Clinical predictors of upgrading to Gleason grade 4 or 5 disease at radical prostatectomy: potential implications for patient selection for radiation and androgen suppression therapy

Concordance between Gleason score of prostate biopsies and radical prostatectomy specimens and its predictive factors

Objective:

The Gleason score is an essential factor for making decisions about prostate cancer management and its prognosis. Thus, we conducted this research to discover the histologic-grading accuracy of needle biopsy specimens, and to identify preoperative clinical and pathological factors that predict upgrading and downgrading from biopsy to radical prostatectomy specimen.

Patients and methods:

This study was performed on 570 patients who were referred to the medical centers affiliated with Shiraz University of Medical Sciences and underwent radical prostatectomy from 2013 to 2017. Concordance was evaluated between the Gleason score of needle biopsy and radical prostatectomy specimens. Predictors of upgrades and downgrades were assessed in univariate and multivariate logistic regression analyses.

Results:

Scores were the same in 50% of cases, downgraded in 26%, and upgraded in 24%. The variables predicting a Gleason score upgrade were higher Prostate specific antigen level, larger tumors, and older age. Lower tumor volume, lower Prostate specific antigen, and low maximum percentage of cancer in cores were predictors of downgrading from Gleason score>6 to ⩽6. Also, Body mass index>30, smaller tumor size, and negative lymph nodes were predictors of downgrading from Gleason score>7 to 7.

Conclusion:

The correlation between biopsy and Radical prostatectomy Gleason scores was only 50%. After dividing them into the new grading groups, this coordination increased by only 5.6%. Physicians need to consider possible limitations of the Gleason score of biopsy and factors that can be predictive of upgrading to high-risk prostate cancer before making treatment decisions.

Application of Machine Learning Algorithms in Breast Cancer Diagnosis and Classification

Breast cancer continues to be the most frequent cancer in females, affecting about one in 8 women and causing the highest number of cancer-related deaths in females worldwide despite remarkable progress in early diagnosis, screening, and patient management. All breast lesions are not malignant, and all the benign lesions do not progress to cancer. However, the accuracy of diagnosis can be increased by a combination or preoperative tests such as physical examination, mammography, fine-needle aspiration cytology, and core needle biopsy. Despite some limitations, these procedures are more accurate, reliable, and acceptable, when compared with a single adopted diagnostic procedure. Recent studies have shown that breast cancer can be accurately predicted and diagnosed using machine learning (ML) technology. The objective of this study was to explore the application of ML approaches to classify breast cancer based on feature values generated from a digitized image of a fine-needle aspiration (FNA) of a breast mass. To achieve this objective, we used ML algorithms, collected a scientific dataset of 569 breast cancer patients from Kaggle (https://www.kaggle.com/uciml/breast-cancer-wisconsin-data), analyze and interpreted the data based on ten real-valued features of a breast mass FNA including the radius, texture, perimeter, area, smoothness, compactness, concavity, concave points, symmetry, and fractal dimension. Among the 569 patients tested, 63% were diagnosed with benign breast cancer and 37% were diagnosed with malignant breast cancer. Benign tumors grow slowly and do not spread while malignant tumors grow rapidly and spread to other parts of the body.

Prediction of pathologic upgrading in Gleason score 3+4 prostate cancer: Who is a candidate for active surveillance?

Purpose

Whether active surveillance (AS) can be safely extended to patients with Gleason score (GS) 3+4 prostate cancer is highly debated. We examined the incidence and predictors of upgrading among patients with GS 3+4 disease.

Materials and Methods

The study involved 377 patients with biopsy GS 3+4 who underwent robot-assisted laparoscopic radical prostatectomy (RP) from 2014 to 2018 at a single institution. We analyzed the rate of GS upgrading and used logistic regression to determine the predictors of upgrading.

Results

A total of 168 (44.6%) patients with GS 3+4 experienced an upgrade in GS. In multivariable analysis, advanced age, prostate-specific antigen (PSA) level, PSA density (PSAD) and Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score were significant predictors of GS upgrading. When structured into a predictive model that included age ≥65 years, PSA ≥7.7 ng/mL, PSAD ≥0.475 ng/mL² and PI-RADS v2 score 4-5, the probability of GS upgrading ranged from 36.4% to 65.7% when one to four of these factors were included.

Conclusions

A substantial proportion of patients with GS 3+4 prostate cancer were upgraded after RP. However, according to our model combining clinical and imaging predictors, patients with a low risk of GS upgrading may be eligible candidates for AS.

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.

Combination possibility and deep learning model as clinical decision-aided approach for prostate cancer

This study aims to introduce as proof of concept a combination model for classification of prostate cancer using deep learning approaches. We utilized patients with prostate cancer who underwent surgical treatment representing the various conditions of disease progression. All possible combinations of significant variables from logistic regression and correlation analyses were determined from study data sets. The combination possibility and deep learning model was developed to predict these combinations that represented clinically meaningful patient's subgroups. The observed relative frequencies of different tumor stages and Gleason score Gls changes from biopsy to prostatectomy were available for each group. Deep learning models and seven machine learning approaches were compared for the classification performance of Gleason score changes and pT2 stage. Deep models achieved the highest F1 scores by pT2 tumors (0.849) and Gls change (0.574). Combination possibility and deep learning model is a useful decision-aided tool for prostate cancer and to group patients with prostate cancer into clinically meaningful groups.

