Incidence of Upgrading and Upstaging in Patients with Low-Volume Gleason Score 3+4 Prostate Cancers at Biopsy: Finding a New Group Eligible for Active Surveillance

Background: The aim of this work is to evaluate the detection rate of magnetic resonance imaging/transrectal ultrasound (MRI/TRUS) fusion-guided biopsy for clinically significant prostate cancers (Cs PCas), with particular interest in biopsy-naive patients and patients in active surveillance. MRI-targeted biopsy improves cancer detection rate (DR) in patients with prior negative biopsies; the current literature focuses on biopsy naive patients. We also evaluated the pathologic concordance between biopsies and surgical specimens. Methods: MRI/TRUS fusion-guided biopsies were performed between February 2016 and February 2019. Patients with previous negative biopsies, biopsy-naive or in active surveillance (AS) were included. Cs PCas were defined through Epstein’s criteria. Results: A total of 416 men were enrolled. The overall DRs and Cs PCa DRs were 49% and 34.3%, respectively. Cs PCas were 17.2%, 44.9% and 73.4%, respectively for PI-RADS 3, 4 or 5. Among biopsy-naive patients, 34.8% were found to have a Cs PCa, while a 43.6% tumour upgrading was achieved in men with a low risk of PCa. In patients who underwent radical prostatectomy (RP), the concordance between biopsy Gleason score (GS) (bGS) and pathological GS (pGS) was 90.8%. Conclusion: Our study highlights the role of MRI/TRUS fusion prostate biopsy in the detection of PCa in patients with previous negative biopsies focusing on Cs PCa diagnosis. The MRI/TRUS fusion biopsy is also emerging as a diagnostic tool in biopsy-naïve patients and deserves a fundamental role in AS protocols. A greater concordance between bGS and pGS can be achieved with targeted biopsies.

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PD45-05 SELECTING IDEAL INTERMEDIATE RISK PATIENTS FOR ACTIVE SURVEILLANCE; A LOOK AT ADVERSE PATHOLOGY AFTER RADICAL PROSTATECTOMY FOR GLEASON SCORE 3+4 ON TARGETED BIOPSY

The Journal of Urology ◽

10.1097/01.ju.0000556599.95443.cd ◽

2019 ◽

Vol 201 (Supplement 4) ◽

Author(s):

Jonathan B. Bloom* ◽

Amir H. Lebastachi ◽

Michael Ahdoot ◽

Sandeep Gurram ◽

Sam A. Gold ◽

...

Keyword(s):

Radical Prostatectomy ◽

Active Surveillance ◽

Gleason Score ◽

Intermediate Risk ◽

Targeted Biopsy ◽

Risk Patients

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Natural history of prostate cancer on active surveillance: stratification by MRI using the PRECISE recommendations in a UK cohort

European Radiology ◽

10.1007/s00330-020-07256-z ◽

2020 ◽

Cited By ~ 2

Author(s):

Francesco Giganti ◽

Armando Stabile ◽

Vasilis Stavrinides ◽

Elizabeth Osinibi ◽

Adam Retter ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Rank Test ◽

Gleason Grade ◽

Clinical Progression ◽

Radiological Progression ◽

Grade Group ◽

Psa Density

Abstract Objectives The PRECISE recommendations for magnetic resonance imaging (MRI) in patients on active surveillance (AS) for prostate cancer (PCa) include repeated measurement of each lesion, and attribution of a PRECISE radiological progression score for the likelihood of clinically significant change over time. We aimed to compare the PRECISE score with clinical progression in patients who are managed using an MRI-led AS protocol. Methods A total of 553 patients on AS for low- and intermediate-risk PCa (up to Gleason score 3 + 4) who had two or more MRI scans performed between December 2005 and January 2020 were included. Overall, 2161 scans were retrospectively re-reported by a dedicated radiologist to give a PI-RADS v2 score for each scan and assess the PRECISE score for each follow-up scan. Clinical progression was defined by histological progression to ≥ Gleason score 4 + 3 (Gleason Grade Group 3) and/or initiation of active treatment. Progression-free survival was assessed using Kaplan-Meier curves and log-rank test was used to assess differences between curves. Results Overall, 165/553 (30%) patients experienced the primary outcome of clinical progression (median follow-up, 74.5 months; interquartile ranges, 53–98). Of all patients, 313/553 (57%) did not show radiological progression on MRI (PRECISE 1–3), of which 296/313 (95%) had also no clinical progression. Of the remaining 240/553 patients (43%) with radiological progression on MRI (PRECISE 4–5), 146/240 (61%) experienced clinical progression (p < 0.0001). Patients with radiological progression on MRI (PRECISE 4-5) showed a trend to an increase in PSA density. Conclusions Patients without radiological progression on MRI (PRECISE 1-3) during AS had a very low likelihood of clinical progression and many could avoid routine re-biopsy. Key Points • Patients without radiological progression on MRI (PRECISE 1–3) during AS had a very low likelihood of clinical progression and many could avoid routine re-biopsy. • Clinical progression was almost always detectable in patients with radiological progression on MRI (PRECISE 4–5) during AS. • Patients with radiological progression on MRI (PRECISE 4–5) during AS showed a trend to an increase in PSA density.

