 95% confidence interval = 1.16-1.82, p < 0.001).

CONCLUSION

A history of higher Bx GG, and hence downgrading at the time of RP, demonstrates some value as a risk-stratification tool for future cancer outcomes after prostatectomy.

The impact of surgical downgrading on prostate cancer recurrence: systematic review and analysis of a multiethnic population

OBJECTIVE

To perform a systematic review and a retrospective cohort analysis evaluating the rates of surgical downgrading of prostate cancer (PCa) from biopsy (PBx) to radical prostatectomy (RP), and their association with biochemical recurrence (BCR) in a multiethnic population.

METHODS

A systematic review of PubMed and other databases was performed. We included retrospective studies evaluating the relationship between surgical downgrading and BCR-free survival. Data regarding Gleason score (GL) downgrading were abstracted from the articles and categorized as follows: GL8-10 to GL7, GL7 to GL6, and GL 7(4 + 3) to GL7(3 + 4). We also performed a retrospective cohort review of patients who underwent RP at our institution from 2005 through 2020. Kaplan-Meier survival analysis and Cox proportional hazards models were used to compare BCR among downgraded versus non-downgraded men.

RESULTS

Systematic review yielded 137 abstracts; of these, 36 full-texts were reviewed, 8 of which were included in our systematic review. Despite substantial variability, all showed that GL at RP is one of the most important factors of BCR-free survival. A total of 1,484 men with PCa were analyzed from our institution. On multivariate analysis, GL7 to GL6 downgrading (HR = 0.50, p = 0.022) and GL8-10 to GL7 downgrading (HR = 0.42, p = 0.011) were associated with reduced risk of BCR when compared to men with GL7 and GL8-10 concordance, respectively. However, GL7(4 + 3) to GL7(3 + 4) downgrading was not significantly associated with reduced BCR (HR = 0.56, p = 0.12), when compared to GL7(4 + 3) concordance, although HR was similar.

CONCLUSION

Surgical downgrading at RP was associated with a reduced risk of BCR compared to GL concordant disease, and these findings have been validated within our multiethnic population. Pathologic downgrading at the time of RP may be a more useful predictor of subsequent BCR in comparison to that associated with GL concordant pathology.

How does a prebiopsy mri approach for prostate cancer diagnosis affect prostatectomy upgrade rates?

BACKGROUND

To compare the pathologic upgrade and downgrade rates after radical prostatectomy (RP) between patients diagnosed by prebiopsy prostate MRI followed by a combination of systematic and fusion biopsy (ComBx) versus patients undergoing systematic biopsy only (SBx).

METHODS

A retrospective review of men undergoing RP at our institution between Jan 2014 and Mar 2020 was performed. These patients were separated into two independent cohorts based on two approaches: Patients receiving prebiopsy prostate MRI during initial evaluation and those who did not receive MRI. Patients with positive MRI findings underwent subsequent ComBx to confirm diagnosis while those without MRI underwent standard trans-rectal ultrasound (TRUS) guided systematic 12-core biopsy (SBx). Primary outcomes were rates of pathological upgrade (prostatectomy grade higher than grade determined at time of biopsy) and downgrade (prostatectomy grade lower than biopsy grade).

RESULTS

A total of 213 patients undergoing radical prostatectomy, 91 diagnosed via a prebiopsy MRI and ComBx approach and 122 diagnosed by a traditional SBx approach, were included in the study. There was no significant difference between age, PSA, or positive family history between the two cohorts. Of the 91 patients who received prebiopsy MRI, 88 patients were determined to have a PIRADS 4 or 5 lesion. Patients who received MRI and subsequent ComBx had a lower rate of any pathological upgrade after RP (9.89% vs. 22.13%, P = 0.018) without a significant difference in pathologic downgrade rate (28.57% vs. 18.85%, P = 0.095). On multivariable logistic regression, receiving prebiopsy MRI during initial evaluation was the single negative independent predictor of pathologic upgrade (OR = 0.23, P = 0.017). A prebiopsy MRI approach was also the single predictor of pathologic downgrade (OR = 3.13, P = 0.041).

CONCLUSIONS

Patients receiving prebiopsy MRI during prostate cancer evaluation were less likely to have their PCa upgraded. Furthermore, although diagnosis via MRI and subsequent ComBx was associated with an increased rate of downgrades after RP, relatively few resulted in a downgrade from clinically significant to clinically insignificant cancer.

Urinary proteomic profiles of prostate cancer with different risk of progression and correlation with histopathological features

Prostate cancer (PCa) is the most common tumor in men with extremely variable outcome, varying from latent or indolent form to very aggressive behavior. High grade tumors, expansions exceeding the prostatic capsule into the surrounding soft tissues and spreading through lymph vascular channels, represent the most consistent unfavorable prognostic factors. However, accuracy in the prediction of the disease progression is sometimes difficult. Along with new molecular diagnostic techniques and more accurate histopathological approaches, proteomic studies challenge to identify potential biomarkers predictive of PCa progression. In our study we analyzed the urinary proteomes of 42 patients affected by PCa through two-dimensional electrophoresis associated with mass spectrometry. Proteomic profiles were correlated to histopathological features including pTNM stage and tumor differentiation in order to provide new promising markers able to define more accurately the PCa aggressiveness and driving new therapeutic approaches.

Association between low prostate-specific antigen levels and greater disease progression in high-grade locally-advanced prostate cancer

PURPOSE

In advanced or high-grade prostate cancer (PCa), prostate-specific antigen (PSA) is usually elevated, however, some patients may present with low initial PSA (iPSA) levels. The objective of this study was to evaluate whether different iPSA levels were associated with dissimilar clinical outcomes among men with high-grade PCa and advanced disease after robot-assisted laparoscopic radical prostatectomy (RaLRP).

METHODS

This study enrolled 69 PCa patients with initial Gleason score ≥8 and pathologic T-stage ≥3a from April 2012 to December 2018. Patients were stratified into 3 groups based on iPSA levels at diagnosis: <5.0, 5.0-9.9, and ≥10.0. The patients' related parameters were compared among these groups.

RESULTS

The median follow-up period was 33.1 months (IQR: 12.1-48.1). There was no difference in biochemical recurrence (BCR) between the 3 groups (Log-rank test, p = 0.484). We found a higher risk of biochemical recurrence in patients with positive surgical margins (HR: 5.04, 95% CI: 1.64-15.50, p = 0.005). In addition, patients with low iPSA levels (<5.0 ng/mL) had poor radiographic progression-free survival (Log-rank test, p = 0.001) and a higher risk of disease progression (HR: 12.2, 95% CI: 1.18-1260.99, p = 0.036) compared with patients with higher iPSA levels (≥10 ng/mL).

CONCLUSION

In patients with high-grade locally-advanced PCa, a low iPSA level was associated with a higher risk of disease progression, but not with biochemical recurrence. In this unique population, serum PSA may not be a reliable marker to detect disease progression. Monitoring of these patients may warrant other biomarkers or imaging.