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.

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.

Grade Group Underestimation in Prostate Biopsy: Predictive Factors and Outcomes in Candidates for Active Surveillance

OBJECTIVE

We intended to analyze the outcomes and predictive factors for underestimating the prostate cancer (PCa) grade group (GG) from prostate biopsies in a large monocentric cohort of patients treated by minimally invasive radical prostatectomy (RP).

MATERIALS AND METHODS

Using a monocentric prospectively maintained database, we included 3062 patients who underwent minimally invasive RP between 2006 and 2013. We explored clinicopathologic features and outcomes associated with a GG upgrade from biopsy to RP. Multivariate logistic regression was used to develop and validate a nomogram to predict upgrading for GG1.

RESULTS

Biopsy GG was upgraded after RP in 51.5% of cases. Patients upgraded from GG1 to GG2 or GG3 after RP had a longer time to biochemical recurrence than those with GG2 or GG3 respectively, on both biopsy and RP, but a shorter time to biochemical recurrence than those who remained GG1 after RP (P < .0001). In multivariate analyses, variables predicting upgrading for GG1 PCa were age (P = .0014), abnormal digital rectal examination (P < .0001), prostate-specific antigen density (P < .0001), percentage of positive cores (P < .0001), and body mass index (P = .037). A nomogram was generated and validated internally.

CONCLUSIONS

Biopsy grading system is misleading in approximately 50% of cases. Upgrading GG from biopsy to RP may have consequences on clinical outcomes. A nomogram using clinicopathologic features could aid the probability of needing to upgrade GG1 patients at their initial evaluation.

Assessment of the Performance of Magnetic Resonance Imaging/Ultrasound Fusion Guided Prostate Biopsy against a Combined Targeted Plus Systematic Biopsy Approach Using 24-Core Transperineal Template Saturation Mapping Prostate Biopsy

Objective. To compare the performance of multiparametric resonance imaging/ultrasound fusion targeted biopsy (MRI/US-TBx) to a combined biopsy strategy (MRI/US-TBx plus 24-core transperineal template saturation mapping biopsy (TTMB)). Methods. Between May 2012 and October 2015, all patients undergoing MRI/US-TBx at our institution were included for analysis. Patients underwent MRI/US-TBx of suspicious lesions detected on multiparametric MRI +/− simultaneous TTMB. Subgroup analysis was performed on patients undergoing simultaneous MRI/US-TBx + TTMB. Primary outcome was PCa detection. Significant PCa was defined as ≥Gleason score (GS) 3 + 4 = 7 PCa. McNemar's test was used to compare detection rates between MRI/US-TBx and the combined biopsy strategy. Results. 148 patients underwent MRI/US-TBx and 80 patients underwent MRI/US-TBx + TTMB. In the MRI/US-TBx versus combined biopsy strategy subgroup analysis (n = 80), there were 55 PCa and 38 significant PCa. The detection rate for the combined biopsy strategy versus MRI/US-TBx for significant PCa was 49% versus 40% (p = 0.02) and for insignificant PCa was 20% versus 10% (p = 0.04), respectively. Eleven cases (14%) of significant PCa were detected exclusively on MRI/US-TBx and 7 cases (8.7%) of significant PCa were detected exclusively on TTMB. Conclusions. A combined biopsy approach (MRI/US-TBx + TTMB) detects more significant PCa than MRI/US-TBx alone; however, it will double the detection rate of insignificant PCa.

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.

Outcomes of men with an elevated prostate-specific antigen (PSA) level as their sole preoperative intermediate- or high-risk feature

OBJECTIVE

To investigate the post-prostatectomy and long-term outcomes of men presenting with an elevated pretreatment prostate-specific antigen (PSA) level (>10 ng/mL), but otherwise low-risk features (biopsy Gleason score ≤6 and clinical stage ≤T2a).

PATIENTS AND METHODS

PSA-incongruent intermediate-risk (PII) cases were defined as those patients with preoperative PSA >10 and ≤20 ng/mL but otherwise low-risk features, and PSA-incongruent high-risk (PIH) cases were defined as men with PSA >20 ng/mL but otherwise low-risk features. Our institutional radical prostatectomy database (1992-2012) was queried and the results were stratified into D'Amico low-, intermediate- and high risk, PSA-incongruent intermediate-risk and PSA-incongruent high-risk cases. Prostate cancer (PCa) features and outcomes were evaluated using appropriate comparative tests. Multivariable analyses were adjusted for age, race and year of surgery.

