Prognosis of Gleason Score 9-10 Prostatic Adenocarcinoma in Needle Biopsies: A Nationwide Population-based Study

Time trends in Gleason score distribution among Gleason score 8 and 9-10 cancers

Reporting of prostate cancer grade has drifted to higher reported grades over the past decades. In prostate cancers diagnosed on needle biopsy of 1 72 112 men reported to The National Prostate Cancer Register of Sweden 2000-2020, we also noted a grade shift among high-grade cancers. We applied multinomial logistic regression to assess time trends. Among International Society of Urological Pathology (ISUP) grade 4 cancers, Gleason score 3+5 increased from 8% in 2000 to 22% in 2020, while Gleason score 4+4 decreased from 88% to 77%. Among ISUP grade 5, Gleason score 4+5 and 5+4 cancers increased from 85% to 93%, while Gleason score 5+5 decreased from 15% to 7%. This may be explained by a reluctance to assign Gleason scores composed of a uniform grade following recommendations to include minimal components of higher grade in the scores. These changes are obscured by merging Gleason scores into ISUP grades.

Patients ask and pathologists answer: ten questions around prostate cancer grading

Pathologists have closely collaborated with clinicians, mainly urologists, to update the Gleason grading system to reflect the current practice and approach in prostate cancer diagnosis, prognosis, and treatment. This has led to the development of what is called patient advocacy and patient information. Ten common questions asked by patients to pathologists concerning PCa grading and the answers given by the latter are reported.

Gleason scores provide more accurate prognostic information than grade groups

Prostate cancer grade is currently often reported both by Gleason scores and by grouping of the scores into five so-called International Society of Urological Pathology (ISUP) grades (also known as grade groups). Using population-based registry data from 172,112 men diagnosed with prostate cancer on needle biopsy, we recently investigated the outcome of Gleason score 8-10 prostate cancer with death due to prostate cancer and death from any cause as endpoints. There was a prognostic heterogeneity between Gleason scores 3+5, 4+4 and 5+3 (ISUP grade 4) and between Gleason scores 4+5, 5+4 and 5+5 (ISUP grade 5). This heterogeneity was lost when the grades collapsed into ISUP grades 4 and 5, respectively. On the other hand, there was also a prognostic overlap between these ISUP grades. The outcome of Gleason score 5+3 and 4+5 cancers was very similar. The prostate-specific mortality of Gleason scores 5+3 and 4+5 was 0.32 (95% confidence interval 0.27-0.36) and 0.30 (0.29-0.31), respectively, after 5 years and 0.44 (0.39-0.49) and 0.45 (0.44-0.46), respectively, after 10 years. The findings emphasise the importance of reporting the Gleason grades and scores for more accurate prognostic information of highly heterogeneous high-grade prostate cancers. It also questions the clinical value of the current recommendations of grouping of Gleason scores into ISUP grades or grade groups.

Rapidly Progressing Prostate Cancer With Low Prostate-Specific Antigen and Gleason Score 5+5: A Case Report

An 87-year-old man presented with worsening urinary dysfunction with urinary retention. The prostate-specific antigen was 1.23 ng/mL. Prostate biopsy confirmed adenocarcinoma with a Gleason score of 5+5; the final diagnosis was T4N1M0. Androgen deprivation therapy and immediate whole-pelvic radiotherapy (80 Gy) were administered. Nadir prostate-specific antigen of 0.40 ng/mL two months later increased to 35.92 ng/mL as the disease metastasized to the corpus cavernosum penis, causing malignant priapism. The best supportive care was provided, and the patient died 11 months later. High-grade prostate cancers with low prostate-specific antigen levels are rare but highly aggressive. Androgen deprivation therapy and radiotherapy alone may be insufficient in such cases, highlighting the need for more effective treatment strategies.

Real-World Treatment Patterns and Survival Outcomes in Metastatic Hormone-Sensitive Prostate Cancer: Insights From a Retrospective Cohort Study

BACKGROUND

Real-world data on treatment patterns and survival outcomes in metastatic hormone-sensitive prostate cancer (mHSPC) remain limited. This study aims to characterize treatment sequencing, duration across lines of therapy, and survival outcomes in patients with mHSPC.

