Korean J Urol.  2009 Sep;50(9):836-842.

Predictive Factors for Upgrading or Upstaging in Biopsy Gleason Score 6 Prostate Cancer

• Kim SC
• Hong JH
• Song K
• Jeong IG
• Song C
• Kim CS
• Ahn H

Abstract

PURPOSE
Although biopsy Gleason score (GS) 6 prostate cancers are expected to demonstrate a more indolent clinical course than those with GS 7 or higher cancers, substantial proportion reveal upgrading or upstaging on final pathology. We investigated predictive factors of upstaging or upgrading after radical prostatectomy (RP) in biopsy GS 6 prostate cancers. MATERIALS AND METHODS: A total of 133 patients with biopsy GS 6 prostate cancer who underwent radical prostatectomy between March 2004 and March 2008 were reviewed. Patients were divided into 4 groups according to the number of positive biopsy core: single positive core (group 1, n=53), 2 (group 2, n=29), 3-5 (group 3, n=39) and 6 or more cores (group 4, n=12). We investigated the value of preoperative variables (age, PSA, Clinical stage, number and laterality of positive core, maximal core length, maximal core percentage) in predicting GS upgrading or upstaging in final pathology. RESULTS: Among all subjects, 70 (52.6%) were upgraded to GS 7 or higher and 29 (21.8%) were upstaged to pT3 at final pathology. Upgrading rates were 39.6%, 55.2%, 56.4% and 91.7%, and upstaging rates were 13.2%, 13.8%, 28.2% and 58.3% for groups 1, 2, 3 and 4, respectively. The upgrading and upstaging rates were similar among groups 1, 2 and 3, but were significantly higher in group 4 compared to the others. In multivariate analysis, number of positive cores 6 or more was the only factor significantly predictive of upgrading or upstaging following RP. No preoperative variables were observed to predict upgrading or upstaging following RP in patients with 5 or less positive biopsy cores. CONCLUSIONS: Of patients with only one or 2 positive core GS 6 prostate cancers, substantial proportion of cancers upgraded or upstaged in RP specimens, but no predictive factor could be identified. We should keep in mind these when counseling patients.

Keyword

Prostatic neoplasms; Biopsy; Prostatectomy

MeSH Terms

Biopsy
Counseling
Humans
Multivariate Analysis
Neoplasm Grading
Prostate
Prostatectomy
Prostatic Neoplasms

Reference

1. The statistics report: the incidence of cancer on 2003-2005 and the survival rate on 1993-2005. 2009. accessed Apr 1, 2009. National Cancer Center; http://www.ncc.re.kr.

2. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998. 280:969–974.

3. Cooperberg MR, Lubeck DP, Meng MV, Mehta SS, Carroll PR. The changing face of low-risk prostate cancer: trends in clinical presentation and primary management. J Clin Oncol. 2004. 22:2141–2149.

4. Albertsen PC, Hanley JA, Fine J. 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA. 2005. 293:2095–2101.

5. Epstein JI, Walsh PC, Carmichael M, Brendler CB. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA. 1994. 271:368–374.

6. Chun FK, Steuber T, Erbersdobler A, Currlin E, Walz J, Schlomm T, et al. Development and internal validation of a nomogram predicting the probability of prostate cancer Gleason sum upgrading between biopsy and radical prostatectomy pathology. Eur Urol. 2006. 49:820–826.

7. Moussa AS, Li J, Soriano M, Klein EA, Dong F, Jones JS. Prostate biopsy clinical and pathological variables that predict significant grading changes in patients with intermediate and high grade prostate cancer. BJU Int. 2009. 103:43–48.

8. Chun FK, Briganti A, Shariat SF, Graefen M, Montorsi F, Erbersdobler A, et al. Significant upgrading affects a third of men diagnosed with prostate cancer: predictive nomogram and internal validation. BJU Int. 2006. 98:329–334.

9. Gofrit ON, Zorn KC, Taxy JB, Lin S, Zagaja GP, Steinberg GD, et al. Predicting the risk of patients with biopsy Gleason score 6 to harbor a higher grade cancer. J Urol. 2007. 178:1925–1928.

10. Steinberg DM, Sauvageot J, Piantadosi S, Epstein JI. Correlation of prostate needle biopsy and radical prostatectomy Gleason grade in academic and community settings. Am J Surg Pathol. 1997. 21:566–576.