RESULTS

Of the total cohort of 17 608 men, 1132 (6.4%) had PII-risk disease and 183 (1.0%) had PIH-risk disease. Compared with the low-risk group, the odds of upgrading at radical prostatectomy (RP) were 2.20 (95% CI 1.93-2.52; P < 0.001) for the PII group and 3.58 (95% CI 2.64-4.85; P < 0.001) for the PIH group, the odds of extraprostatic disease at RP were 2.35 (95% CI 2.05-2.68; P < 0.001) for the PII group and 6.68 (95% CI 4.89-9.15; P < 0.001) for the PIH group, and the odds of positive surgical margins were 1.97 (95% CI 1.67-2.33; P < 0.001) for the PII group and 3.54 (95% CI 2.50-4.95, P < 0.001) for the PIH group. Compared with low-risk disease, PII-risk disease was associated with a 2.85-, 2.99- and 3.32-fold greater risk of biochemical recurrence (BCR), metastasis and PCa-specific mortality, respectively, and PIH-risk disease was associated with a 5.32-, 6.14- and 7.07-fold greater risk of BCR, metastasis and PCa-specific mortality, respectively (P ≤ 0.001 for all comparisons). For the PII group, the higher risks of positive surgical margins, upgrading, upstaging and BCR were dependent on PSA density (PSAD): men in the PII group who had a PSAD <0.15 ng/mL/g were not at higher risk compared with those in the low-risk group. Men in the PII group with a PSAD ≥0.15 ng/mL/g and men in the PIH group were more likely to have an anterior component of the dominant tumour (59 and 64%, respectively) compared with those in the low- (35%) and intermediate-risk group (39%) and those in the PII-risk group with PSAD <0.15 ng/mL/g (29%).

CONCLUSIONS

Men with PSA >20 ng/mL or men with PSA >10 and ≤20 ng/mL with a PSAD ≥0.15 ng/mL/g, but otherwise low-risk PCa, are at greater risk of adverse pathological and oncological outcomes and may be inappropriate candidates for active surveillance. These men are at greater risk of having anterior tumours that are undersampled at biopsy, so if treatment is deferred, ancillary testing such as anterior zone sampling or magnetic resonance imaging should be strongly encouraged. Men with elevated PSA levels >10 and ≤20 ng/mL but low PSAD have outcomes similar to those in the low-risk group, and consideration of surveillance is appropriate in these cases.

Predicting the risk of harboring high-grade disease for patients diagnosed with prostate cancer scored as Gleason ≤ 6 on biopsy cores

PURPOSE

Biopsy and final pathological Gleason score (GS) are inconstantly correlated with each other. The aim of the current study was to develop and validate a predictive score to screen patients diagnosed with a biopsy GS ≤ 6 prostate cancer (PCa) at risk of GS upgrading.

METHODS

Clinical and pathological data of 1,179 patients managed with radical prostatectomy for a biopsy GS ≤ 6, clinical stage ≤ T2b and preoperative PSA ≤ 20 ng/ml PCa were collected. The population study was randomly split into a development (n = 822) and a validation (n = 357) cohort. A prognostic score was established using the independent factors related to GS upgrading identified in multivariate analysis. The cutoff value derived from the area under the receiver operating characteristic curve of the score.

RESULTS

After RP, the rate of GS upgrading was 56.7%. In multivariate analysis, length of cancer per core > 5 mm (OR 2.938; p < 0.001), PSA level > 15 ng/ml (OR 2.365; p = 0.01), age > 70 (OR 1.746; p = 0.016), number of biopsy cores > 12 (OR 0.696; p = 0.041) and prostate weight > 50 g (OR 0.656; CI; p < 0.007) were independent predictive factors of GS upgrading. A score ranged between -4 and 12 with a cutoff value of 2 was established. In the development cohort, the accuracy of predictive score was 63.7% and the positive predictive value was 71.2%. Results were confirmed in the validation cohort.

CONCLUSION

This predictive tool might be used to screen patients initially diagnosed with low-grade PCa but harboring occult high-grade disease.

Predictors of Gleason score upgrading in patients with prostate biopsy Gleason score ≤6

INTRODUCTION

The discrepancy between prostate biopsy and prostatectomy Gleason scores is common. We investigate the predictive value of prostate biopsy features for predicting Gleason score (GS) upgrading in patients with biopsy Gleason scores ≤6 who underwent radical retropubic prostatectomy (RRP). Our aim was to determine predictors of GS upgrading and to offer guidance to clinicians in determining the therapeutic option.

METHODS

We performed a retrospective study of patients who underwent RRP for clinically localized prostate cancer at 2 major centres between January 2007 and March 2013. All patients with either abnormal digital examination or elevated prostate-specific antigen at screening underwent transrectal ultrasound-guided prostate biopsy. Variables were evaluated among the patients with and without GS upgrading. Our study limitations include its retrospective design, the fact that all subjects were Turkish and the fact that we had a small sample size.

RESULTS

In total, 321 men had GS ≤6 on prostate biopsy. Of these, 190 (59.2%) had GS≤6 concordance and 131 (40.8%) had GS upgrading from ≤6 on biopsy to 7 or higher at the time of the prostatectomy. Independent predictors of pathological upgrading were prostate volume <40 cc (p < 0.001), maximum percent of cancer in any core (p = 0.011), and >1 core positive for cancer (p < 0.001).

CONCLUSIONS

When obtaining an extended-core biopsy scheme, patients with small prostates (≤40 cc), greater than 1 core positive for cancer, and an increased burden of cancer are associated with increased risk of GS upgrading. Patients with GS ≤6 on biopsy with these pathological parameters should be carefully counselled on treatment decisions.

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.

Preoperative prostate-specific antigen isoform p2PSA ≤ 22.5 pg/ml predicts advanced prostate cancer in patients undergoing radical prostatectomy

BACKGROUND

The prediction value of prostate-specific antigen (PSA) isoform [-2]proPSA (p2PSA) for detecting advanced prostate cancer (PCa) remains unclear. Our objective was to evaluate the additional clinical utility of p2PSA compared with total PSA (tPSA), free PSA (fPSA), and preoperative Gleason score (Gls) in predicting locally advanced PCa (pT3/T4) with high-accuracy discrimination. The aim was to develop a novel classification based on p2PSA and preoperative Gls for predicting advanced PCa.