METHODS

This single-center, retrospective, non-interventional study included men newly diagnosed with mHSPC at King Abdullah Medical City Cancer Center between 2016 and 2023. Treatment patterns, including sequencing and duration of therapy, were described. Kaplan-Meier methods were used to estimate overall survival (OS) from mHSPC diagnosis to death or censoring at the end of follow-up.

RESULTS

Among 102 patients, the mean age was 70 years, BMI of 26, with 53% having a performance status of 2. Comorbidities included hypertension (51%), diabetes (45%), and cardiovascular disease (20.6%). Nearly half (48%) had a Gleason score of nine, with 62.7% presenting with bone metastases. Novel hormonal therapy (NHT) was the predominant first-line treatment (86%), with abiraterone used in 43% of cases. Second- and third-line treatments were received by 34% and 13% of patients, respectively. The median durations of first-, second-, and third-line therapies were 21, 5, and 2.6 months, respectively. Median OS from diagnosis was 24 months.

CONCLUSION

Despite the predominant use of novel hormonal therapy (NHT), patients in this cohort exhibited aggressive disease and poor survival outcomes. These findings highlight a critical need for more intensive and tailored treatment strategies for mHSPC.

Optimizing treatment for Gleason 10 prostate cancer: radiation dose escalation and 68Ga-PSMA-PET/CT staging

PURPOSE

This study aimed to investigate the effects of dose escalation through focal boost (FB) to intraprostatic lesions (IPLs) as well as the role of gallium-68 prostate-specific membrane antigen positron-emission tomography (68Ga-PSMA-PET/CT) for staging and treatment planning in patients with Gleason score (GS) 10 prostate cancer (PCa) receiving definitive radiotherapy (RT) and androgen deprivation therapy (ADT).

MATERIALS AND METHODS

We retrospectively analyzed data of 92 patients with GS 10 PCa who underwent definitive RT and ADT from March 2010 to October 2022. Freedom from biochemical failure (FFBF), prostate cancer-specific survival (PCSS), distant metastasis-free survival (DMFS), and overall survival (OS) rates were calculated using the Kaplan-Meier method. Survival outcomes were compared between patients staged with 68Ga-PSMA-PET/CT and those staged with conventional imaging modalities as well as between those who received a simultaneous integrated boost (SIB) and those who did not.

RESULTS

At a median follow-up time of 73 months, the 5‑year FFBF, PCSS, DMFS, and OS rates were 59.2%, 77.0%, 62.9%, and 67.6%, respectively. Disease progression was observed in 39 patients (42.4%), with most cases manifesting as distant metastasis (DM). A total of 56 patients (60.9%) were staged using 68Ga-PSMA-PET/CT, while 43 patients (46.7%) received FB to IPLs. Patients staged with 68Ga-PSMA-PET/CT had better FFBF and PCSS compared to those staged with conventional imaging. Patients undergoing an SIB had improved PCSS and DMFS. In the multivariable analysis, an ADT duration of 18 months or more was associated with improved FFBF, PCSS, DMFS, and OS. Application of an SIB was an additional independent predictor for improved FFBF, while staging with 68Ga-PSMA-PET/CT was associated with better PCSS.

CONCLUSION

We found that long-term ADT, increasing the radiation dose to primary tumor, and staging with 68Ga-PSMA-PET/CT improved clinical outcomes. Additional research is needed for validation.

Clinical characteristics and survival of patients with de novo metastatic prostate cancer treated with androgen deprivation therapy and taxane-based chemotherapy in Uganda: a retrospective study

BACKGROUND

Prostate cancer is the second most common cancer among men worldwide. Mortality is highest among patients in resource-limited settings (RLS), in part due to late-stage disease. Among patients with metastatic prostate cancer (mPCa), studies have shown significant improvement in overall survival with the use of androgen deprivation therapy (ADT) and taxane-based chemotherapy. However, outcome data among patients treated with chemo-endocrine therapy are scarce in many resource-limited settings. The aim of this study was to determine the clinical characteristics and 5-year overall survival (OS) of patients with de novo mPCa treated at the Uganda Cancer Institute (UCI).

