Upgrading and Downgrading of Prostate Cancer from Biopsy to Radical Prostatectomy: Incidence and Predictive Factors Using the Modified Gleason Grading System and Factoring in Tertiary Grades

Abstract

Background Prior studies assessing the correlation of Gleason score (GS) at needle biopsy and corresponding radical prostatectomy (RP) predated the use of the modified Gleason scoring system and did not factor in tertiary grade patterns. Objective To assess the relation of biopsy and RP grade in the largest study to date. Design, setting, and participants A total of 7643 totally embedded RP and corresponding needle biopsies (2004–2010) were analyzed according to the updated Gleason system. Interventions All patients underwent prostate biopsy prior to RP. Measurements The relation of upgrading or downgrading to patient and cancer characteristics was compared using the chi-square test, Student t test, and multivariable logistic regression. Results and limitations A total of 36.3% of cases were upgraded from a needle biopsy GS 5–6 to a higher grade at RP (11.2% with GS 6 plus tertiary). Half of the cases had matching GS 3 + 4 = 7 at biopsy and RP with an approximately equal number of cases downgraded and upgraded at RP. With biopsy GS 4 + 3 = 7, RP GS was almost equally 3 + 4 = 7 and 4 + 3 = 7. Biopsy GS 8 led to an almost equal distribution between RP GS 4 + 3 = 7, 8, and 9–10. A total of 58% of the cases had matching GS 9–10 at biopsy and RP. In multivariable analysis, increasing age (p < 0.0001), increasing serum prostate-specific antigen level (p < 0.0001), decreasing RP weight (p < 0.0001), and increasing maximum percentage cancer/core (p < 0.0001) predicted the upgrade from biopsy GS 5–6 to higher at RP. Despite factoring in multiple variables including the number of positive cores and the maximum percentage of cancer per core, the concordance indexes were not sufficiently high to justify the use of nomograms for predicting upgrading and downgrading for the individual patient. Conclusions Almost 20% of RP cases have tertiary patterns. A needle biopsy can sample a tertiary higher Gleason pattern in the RP, which is then not recorded in the standard GS reporting, resulting in an apparent overgrading on the needle biopsy.

Automatic classification of prostate cancer Gleason scores from multiparametric magnetic resonance images

“…GS is a well-validated factor and known to be a powerful predictor of disease progression, mortality, and outcomes (4,5). However, owing to random sampling, the GS determined through biopsies is known to differ from those determined following radical prostatectomy (6,7), as well as between immediate repeat biopsies (8). Therefore, the ability to automatically detect the GS with high accuracy from the diagnostic MRIs would have a significant impact on clinical decision making, treatment selection, and prediction of outcomes for patients and spare them from painful biopsies and their accompanying risk of complications.…”

Prostat adenokarsinomlarında iğne biyopsileri ve radikal prostatektomi materyallerinin Gleason skoru açısından karşılaştırılması

“…Bu çalışmalarda biyopsi ve RP GS uyumsuzluk oranları % 24-50 arasında bildirilmiştir (7)(8)(9)(10)(11). Bu uyumsuzluğun teknik sebepleri arasında patolojik yorum farklılıkları, ara dereceler ve örnekleme hataları yer almaktadır (17). Bunlara ek olarak uyumsuzluğa neden olabilecek çok sayıda faktör bulunmaktadır.…”

“…Bu faktörler arasında küçük prostat hacmi (18,19), yüksek PSA değerleri (19)(20)(21), ileri yaş, tümörlü kor sayısı (11,22), biyopsideki tümör hacminin büyük (22-24) olması sayılabilir. GS artış insidansı ve prediktif faktörlerin değerlendirildiği literatürdeki en geniş seride 7643 hastanın biyopsi ve RP GS değerleri karşılaştırılmış ve GS artış oranı %36.3 olarak bulunmuştur (17). Bu çalışmada GS artışını öngören faktörler arasında ileri yaş, yüksek PSA, düşük prostat hacmi sayılmıştır.…”

“…İleri yaş, TRUS biyopsi ile RP GS arasındaki uyumsuzluğa etki eden faktörlerden birsidir. Yapılan çalışmaların hemen hepsinde ileri yaşın GS artışı ile ilişkili olduğu gösterilmiştir (12,17,30). Bununla birlikte bizim çalışmamızda 60 yaş üzeri 20 olgu için uyumun orta derecede (kappa:0.47 [p=0.01]) olduğu tespit edilmiştir.…”

Quantified Clinical Risk Change as an End Point During Prostate Cancer Active Surveillance

“…The occurrence of Gleason grade reclassification has been attributed to several factors including the detection of higher grade or volume tumor as a consequence of initial biopsy inaccuracy and the contribution of genuine cancer progression over time; however, the directionality of sampling limitations does not uniformly favor underdetection. This has been reflected in RP series in which misclassification at initial biopsy has resulted in both pathologic upgrade and downgrade [8]. Consequently, reclassification metrics based solely on a single clinical parameter may incompletely account for an individual's risk of clinically significant disease progression and expose many to early treatment.…”