MATERIALS AND METHODS

In 208 consecutive men diagnosed with clinically localized PCa who underwent radical prostatectomy, we determined the predictive and discriminatory accuracy of serum tPSA, fPSA, percentage of fPSA to tPSA, p2PSA, p2PSA density, percentage of p2PSA to fPSA, and the Prostate Health Index. The cutoff level of p2PSA with best accuracy was estimated. The novel classification was developed by analyzing the interaction between p2PSA and Gls in predicting pathologic outcomes using a chi-square automatic interaction detection analysis. Decision curve analysis was applied to test the clinical consequences of using the novel classification.

RESULTS

On univariate analyses, p2PSA, p2PSA density, percentage of p2PSA to fPSA, and Prostate Health Index were accurate but were not independent predictors by multivariate analysis. The p2PSA cutoff level of 22.5 pg/ml showed the best accuracy level for predicting and discriminating advanced diseases (area under the curve [AUC] = 0.725, sensitivity = 51.4%, specificity = 81.8%). By chi-square automatic interaction detection, univariate and multivariate analysis, a p2PSA level > 22.5 pg/ml was significantly associated with an increased frequency and risk of advanced disease. In patients with a p2PSA level ≤ 22.5 pg/ml, 91.8% of Gleason sum 6 PCa was organ confined. The combination of p2PSA and Gls enhanced slightly but significantly the predictive and discriminatory accuracy for advanced disease (0.6%-3.6%).

CONCLUSIONS

The p2PSA cutoff level of 22.5 pg/ml can accurately discriminate between organ-confined and advanced PCa. The additional use of p2PSA enhanced slightly the predictive accuracy for advanced PCa (pT3/pT4) and has limited additional predictive value in identifying aggressive PCa (Gls > 7a).

Concordance Between Prostate Needle Biopsy and Surgical Histopathology in a Primarily African-American Population

Introduction. Prior studies have revealed that the concordance between biopsy and surgical specimens has been improving over time. However, to date, this has not been analyzed in an African American population, for whom data have often shown more aggressive prostate cancer than for other races. Methods. We analyzed 250 patients who were operated on at the NY Harbor Department of Veterans Affairs for localized prostate cancer between 2003 and 2010. The clinical biopsy scores were compared with the pathological biopsy scores. We compared the concordance using the κ coefficient. Univariate and multivariate logistic regressions were used to identify predictors for poor concordance. Results. This population consisted of 59.6% African Americans, 32% Caucasians, and 8.4% Hispanics. Overall, there was a 50% exact concordance between the biopsy and surgical specimens. The κ was 0.33, indicating fair agreement. Patients with a Gleason score of 6 were found to have an exact concordance 66% of the time, and those with a score of Gleason 7 (3 + 4) had an exact concordance 50% of the time. On univariate and multivariate analyses, only an increasing prostate-specific antigen was associated with reduced concordance. Race was not a significant predictor. Conclusions. These data are in line with prior studies of concordance. Despite being a population with more aggressive prostate cancer, there does not appear to be an increase in the risk of discordance in African American men.

Improving the Gleason grading accuracy of transrectal ultrasound-guided biopsy

BACKGROUND

Transrectal ultrasound (TRUS)-guided prostate biopsy is the technique of choice for the assessment of clinical suspicion of prostate cancer (PC) based on abnormal digital rectal examination (DRE) and/or elevated or rising levels of prostate-specific antigen (PSA).

PURPOSE

To identify factors involved in TRUS-guided prostate biopsy, which can be modified by radiologists in order to improve Gleason score (GS) accuracy, and to assess the influence of clinical variables.

MATERIAL AND METHODS

We carried out a retrospective review of the records of 185 patients with PC treated surgically at our hospital between 2005 and 2008. Biopsy schemes were classified according to the number of cores (≤7, 8-9, 10-11, 12-15) and the needle length (11, 16, 20 mm). Clinical characteristics - age, family history of PC, DRE, PSA levels, and sonographic data - and prostatectomy GS (pGS) were collected.

RESULTS

Non-random concordance between biopsy Gleason score (bGS) and pGS was obtained for 36% of patients (P < 0.001). Under- and over-staging were 30% and 4%, respectively. Concordance was correlated with the core number (45% for ≤7, 54% for 8-9, 85% for 10-11, and 80% for 12-15; P < 0.001), but not with the needle length. The concordance rate showed a seven-fold increase when 10-11 cores were obtained (95% CI, 2-18; P < 0.001) compared to those cases in which the core number obtained was ≤7. Among clinical variables, only PSA correlated with concordance, showing an inverse relationship.

CONCLUSION

The Gleason correlation values were not improved when 12 or more cores were collected. These values reached a plateau beyond that number of samples. Therefore, when determining treatment strategies, physicians must consider the biopsy scheme used since it has proven to be a predictor of the accuracy of the PC grading system.

Importance of prostate-specific antigen (PSA) as a predictive factor for concordance between the Gleason scores of prostate biopsies and RADICAL prostatectomy specimens

OBJECTIVE

To evaluate the concordance between the Gleason scores of prostate biopsies and radical prostatectomy specimens, thereby highlighting the importance of the prostate-specific antigen (PSA) level as a predictive factor of concordance.