11. Cookson MS, Fleshner NE, Soloway SM, Fair WR. Correlation between Gleason score of needle biopsy and radical prostatectomy specimen: accuracy and clinical implications. J Urol. 1997. 157:559–562.

12. King CR. Patterns of prostate cancer biopsy grading: trends and clinical implications. Int J Cancer. 2000. 90:305–311.

13. Pinthus JH, Witkos M, Fleshner NE, Sweet J, Evans A, Jewett MA, et al. Prostate cancers scored as Gleason 6 on prostate biopsy are frequently Gleason 7 tumors at radical prostatectomy: implication on outcome. J Urol. 2006. 176:979–984.

14. D'Amico AV, Renshaw AA, Arsenault L, Schultz D, Richie JP. 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. Int J Radiat Oncol Biol Phys. 1999. 45:841–846.

15. Fukagai T, Namiki T, Namiki H, Carlile RG, Shimada M, Yoshida H. Discrepancies between Gleason scores of needle biopsy and radical prostatectomy specimens. Pathol Int. 2001. 51:364–370.

16. Oesterling JE, Brendler CB, Epstein JI, Kimball AW Jr, Walsh PC. Correlation of clinical stage, serum prostatic acid phosphatase and preoperative Gleason grade with final pathological stage in 275 patients with clinically localized adenocarcinoma of the prostate. J Urol. 1987. 138:92–98.

17. Schmid H, Oberpenning F, Pummer K. Diagnosis and staging of prostatic carcinoma: What is really necessary? Urol Int. 1999. 63:57–61.

18. Herman CM, Kattan MW, Ohori M, Scardino PT, Wheeler TM. Primary Gleason pattern as a predictor of disease progression in gleason score 7 prostate cancer: a multivariate analysis of 823 men treated with radical prostatectomy. Am J Surg Pathol. 2001. 25:657–660.

19. Hong SK, Han BK, Lee ST, Kim SS, Min KE, Jeong SJ, et al. Prediction of Gleason score upgrading in low-risk prostate cancers diagnosed via multi (> or =12)-core prostate biopsy. World J Urol. 2009. 27:271–276.

20. Dong F, Jones JS, Stephenson AJ, Magi-Galluzzi C, Reuther AM, Klein EA. Prostate cancer volume at biopsy predicts clinically significant upgrading. J Urol. 2008. 179:896–900.

21. Humphrey PA, Frazier HA, Vollmer RT, Paulson DF. Stratification of pathologic features in radical prostatectomy specimens that are predictive of elevated initial postoperative serum prostate-specific antigen levels. Cancer. 1993. 71:1821–1827.

22. Zincke H, Bergstralh EJ, Blute ML, Myers RP, Barrett DM, Lieber MM, et al. Radical prostatectomy for clinically localized prostate cancer: long-term results of 1,143 patients from a single institution. J Clin Oncol. 1994. 12:2254–2263.

23. Kulkarni GS, Lockwood G, Evans A, Toi A, Trachtenberg J, Jewett MA, et al. Clinical predictors of Gleason score upgrading: implications for patients considering watchful waiting, active surveillance, or brachytherapy. Cancer. 2007. 109:2432–2438.

24. Mian BM, Lehr DJ, Moore CK, Fisher HA, Kaufman RP Jr, Ross JS, et al. Role of prostate biopsy schemes in accurate prediction of Gleason scores. Urology. 2006. 67:379–383.

25. King CR, McNeal JE, Gill H, Presti JC Jr. Extended prostate biopsy scheme improves reliability of Gleason grading: implications for radiotherapy patients. Int J Radiat Oncol Biol Phys. 2004. 59:386–391.

26. Surveillance, Epidemiology, and End Results (SEER) Program. accessed April 1, 2009. National Cancer Institute; http://www.seer.cancer.gov.

27. Song C, Ro JY, Lee MS, Hong SJ, Chung BH, Choi HY, et al. Prostate cancer in Korean men exhibits poor differentiation and is adversely related to prognosis after radical prostatectomy. Urology. 2006. 68:820–824.

28. Kim YJ, Lee SC, Chang IH, Gil MC, Hong SK, Byun SS, et al. Clinical significance of a single-core positive prostate cancers detected on extended prostate needle biopsy. Korean J Urol. 2006. 47:475–481.

29. Lee HW, Kwak KW, Lee HM, Choi HY. The diagnostic value of predictive factors for clinically insignificant prostate cancer. Korean J Urol. 2008. 49:398–403.