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Essential Updates in Grading, Morphotyping, Reporting, and Staging of Prostate Carcinoma for General Surgical Pathologists

Archives of Pathology & Laboratory Medicine ◽

10.5858/arpa.2018-0334-ra ◽

2019 ◽

Vol 143 (5) ◽

pp. 550-564 ◽

Cited By ~ 5

Author(s):

Gladell P. Paner ◽

Jatin Gandhi ◽

Bonnie Choy ◽

Mahul B. Amin

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Prostate Carcinoma ◽

Multidisciplinary Care ◽

Tnm Staging ◽

International Consensus ◽

Gleason Pattern ◽

Consensus Conferences ◽

Worse Prognosis

Context.— Within this decade, several important updates in prostate cancer have been presented through expert international consensus conferences and influential publications of tumor classification and staging. Objective.— To present key updates in prostate carcinoma. Data Sources.— The study comprised a review of literature and our experience from routine and consultation practices. Conclusions.— Grade groups, a compression of the Gleason system into clinically meaningful groups relevant in this era of active surveillance and multidisciplinary care management for prostate cancer, have been introduced. Refinements in the Gleason patterns notably result in the contemporarily defined Gleason score 6 cancers having a virtually indolent behavior. Grading of tertiary and minor higher-grade patterns in radical prostatectomy has been clarified. A new classification for prostatic neuroendocrine tumors has been promulgated, and intraductal, microcystic, and pleomorphic giant cell carcinomas have been officially recognized. Reporting the percentage of Gleason pattern 4 in Gleason score 7 cancers has been recommended, and data on the enhanced risk for worse prognosis of cribriform pattern are emerging. In reporting biopsies for active surveillance criteria–based protocols, we outline approaches in special situations, including variances in sampling or submission. The 8th American Joint Commission on Cancer TNM staging for prostate cancer has eliminated pT2 subcategorization and stresses the importance of nonanatomic factors in stage groupings and outcome prediction. As the clinical and pathology practices for prostate cancer continue to evolve, it is of utmost importance that surgical pathologists become fully aware of the new changes and challenges that impact their evaluation of prostatic specimens.

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Low Prostate-specific Antigen and No Gleason Score Upgrade Despite More Extensive Cancer During Active Surveillance Predicts Insignificant Prostate Cancer at Radical Prostatectomy

Urology ◽

10.1016/j.urology.2012.05.045 ◽

2012 ◽

Vol 80 (4) ◽

pp. 883-888 ◽

Cited By ~ 8

Author(s):

Jeong S. Han ◽

Adam D. Toll ◽

Ali Amin ◽

H. Ballentine Carter ◽

Patricia Landis ◽

...

Keyword(s):

Prostate Cancer ◽

Radical Prostatectomy ◽

Prostate Specific Antigen ◽

Active Surveillance ◽

Gleason Score ◽

Specific Antigen ◽

Insignificant Prostate Cancer

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Multiparametric prostate MRI and MRI/ultrasound fusion biopsy as tools to follow prostate cancer progression for men on active surveillance.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.4_suppl.63 ◽

2014 ◽

Vol 32 (4_suppl) ◽

pp. 63-63 ◽

Cited By ~ 2

Author(s):

Nabeel Shakir ◽

Annerleim Walton-Diaz ◽

Soroush Rais-Bahrami ◽

Baris Turkbey ◽

Jason Rothwax ◽

...

Keyword(s):

Prostate Cancer ◽

Active Surveillance ◽

Gleason Score ◽

Cancer Progression ◽

Predictive Value ◽

Low Risk ◽

Fusion Biopsy ◽

Trus Biopsy ◽

Risk Prostate Cancer ◽

Low Risk Prostate Cancer

63 Background: Active surveillance (AS) is an option for patients with low risk prostate cancer (PCa); however, determining disease progression is challenging. At the NCI, multiparametric MRI (MP-MRI) with our biopsy protocol (MR-US fusion-guided plus 12 core extended sextant biopsy) has been used to confirm eligibility for AS. We evaluated the utility of these modalities in monitoring patients on AS. Methods: Patients who underwent MP-MRI of the prostate with biopsy per our protocol between 2007-2012 were reviewed. We selected a subset who met Johns Hopkins criteria for AS (Gleason score≤6, PSA density≤0.15, tumor involvement of ≤2 cores, and ≤50% of any single core) by outside 12−core TRUS biopsy. Patients with Gleason score≤6 confirmed at first NCI biopsy session were followed with annual MP-MRI and biopsy. MRI progression was defined as an increase in MP-MRI suspicion level, lesion diameter, or number of lesions. Pathologic progression was defined as an increase to Gleason score≥7 in either 12-core or MR-fusion biopsy. We determined the association between MRI and pathologic progression. Results: 129 patients met JHU criteria for AS by outside biopsy. Mean age was 61.6 years and mean PSA 5.16ng/mL. 28/129 (21.7%) patients had Gleason score ≥7 at first NCI biopsy session.31 patients had at least two biopsy sessions (mean follow up 18 months, range 12-54 months) of which 9/31 (29%) increased in Gleason score, all to 3+4=7. Fusion biopsy detected more pathologic progression than did standard biopsy (Table). The positive predictive value of MP-MRI for pathologic progression was 50%, while the negative predictive value was 84%. The sensitivity and specificity of MP-MRI for increase in Gleason score was 67% and 73%, respectively. Conclusions: Stable findings on MP-MRI are associated with Gleason score stability in patients with low-risk PCa choosing AS. The majority of patients who had pathologic progression were detected on fusion biopsy, which may suggest that random biopsies are unnecessary in this population. Larger studies are needed to validate these findings. [Table: see text]

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