METHODS

We retrospectively analyzed 253 radical prostatectomy cases performed between 2006 and 2011. The patients were divided into 4 groups for the data analysis and dichotomized according to the preoperative PSA, <10 ng/mL and ≥10 ng/mL. A p-score <0.05 was considered significant.

RESULTS

The average patient age was 63.3±7.8 years. The median PSA level was 9.3±4.9 ng/mL. The overall concordance between the Gleason scores was 52%. Patients presented preoperative PSA levels <10 ng/mL in 153 of 235 cases (65%) and ≥10 ng/mL in 82 of 235 cases (35%). The Gleason scores were identical in 86 of 153 cases (56%) in the <10 ng/mL group and 36 of 82 (44%) cases in the ≥10 ng/mL group (p=0.017). The biopsy underestimated the Gleason score in 45 (30%) patients in the <10 ng/mL group and 38 (46%) patients in the ≥10 ng/mL (p=0.243). Specifically, the patients with Gleason 3 + 3 scores according to the biopsies demonstrated global concordance in 56 of 110 cases (51%). In this group, the patients with preoperative PSA levels <10 ng/dL had higher concordance than those with preoperative PSA levels ≥10 ng/dL (61% x 23%, p=0.023), which resulted in 77% upgrading after surgery in those patients with PSA levels ≥10 ng/dl.

CONCLUSION

The Gleason scores of needle prostate biopsies and those of the surgical specimens were concordant in approximately half of the global sample. The preoperative PSA level was a strong predictor of discrepancy and might improve the identification of those patients who tended to be upgraded after surgery, particularly in patients with Gleason scores of 3 + 3 in the prostate biopsy and preoperative PSA levels ≥10 ng/mL.

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.

Importance and determinants of Gleason score undergrading on biopsy sample of prostate cancer in a population-based study

Background

In this population-based study, we investigated the degree of concordance between Gleason scores obtained from prostate biopsies and those obtained from prostatectomy specimens, as well as the determinants of biopsy understaging.

Methods

We considered for this study all 371 prostate cancer patients recorded at the Geneva Cancer Registry diagnosed from 2004 to 2006 who underwent a radical prostatectomy. We used the kappa statistic to evaluate the Gleason score concordance from biopsy and prostatectomy specimens. Logistic regression was used to determine the parameters that predict the undergrading of the Gleason score in prostate biopsies.

Results

The kappa statistic between biopsy and prostatectomy Gleason score was 0.42 (p < 0.0001), with 67% of patients exactly matched, and 26% (n = 95) patients with Gleason score underestimated by the biopsy. In a multi-adjusted model, increasing age, advanced clinical stage, having less than ten biopsy cores, and longer delay between the two procedures, were all independently associated with biopsy undergrading. In particular, the proportion of exact match increased to 72% when the patients had ten or more needle biopsy cores. The main limitation of the study is that both biopsy and prostatectomy specimens were examined by different laboratories.

Conclusions

The data show that concordance between biopsy and prostatectomy Gleason scores lies within the classic clinical standards in this population-based study. The number of biopsy cores appears to strongly impact on the concordance between biopsy and radical prostatectomy Gleason score.

Anti-Oligomannose Antibodies as Potential Serum Biomarkers of Aggressive Prostate Cancer

[Table: see text] This study bridges a carbohydrate microarray discovery and a large-scale serological validation of anti-oligomannose antibodies as novel serum biomarkers of aggressive prostate cancer (PCa). Experimentally, a Man9-cluster-specific enzyme-linked immunosorbent assay was established to enable sensitive detection of anti-Man9 antibodies in human sera. A large-cohort of men with PCa or benign prostatic hyperplasia (BPH) whose sera were banked at Stanford University was characterized using this assay. Subjects included patients with 100% Gleason grade 3 cancer (n = 84), with Gleason grades 4 and/or 5 cancer (n = 204), and BPH controls (n = 135). Radical prostatectomy Gleason grades and biochemical (PSA) recurrence served as key parameters for serum biomarker evaluation. It was found that IgG^Man9 and IgM^Man9 were widely present in the sera of men with BPH, as well as those with cancer. However, these antibody reactivities were significantly increased in the subjects with the largest volumes of high grade cancer. Detection of serum IgG^Man9 and IgM^Man9 significantly predicted the clinical outcome of PCa post-radical prostatectomy. Given these results, we suggest that IgG^Man9 and IgM^Man9 are novel serum biomarkers for monitoring aggressive progression of PCa. The potential of oligomannosyl antigens as targets for PCa subtyping and targeted immunotherapy is yet to be explored.