METHODS

A retrospective chart review study was conducted between 2015 and 2019, and the data of patients with histologically confirmed prostate cancer and radiological evidence of metastasis were reviewed. Sample size was estimated for Cox Proportion Hazard regression. Data on clinical and laboratory characteristics, overall survival, and predictors of survival were extracted. P < 0.05 was considered to indicate statistical significance.

RESULTS

A total of 300 patients were enrolled over the 5-year study period. The median age was 68 (IQR 61.5-74) years. At presentation, lower urinary tract symptoms were reported in nearly all patients (96.7%, n = 290), median total prostate specific antigen (PSA) was 414.75 ng/ml and 40% (n = 120) of patients had grade 5 histological scores. In addition to receiving ADT, majority of patients (70.3%, n = 211) received at least 6 cycles of chemotherapy. Overall survival at one year was 92.4% (95% CI: 88.6-94.9%), but it declined to 45.2% (95% CI: 36.8-53.2%) at 5 years. A high Gleason score, the presence of visceral metastasis and receiving less than 6 cycles of chemotherapy were predictors of poor outcomes.

CONCLUSION

Patients with de novo mPCa in Uganda present with high histologic grades and high baseline Prostate Specific Antigen (PSA) levels but have improved 5-year overall survival with a combination of chemotherapy and ADT as a first-line treatment. We recommend interventions to reduce late presentation and prospective studies to evaluate treatment efficacy in this population.

Results after Four Years of Screening for Prostate Cancer with PSA and MRI

BACKGROUND

Data on the efficacy and safety of screening for prostate cancer with magnetic resonance imaging (MRI) are needed from studies of follow-up screening.

METHODS

In a population-based trial that started in 2015, we invited men who were 50 to 60 years of age to undergo prostate-specific antigen (PSA) screening. Men with a PSA level of 3 ng per milliliter or higher underwent MRI of the prostate. Men were randomly assigned to the systematic biopsy group, in which they underwent systematic biopsy and, if suspicious lesions were found on MRI, targeted biopsy, or the MRI-targeted biopsy group, in which they underwent MRI-targeted biopsy only. At each visit, men were invited for repeat screening 2, 4, or 8 years later, depending on the PSA level. The primary outcome was detection of clinically insignificant (International Society of Urological Pathology [ISUP] grade 1) prostate cancer; detection of clinically significant (ISUP grade ≥2) cancer was a secondary outcome, and detection of clinically advanced or high-risk (metastatic or ISUP grade 4 or 5) cancer was also assessed.

RESULTS

After a median follow-up of 3.9 years (approximately 26,000 person-years in each group), prostate cancer had been detected in 185 of the 6575 men (2.8%) in the MRI-targeted biopsy group and 298 of the 6578 men (4.5%) in the systematic biopsy group. The relative risk of detecting clinically insignificant cancer in the MRI-targeted biopsy group as compared with the systematic biopsy group was 0.43 (95% confidence interval [CI], 0.32 to 0.57; P<0.001) and was lower at repeat rounds of screening than in the first round (relative risk, 0.25 vs. 0.49); the relative risk of a diagnosis of clinically significant prostate cancer was 0.84 (95% CI, 0.66 to 1.07). The number of advanced or high-risk cancers detected (by screening or as interval cancer) was 15 in the MRI-targeted biopsy group and 23 in the systematic biopsy group (relative risk, 0.65; 95% CI, 0.34 to 1.24). Five severe adverse events occurred (three in the systematic biopsy group and two in the MRI-targeted biopsy group).

