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Pathological upgrading from biopsy Gleason score 3+4 (Grade Group 2) to final radical prostatectomy pathology
Shulin Wu, MD, PhD, Sharron X. Lin, PhD, Alfred Anthony Barney, IV, MS, Michelle M. Kim, MD, Mukesh G. Harisinghani, MD, Adam S. Feldman, MD, MPH, Chin-Lee Wu, MD, PhD, Douglas M. Dahl, MD.
Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: Biopsy (Bx) Gleason score (GS) 3+4 prostate cancer (PCa) exhibits clinical heterogeneity that complicates active surveillance decision-making. Pathological upgrading at radical prostatectomy (RP) in this cohort remains understudied. We assessed upgrading rates from Bx 3+4 to RP ≥4+3 by biopsy approach (transperineal (TP) vs. transrectal (TR)) and method (systematic biopsy (SBx), mpMRI-targeted biopsy (TBx), and combined), and identified predictors of upgrading.
METHODS: We identified 421 patients diagnosed with Bx 3+4 by combined SBx and TBx via TP (n=214; median cores: SBx 20 + TBx 3; September 2019-March 2023) or TR (n=207; median cores: SBx 12 + TBx 3; July 2014-February 2021) who subsequently underwent RP. Clinical, MRI, and pathological data were collected. Upgrading rates were compared across approaches and methods. Univariable and multivariable analyses identified predictors of RP upgrading.
RESULTS: Overall, 58 patients (13.8%) were upgraded at RP, including 43 (10.2%) to GS 4+3 and 15 (3.6%) to GS ≥8. Upgrading rates did not differ significantly between TP and TR (14.9% vs. 12.6%) or among SBx, TBx, and combined biopsy (14.1%, 12.8%, and 12.6%, respectively; all p>0.05). Gleason pattern 4 percentage (GP4%) across SBx, TBx, and RP specimens was significantly correlated. The upgrading group demonstrated significantly higher PSA (7.2 vs. 5.9 ng/mL, p=0.006), higher PSA density (0.20 vs. 0.15, p=0.025), larger index lesion diameter (13 vs. 11 mm, p=0.007), greater frequency of PI-RADS 5 (46.6% vs. 29.8%, p=0.043), and transitional zone index location (32.8% vs. 19.6%, p=0.037). On multivariable analysis, higher GP4% in TBx was the only independent predictor of upgrading (OR=30.7, 95% CI 1.65-570, p=0.022).
CONCLUSIONS: Bx 3+4 was upgraded to RP ≥4+3 in 13.8% and to RP ≥8 in 3.6% of cases. Upgrading rates were comparable across biopsy approaches and methods. Higher GP4% on TBx independently predicted RP upgrading.
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