IGFBP-3 nuclear localization predicts human prostate cancer recurrence

Insulin-like growth factor binding protein-3 (IGFBP-3) is a pro-apoptotic, anti-metastasic, and anti-angiogenic protein. Low serum IGFBP-3 has been associated with risk of more aggressive prostate cancer (PCa). We investigated the impact of nuclear and cytoplasmic IGFBP-3 protein expression levels in PCa by examining their in situ expression across a wide spectrum of primary tumors by immunohistochemical analysis of tissue microarrays. Immunohistochemistry was performed on PCa microarrays constructed from 226 hormone naïve patients who underwent radical prostatectomy. Both cytoplasmic and nuclear IGFBP-3 expressions were scored in a semi-quantitative fashion using an integrated measure of intensity and positivity. The distribution of IGFBP-3 protein expression was examined across the spectrum of epithelial tissues, and its association with standard clinicopathological covariates and tumor recurrence was examined. There was a broad range of IGFBP-3 staining across all histologies examined. Tumor had higher IGFBP-3 cytoplasmic and nuclear staining than benign histologies. For IGFBP-3 nuclear staining, PCa was significantly different than benign prostatic hyperplasia, normal prostate, and prostate intraepithelial neoplasia. As both a continuous and dichotomized variable, higher nuclear IGFBP-3 expression had statistically significant associations with PCa recurrence. The cytoplasmic staining had no significance in any patient subgroup. In patients with low-grade cancer, IGFBP-3 nuclear positivity was a better predictor of recurrence than baseline PSA, tumor margin status, TNM tumor stage, or presence of capsular invasion. High nuclear IGFBP-3 is amongst the strongest predictors of cancer recurrence in patients with low-grade prostate cancers and may therefore play an important role in risk stratification.

Knife or needles? A cohort analysis of outcomes after radical prostatectomy or brachytherapy for men with low- or intermediate-risk adenocarcinoma of the prostate

PURPOSE

The purpose of this study was to evaluate long-term outcomes for men with early stage prostate cancer treated with radical prostatectomy (RP) or brachytherapy (BT) at a single tertiary care center.

METHODS AND MATERIALS

We retrospectively analyzed data from 371 men with clinical T1a-T2c disease with prostate-specific antigen level <20 ng/mL and Gleason score (GS) 6-7 who were treated with RP (n=279) or BT (n=92) at MD Anderson Cancer Center in 2000-2001. Biochemical recurrence-free survival (BRFS) and prostate cancer-specific survival rates were compared by treatment modality.

RESULTS

The median followup time was 7.2 and 7.6 years for patients treated with RP and BT, respectively. Disease was upgraded from GS 6 to 7 after central review of the biopsy specimen for 36 men treated with RP (12.9%) and 15 men treated with BT (16.3%). After RP, GS was upgraded in 121 men (43.4%) between the centrally reviewed biopsy and the RP specimen. After RP, 5-year BRFS rates were 96.1% and 90.6% for low- and intermediate-risk disease, respectively (p=0.003). After BT, 5-year BRFS rates were 92.5% and 95.8% for low- and intermediate-risk disease, respectively (p=0.017). After RP or BT, 5-year BRFS rates were not significantly different with GS upgraded. Five-year prostate cancer-specific survival rates for patients with upgraded GS were 100% for both RP and BT.

CONCLUSIONS

Excellent disease control outcomes can be achieved after either RP or BT as monotherapy for men with early stage prostate cancer. Upgrading of GS from 6 to 7, either (3+4) or (4+3), did not predict for worse outcomes.

Results of a surgically derived nomogram to predict Gleason score upgrading applied to a cohort of patients with "favorable-risk" prostate cancer treated with permanent seed brachytherapy

OBJECTIVE

To examine a 2-year cohort of patients treated with brachytherapy to determine the likelihood of unfavorable pathologic features using a nomogram recently developed at our center to estimate the likelihood of Gleason score upgrading for patients with favorable prostate cancer undergoing radical prostatectomy. The brachytherapy outcomes for patients with a high likelihood of upgrading were compared with those with a lower likelihood to affirm the effectiveness of brachytherapy in this setting. Information on the likelihood of upgrading could help in the selection between active treatment and surveillance for patients with favorable-risk prostate cancer.

METHODS

The records were examined for 259 men undergoing prostate brachytherapy in 2006 to 2007, of whom 217 had favorable risk cancer. The likelihood of Gleason score upgrading (GSU) was predicted using the radical prostatectomy-derived nomogram.

RESULTS

The median age was 62 years (range 44-77), and the median prostate-specific antigen level was 4.71 ng/mL (range 0.56-9.87). Central pathology review was available for 88%, and 83% had undergone extended biopsies. Two men had received androgen deprivation therapy for prostate downsizing. The median predicted likelihood of GSU was 51.2%. The median prostate-specific antigen level for 199 patients without treatment failure after a median follow-up of 4.2 years in this cohort was 0.07 ng/mL (interquartile range undetectable to 0.23).

CONCLUSION

In the present cohort of patients with favorable-risk prostate cancer treated with brachytherapy, the estimated likelihood of GSU using the surgically derived nomogram was substantial. Follow-up with prostate-specific antigen measurement has indicated that brachytherapy is a highly effective treatment option despite less favorable clinical and pathologic factors. Patients should not be discouraged from brachytherapy on the basis of a high likelihood of GSU.

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.

Preoperative insulin-like growth factor-binding protein-3 (IGFBP-3) blood level predicts gleason sum upgrading

BACKGROUND

About 43% of men with low Gleason grade prostate cancer (PCa) at biopsy will be finally diagnosed with high-grade PCa at radical prostatectomy (RP). Gleason sum at RP is a good indicator of biochemical recurrence and poor clinical outcome. Therefore, there is a need to improve clinical evaluation of PCa aggressiveness in order to choice appropriate treatment. To this aim an easy-available tool is represented by circulating biomarkers. Among these, the best candidates are some molecules involved in PCa pathogenesis such as IGFBP-2 and IGFBP-3, IL-6, and its soluble receptor (SIL-6R).

