Investig Clin Urol.  2020 Jul;61(4):405-410. 10.4111/icu.2020.61.4.405.

Prediction of pathologic upgrading in Gleason score 3+4 prostate cancer: Who is a candidate for active surveillance?

  • 1Department of Urology, Cho Ray Hospital, Ho Chi Minh, Viet Nam
  • 2Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea


Whether active surveillance (AS) can be safely extended to patients with Gleason score (GS) 3+4 prostate cancer is highly debated. We examined the incidence and predictors of upgrading among patients with GS 3+4 disease.
Materials and Methods
The study involved 377 patients with biopsy GS 3+4 who underwent robot-assisted laparoscopic radical prostatectomy (RP) from 2014 to 2018 at a single institution. We analyzed the rate of GS upgrading and used logistic regression to determine the predictors of upgrading.
A total of 168 (44.6%) patients with GS 3+4 experienced an upgrade in GS. In multivariable analysis, advanced age, prostate-specific antigen (PSA) level, PSA density (PSAD) and Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score were significant predictors of GS upgrading. When structured into a predictive model that included age ≥65 years, PSA ≥7.7 ng/mL, PSAD ≥0.475 ng/mL2 and PI-RADS v2 score 4–5, the probability of GS upgrading ranged from 36.4% to 65.7% when one to four of these factors were included.
A substantial proportion of patients with GS 3+4 prostate cancer were upgraded after RP. However, according to our model combining clinical and imaging predictors, patients with a low risk of GS upgrading may be eligible candidates for AS.


Pathology; Prognosis; Prostate neoplasms; Prostatectomy
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