Korean J Urol.  2015 Sep;56(9):624-629. 10.4111/kju.2015.56.9.624.

Pathological upgrading in prostate cancer patients eligible for active surveillance: Does prostate-specific antigen density matter?

• Jin BS
• Kang SH
• Kim DY
• Oh HG
• Kim CI
• Moon GH
• Kwon TG
• Park JS

• KMID: 2344100
• DOI: http://doi.org/10.4111/kju.2015.56.9.624

Abstract

PURPOSE
To evaluate prospectively the role of prostate-specific antigen (PSA) density in predicting Gleason score upgrading in prostate cancer patients eligible for active surveillance (T1/T2, biopsy Gleason score< or =6, PSA< or =10 ng/mL, and < or =2 positive biopsy cores).
MATERIALS AND METHODS
Between January 2010 and November 2013, among patients who underwent greater than 10-core transrectal ultrasound-guided biopsy, 60 patients eligible for active surveillance underwent radical prostatectomy. By use of the modified Gleason criteria, the tumor grade of the surgical specimens was examined and compared with the biopsy results.
RESULTS
Tumor upgrading occurred in 24 patients (40.0%). Extracapsular disease and positive surgical margins were found in 6 patients (10.0%) and 8 patients (17.30%), respectively. A statistically significant correlation between PSA density and postoperative upgrading was found (p=0.030); this was in contrast with the other studied parameters, which failed to reach significance, including PSA, prostate volume, number of biopsy cores, and number of positive cores. Tumor upgrading was also highly associated with extracapsular cancer extension (p=0.000). The estimated optimal cutoff value of PSA density was 0.13 ng/mL2, obtained by receiver operating characteristic analysis (area under the curve=0.66; p=0.020; 95% confidence interval, 0.53-0.78).
CONCLUSIONS
PSA density is a strong predictor of Gleason score upgrading after radical prostatectomy in patients eligible for active surveillance. Because tumor upgrading increases the potential for postoperative pathological adverse findings and prognosis, PSA density should be considered when treating and consulting patients eligible for active surveillance.

Keyword

Neoplasm grading; Prostate specific antigen; Prostatectomy

MeSH Terms

Aged
Biopsy, Needle
Humans
Male
Middle Aged
Neoplasm Grading
Neoplasm Invasiveness
Neoplasm, Residual
Organ Size
Predictive Value of Tests
Prospective Studies
Prostate/*pathology
Prostate-Specific Antigen/*blood
Prostatic Neoplasms/*blood/*pathology/surgery
ROC Curve
Watchful Waiting/*methods
Prostate-Specific Antigen

Figure

• 

  Fig. 1 Receiver operating characteristic curve analysis for prostatespecific antigen (PSA) density cutoff value of 0.13 ng/mL2.

Reference

1. Klotz L, Zhang L, Lam A, Nam R, Mamedov A, Loblaw A. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol. 2010; 28:126–131.

2. 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.

3. 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.

4. Kvale R, Moller B, Wahlqvist R, Fossa SD, Berner A, Busch C, et al. Concordance between Gleason scores of needle biopsies and radical prostatectomy specimens: a population-based study. BJU Int. 2009; 103:1647–1654.

5. Thickman D, Speers WC, Philpott PJ, Shapiro H. Effect of the number of core biopsies of the prostate on predicting Gleason score of prostate cancer. J Urol. 1996; 156:110–113.

6. Corcoran NM, Hong MK, Casey RG, Hurtado-Coll A, Peters J, Harewood L, et al. Upgrade in Gleason score between prostate biopsies and pathology following radical prostatectomy significantly impacts upon the risk of biochemical recurrence. BJU Int. 2011; 108(8 Pt 2):E202–E210.

7. Epstein JI, Allsbrook WC Jr, Amin MB, Egevad LL. ISUP Grading Committee. The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. Am J Surg Pathol. 2005; 29:1228–1242.

8. Cohen MS, Hanley RS, Kurteva T, Ruthazer R, Silverman ML, Sorcini A, et al. Comparing the Gleason prostate biopsy and Gleason prostatectomy grading system: the Lahey Clinic Medical Center experience and an international meta-analysis. Eur Urol. 2008; 54:371–381.

9. Fernandes ET, Sundaram CP, Long R, Soltani M, Ercole CJ. Biopsy Gleason score: how does it correlate with the final pathological diagnosis in prostate cancer? Br J Urol. 1997; 79:615–617.

10. 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.

11. Capitanio U, Karakiewicz PI, Valiquette L, Perrotte P, Jeldres C, Briganti A, et al. Biopsy core number represents one of foremost predictors of clinically significant gleason sum upgrading in patients with low-risk prostate cancer. Urology. 2009; 73:1087–1091.

12. Coogan CL, Latchamsetty KC, Greenfield J, Corman JM, Lynch B, Porter CR. Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score. BJU Int. 2005; 96:324–327.

13. Chambo RC, Tsuji FH, de Oliveira Lima F, Yamamoto HA, Nobrega de. What is the ideal core number for ultrasound-guided prostate biopsy? Korean J Urol. 2014; 55:725–731.

14. 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.

15. 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.

16. 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.

17. Garnett JE, Oyasu R, Grayhack JT. The accuracy of diagnostic biopsy specimens in predicting tumor grades by Gleason's classification of radical prostatectomy specimens. J Urol. 1984; 131:690–693.

18. 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.

19. 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.

20. Kassouf W, Nakanishi H, Ochiai A, Babaian KN, Troncoso P, Babaian RJ. Effect of prostate volume on tumor grade in patients undergoing radical prostatectomy in the era of extended prostatic biopsies. J Urol. 2007; 178:111–114.

21. Freedland SJ, Isaacs WB, Platz EA, Terris MK, Aronson WJ, Amling CL, et al. Prostate size and risk of high-grade, advanced prostate cancer and biochemical progression after radical prostatectomy: a search database study. J Clin Oncol. 2005; 23:7546–7554.

22. Paulson DF. Impact of radical prostatectomy in the management of clinically localized disease. J Urol. 1994; 152(5 Pt 2):1826–1830.

23. Allsbrook WC Jr, Mangold KA, Johnson MH, Lane RB, Lane CG, Epstein JI. Interobserver reproducibility of Gleason grading of prostatic carcinoma: general pathologist. Hum Pathol. 2001; 32:81–88.

24. Allsbrook WC Jr, Mangold KA, Johnson MH, Lane RB, Lane CG, Amin MB, et al. Interobserver reproducibility of Gleason grading of prostatic carcinoma: urologic pathologists. Hum Pathol. 2001; 32:74–80.

25. Corcoran NM, Casey RG, Hong MK, Pedersen J, Connolly S, Peters J, et al. The ability of prostate-specific antigen (PSA) density to predict an upgrade in Gleason score between initial prostate biopsy and prostatectomy diminishes with increasing tumour grade due to reduced PSA secretion per unit tumour volume. BJU Int. 2012; 110:36–42.

26. Kojima M, Troncoso P, Babaian RJ. Use of prostate-specific antigen and tumor volume in predicting needle biopsy grading error. Urology. 1995; 45:807–812.

27. Magheli A, Hinz S, Hege C, Stephan C, Jung K, Miller K, et al. Prostate specific antigen density to predict prostate cancer upgrading in a contemporary radical prostatectomy series: a single center experience. J Urol. 2010; 183:126–131.