METHODS

In this study, we evaluated the ability of preoperative IGFBP-2, IGFBP-3, IL-6, and SIL-6R serum levels to predict Gleason score upgrade in 52 PCa patients.

RESULTS

We found that IGFBP-3 median levels were significantly lower in patients who showed Gleason upgrading from biopsy to RP (P = 0.024). We also found an association between biopsy T-stage and Gleason Upgrade (P = 0.011). Using multivariate logistic regression model, we demonstrated that the association of IGFBP-3 serum levels together with biopsy T-stage and biopsy Gleason score was useful to calculate a prognostic risk score. ROC curve analysis of risk score showed a good ability to predict GSU (AUC = 0.81; 95% CI 0.69-0.93).

CONCLUSIONS

Our results suggest that preoperative IGFBP-3 circulating levels determination may be useful to predict Gleason score upgrading alone and/or in combination with biopsy T-stage and biopsy Gleason score.

Gleason score 7 prostate cancer on needle biopsy: relation of primary pattern 3 or 4 to pathological stage and progression after radical prostatectomy

PURPOSE

There have been only a few contradictory publications assessing whether Gleason score 4 + 3 = 7 has a worse prognosis than 3 + 4 = 7 on biopsy material in predicting pathological stage and biochemical recurrence. Older studies predated the use of the modified Gleason grading system established in 2005.

MATERIALS AND METHODS

We retrospectively studied 1,791 cases of Gleason score 7 on prostatic biopsy to determine whether the breakdown of Gleason score 7 into 3 + 4 vs 4 + 3 has prognostic significance in the modern era.

RESULTS

There was no difference in patient age, preoperative serum prostate specific antigen, maximum tumor percent per core or the number of positive cores between Gleason score 3 + 4 = 7 and Gleason score 4 + 3 = 7. Gleason score 4 + 3 = 7 showed an overall correlation with pathological stage (organ confined, focal extraprostatic extension, nonfocal extraprostatic extension, seminal vesicle invasion/lymph node metastases, p = 0.005). On multivariate analysis Gleason score 4 + 3 = 7 (p = 0.03), number of positive cores (p = 0.002), maximum percent of cancer per core (p = 0.006) and preoperative serum prostate specific antigen (p = 0.03) all correlated with pathological stage. Gleason score 4 + 3 = 7 on biopsy was also associated with an increased risk of biochemical progression after radical prostatectomy (p = 0.0001). On multivariate analysis Gleason score 4 + 3 = 7 (p = 0.001), maximum percent of cancer per core (p <0.0001) and preoperative serum prostate specific antigen (p <0.0001) but not number of positive cores correlated with the risk of biochemical progression after radical prostatectomy.

CONCLUSIONS

Our study further demonstrates that Gleason score 7 should not be considered a homogenous group for the purposes of disease management and prognosis.

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.

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.

Predictive and prognostic models in radical prostatectomy candidates: a critical analysis of the literature

CONTEXT

Numerous predictive and prognostic tools have recently been developed for risk stratification of prostate cancer (PCa) patients who are candidates for or have been treated with radical prostatectomy (RP).

OBJECTIVE

To critically review the currently available predictive and prognostic tools for RP patients and to describe the criteria that should be applied in selecting the most accurate and appropriate tool for a given clinical scenario.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline, Scopus, and Web of Science databases. Relevant reports published between 1996 and January 2010 identified using the keywords prostate cancer, radical prostatectomy, predictive tools, predictive models, and nomograms were critically reviewed and summarised.

EVIDENCE SYNTHESIS

We identified 16 predictive and 22 prognostic validated tools that address a variety of end points related to RP. The majority of tools are prediction models, while a few consist of risk-stratification schemes. Regardless of their format, the tools can be distinguished as preoperative or postoperative. Preoperative tools focus on either predicting pathologic tumour characteristics or assessing the probability of biochemical recurrence (BCR) after RP. Postoperative tools focus on cancer control outcomes (BCR, metastatic progression, PCa-specific mortality [PCSM], overall mortality). Finally, a novel category of tools focuses on functional outcomes. Prediction tools have shown better performance in outcome prediction than the opinions of expert clinicians. The use of these tools in clinical decision-making provides more accurate and highly reproducible estimates of the outcome of interest. Efforts are still needed to improve the available tools' accuracy and to provide more evidence to further justify their routine use in clinical practice. In addition, prediction tools should be externally validated in independent cohorts before they are applied to different patient populations.

CONCLUSIONS

Predictive and prognostic tools represent valuable aids that are meant to consistently and accurately provide most evidence-based estimates of the end points of interest. More accurate, flexible, and easily accessible tools are needed to simplify the practical task of prediction.

The novel nomogram of Gleason sum upgrade: possible application for the eligible criteria of low dose rate brachytherapy

OBJECTIVE

To examine the rate of Gleason sum upgrading (GSU) from a sum of 6 to a Gleason sum of ≥7 in patients undergoing radical prostatectomy (RP), who fulfilled the recommendations for low dose rate brachytherapy (Gleason sum 6, prostate-specific antigen ≤10 ng/mL, clinical stage ≤T2a and prostate volume ≤50 mL), and to test the performance of an existing nomogram for prediction of GSU in this specific cohort of patients.

