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Gleason upgrading and Increased Cancer Volume on Repeat Prostate Biopsy in Patients on Active Surveillance
Mark A. Preston, M.D., Robert Carrasquillo, M.D., Jonathan J. Paly, M.D., John J. Coen, M.D., Anthony I. Zietman, M.D., Matthew R. Smith, M.D., Chin-Lee Wu, M.D., W. Scott McDougal, M.D., Adam S. Feldman, M.D..
Massachusetts General Hospital, Boston, MA, USA.

BACKGROUND: The choice to terminate active surveillance (AS) for localized prostate cancer in favor of initiating definitive treatment is based on a variety of factors. These may include pathologic change on re-biopsy, progression in PSA or DRE, or patient preference. The relative extent to which each of these factors plays a role in the termination of AS is not clearly established. Our objective was to determine the prevalence of prostate re-biopsy and subsequent pathologic change in an AS cohort.
METHODS:Under IRB approved protocol, a historical cohort study of men diagnosed with prostate cancer was performed at a single tertiary-care center between 1997 and October 2009. Although AS had been practiced throughout this period, in 2008 our group agreed upon a protocol for repeat biopsy at 12-18 months after diagnosis. Subsequent biopsy was left to the discretion of the treating physician. Only men with active surveillance as the initial management option were included.
RESULTS: The median follow-up was 4.8 years for the 499 patients included in the study. Median PSA at diagnosis was 5.1 ng/mL (0.4-19.2). 98.2% (490/499) of patients were Gleason 6, 1.8% (9/499) were Gleason 7 and 94.0% (469/499) were stage T1a/c. 322/499 (64.5%) patients underwent re-biopsy. The number of re-biopsies ranged from 1 - 5 with 113/499 (22.6%) patients having more than one re-biopsy. Findings on initial re-biopsy revealed prostate cancer in 70.8% (228/322), benign tissue in 20.8% (67/322), PIN in 7.1% (23/322), and atypia in 1.2% (4/322). The Gleason sum increased in 18.5% of patients whose re-biopsy revealed cancer. Cancer volume increased (expressed as percentage of positive cores in quartiles) in 26.0% of patients on re-biopsy. Of 123 patients who required active treatment, 45.5% (56/123) was due to pathologic progression.
CONCLUSIONS: We identified a significant proportion of Gleason upgrading and volume progression on repeat biopsy in this cohort. Repeat biopsy often resulted in a significant change in management of our AS population. These findings support the critical role of repeat biopsy in an AS protocol.


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