CONCLUSIONS

In this trial, omitting biopsy in patients with negative MRI results eliminated more than half of diagnoses of clinically insignificant prostate cancer, and the associated risk of having incurable cancer diagnosed at screening or as interval cancer was very low. (Funded by Karin and Christer Johansson's Foundation and others; GÖTEBORG-2 ISRCTN registry number, ISRCTN94604465.).

Prognosis of Gleason score 8 prostatic adenocarcinoma in needle biopsies: a nationwide population-based study

A 5-tier grouping of Gleason scores has recently been proposed. Studies have indicated prognostic heterogeneity within these groups. We assessed prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM) for men diagnosed with Gleason score 3 + 5 = 8, 4 + 4 = 8 and 5 + 3 = 8 acinar adenocarcinoma on needle biopsy in a population-based national cohort. The Prostate Cancer data Base Sweden 5.0 was used for survival analysis with PCSM and ACM at 5 and 10 years as endpoints. Multivariable Cox regression models controlling for socioeconomic factors, stage and primary treatment type were used for PCSM and ACM. Among 199,620 men reported with prostate cancer in 2000-2020, 172,112 were diagnosed on needle biopsy. In 18,281 (11%), there was a Gleason score of 8 in needle biopsies, including a Gleason score of 3 + 5, 4 + 4 and 5 + 3 in 11%, 86% and 2.3%, respectively. The primary treatment was androgen deprivation therapy (55%), deferred treatment (8%), radical prostatectomy (16%) or radical radiotherapy (21%). PCSM in men with Gleason scores of 3 + 5, 4 + 4 and 5 + 3 at 5 years of follow-up was 0.10 (95% CI 0.09-0.12), 0.22 (0.22-0.23) and 0.32 (0.27-0.36), respectively, and at 10 years 0.19 (0.17-0.22), 0.34 (0.33-0.35) and 0.44 (0.39-0.49), respectively. There was a significantly higher PCSM after 5 and 10 years in men with Gleason score 5 + 3 cancers than in those with 4 + 4 and in Gleason score 4 + 4 cancers than in those with 3 + 5. Grouping of Gleason scores will eliminate the prognostic granularity of Gleason scoring, thus diminishing the prognostic significance of this proposed grading system.

Long term evaluation of optimized Gleason grading in a large cohort of men with prostate cancer in Canada

OBJECTIVES

To evaluate the International Society of Urological Pathology (ISUP) 5-tier grade grouping (GG) system of prostate cancers as well as previously proposed optimizations.

PATIENTS AND METHODS

The PROCURE biobank is a prospective cohort study of patients with localized prostate cancer who underwent radical prostatectomy in Quebec province between 2005 and 2013. Surgical specimens were graded by experienced genitourinary pathologists using 2019 ISUP criteria. Follow-up was conducted until November 2021. The current 5-tier and a proposed 6-tier GG system were evaluated, the latter having two changes: 1) Gleason 3 + 4 and 4 + 3 tumors with minor/tertiary Gleason 5 patterns were upgraded to GG 3 and 4, respectively; and 2) patients in GG5 were separated based on primary Gleason pattern (4 or 5). Cox proportional hazards models and Harrell's concordance (C) indices were used for statistical analyses.

RESULTS

2003 patients were included (median follow-up: 8.7 years). The current 5-tier GG system predicted time to recurrence (hazard ratio [HR] 2.12, 95% confidence interval [95%CI] 1.99-2.25, C 0.717), androgen-deprivation therapy (HR 2.58, 95%CI 2.38-2.80, C 0.790), metastasis (HR 2.48, 95%CI 2.17-2.83, C 0.806), castration-resistant prostate cancer (HR 2.67, 95%CI 2.28-3.13, C 0.829), and cancer-specific mortality (HR 2.80, 95%CI 2.27-3.44, C 0.835). Goodness-of-fit further improved with the proposed 6-tier GG system, with Harrell's C of 0.733, 0.807, 0.827, 0.853, and 0.853, respectively.

CONCLUSIONS

The 5-tier GG system predicted short- and long-term outcomes for patients with localized prostate cancer, and the proposed 6-tier GG system further improved its accuracy.