METHODS

The analysis focused on 414 patients, who fulfilled the European Society for Therapeutic Radiation and Oncology and American Brachytherapy Society criteria for low dose rate brachytherapy (LD-BT) and underwent a 10-core prostate biopsy followed by RP. The rate of GSU was tabulated and the ability of available clinical and pathological parameters for predicting GSU was tested. Finally, the performance of an existing GSU nomogram was explored.

RESULTS

The overall rate of GSU was 35.5%. When applied to LD-BT candidates, the existing nomogram was 65.8% accurate versus 70.8% for the new nomogram. In decision curve analysis tests, the new nomogram fared substantially better than the assumption that no patient is upgraded and better than the existing nomogram.

CONCLUSIONS

GSU represents an important issue in LD-BT candidates. The new nomogram might improve patient selection for LD-BT and cancer control outcome by excluding patients with an elevated probability of GSU.

Permanent prostate brachytherapy in prostate glands <20 cm(3)

PURPOSE

To investigate the dosimetry, treatment-related morbidity, and biochemical outcomes for brachytherapy in patients with prostate glands <20 cm(3).

METHODS AND MATERIALS

From November 1996 to October 2006, 104 patients with prostate glands <20 cm(3) underwent brachytherapy. Multiple prostate, urethral, and rectal dosimetric parameters were evaluated. Treatment-related urinary and rectal morbidity were assessed from patient questionnaires. Cause-specific survival, biochemical progression-free survival, and overall survival were recorded.

RESULTS

The median patient age, follow up, and pre-treatment ultrasound volume was 64 years, 5.0 years and 17.6cm(3), respectively. Median day 0 dosimetry was significant for the following: V100 98.5%, D90 126.1% and R100 <0.5% of prescription dose. The mean urethral and maximum urethral doses were 119.6% and 133.8% of prescription. The median time to International Prostate Symptom Score resolution was 4 months. There were no RTOG grade III or IV rectal complications. The cause-specific survival, biochemical progression-free survival, and overall survival rates were 100%, 92.5%, and 77.8% at 9 years. For biochemically disease-free patients, the median most recent postbrachytherapy PSA value was 0.02 ng/mL.

CONCLUSION

Our results demonstrate that brachytherapy for small prostate glands is highly effective, with an acceptable morbidity profile, excellent postimplant dosimetry, acceptable treatment-related morbidity, and favorable biochemical outcomes.

External validation of a nomogram predicting the probability of prostate cancer Gleason sum upgrading between biopsy and radical prostatectomy pathology among Japanese patients

OBJECTIVES

To explore the rate of upgrading in a contemporary cohort from 2 Japanese institutions, and evaluating the predictive accuracy of the nomogram when applied to patients, regardless of race. Previous reports have indicated that a maximum of 43% of men with prostate cancer will show an upgraded Gleason score from biopsy to radical prostatectomy (RP). A preparative nomogram was developed at the University of Hamburg to predict the probability of upgrading from biopsy to RP specimen.

METHODS

Clinical and pathologic data of 503 patients from 2 Japanese institutions were supplied for validation. Nomogram-predicted probabilities of upgrading from biopsy to RP specimen were compared with actual rate of upgrading. The area under the receiver operating characteristic curve (AUC) was calculated for all patients. Calibration of the nomogram was achieved by comparing the predicted upgrading rate with that of an ideal nomogram.

RESULTS

Gleason sum upgrading was recorded in 29.8% of patients at RP. Accuracy of the nomogram was 79.2% (confidence interval, 75.1%-83.2%). Overall AUC was 0.79 when applied to the validation dataset, with individual institutional AUCs ranging from 0.79-0.80. Nomogram predictions of upgrading were not within 10% of an ideal nomogram.

CONCLUSIONS

Gleason sum upgrading between biopsy and final pathology represents an important consideration in treatment decision-making, and nearly one third of patients with prostate cancer will be upgraded. The Hamburg nomogram seems to provide reasonably accurate predictions regardless of minor variations in pathologic assessment, but is not necessarily so accurate when applied to Japanese patient population.

The probability of Gleason score upgrading between biopsy and radical prostatectomy can be accurately predicted

The objective of this study was to test the external validity of a previously developed nomogram for the prediction of Gleason score upgrading (GSU) between biopsy and radical prostatectomy (RP). The study population consisted of 973 assessable patients treated with RP at a tertiary care institution. The accuracy of the nomogram was quantified with the receiver operating characteristics curve-derived area under the curve. The performance characteristics (predicted vs observed rate of GSU) were tested within a calibration plot. Overall, GSU was recorded in 39.8% (n = 387) of patients at RP. Of patients with GSU, 70 (18.1%), 23 (5.9%) and 32 (8.3%), respectively, had extracapsular extension, seminal vesicle invasion and lymph node invasion. The accuracy of the nomogram was 74.9% (confidence interval 72.1-77.6%). The model tended to underestimate the observed rate of GSU and the discordance between the predicted and observed rate of GSU ranged from -7 to +10%. The current tool represents the most accurate method of predicting GSU between biopsy and RP. Nonetheless it is not perfect and its performance characteristics should be known prior to its use in clinical decision-making.