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Pathologic Upgrading in Biopsy Grade Group 1, PI-RADS ≥3 Prostate Cancer: Factors Associated with Clinically Significant Disease on Radical Prostatectomy
Alfred Anthony Barney, IV, MS, Shulin Wu, MD, PhD, Adam S. Feldman, MD, MPH, Chin-Lee Wu, MD, PhD, Douglas M. Dahl, MD.
Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: Active surveillance (AS) is the recommended management for most biopsy Gleason Grade Group (GG) 1 prostate cancer (PCa). However, a portion of men with suspicious imaging (PI-RADS ≥3), if managed through radical prostatectomy (RP), are found to have higher-grade disease. We aimed to quantify the rate of pathologic upgrading in surgically selected patients with GG1/PI-RADS ≥3 who underwent RP and to investigate the features that distinguish patients with unexpectedly clinically significant cancer.
METHODS: A single-center retrospective review of patients undergoing imaging and transperineal ultrasound-guided fusion biopsy (TPBx) (September 2021-October 2023) at our institution. Patients with GG1 on TPBx and mpMRI PI-RADS ≥3 were included and grouped by RP status. Multivariable Firth-penalized logistic regression in the RP cohort included age, prostate volume (mL), and percent tumor in the maximum systematic core percent involvement (max SBx-core involvement), each reported per +1 interquartile range (IQR).
RESULTS: Of the 1,457 TPBx cases, 244 (16.7%) met the concurrent GG1, PI-RADS ≥3 inclusion criteria, and 62 (25.4% of 244) underwent radical prostatectomy. RP patients were significantly younger, had smaller prostates, and had a higher biopsy tumor burden (all p < 0.05). Of the 62 patients, 45 (72.6%) were upgraded to GG ≥2 on final pathology. Within the surgical cohort, men with upgraded disease had significantly smaller prostate volumes (41 vs 51 mL, p = 0.031) and greater tumor percentage in max SBx-core involvement (50% vs 40%, p = 0.044). On multivariable analysis, these factors remained independent predictors.
CONCLUSIONS: The high rate of pathologic upgrading (72.6%) in men selected for surgery with GG1, PI-RADS ≥3 disease indicates a substantial burden of underdiagnosed, clinically significant cancer among those selected for surgery. Two readily available measures—max SBx-core involvement and prostate volume—summarize most of the actionable signals. These metrics may help establish expectations when counseling patients with similar conditions.
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