Pathological Findings and Prostate Specific Antigen Outcomes After Radical Prostatectomy in Men Eligible for Active Surveillance—Does the Risk of Misclassification Vary According to Biopsy Criteria?

Abstract

Word count abstract: Word count text :2 ABSTRACT Purpose: To evaluate and compare the pathological findings and the PSA outcomes after radical prostatectomy (RP) in men eligible for AS, according to 3 different biopsy inclusion criteria. Materials and Methods:The study population included 177 men eligible for AS who fulfilled clinico-biological criteria (Gleason score ≤6, PSA<10, clinical stage T1c) and biopsy criteria as follows: (1) <3 positive cores and <3 mm of total tumour length; (2) and/or <3 positive cores with a cancer involvement <50% in any core; (3) and/or <33% of positive cores. PSA density cut-offs of 15 and 20 ng/ml/gr were also studied among these groups. Pathological findings on RP specimens and biochemical recurrence-free survival (RFS) were studied. Median follow-up was 34 months.Results: Cancers were graded Gleason 7 on RP specimens from 48.3% to 55.4% of cases. The rates of extracapsular extension (ECE) and vesicle seminal invasion (SVI) ranged from 11.2% to 17.5%, and from 1.1% to 1.8%, respectively, regardless of PSA density. The use of PSA density as AS criterion decreased for AS by 1.4-fold and by 2.3-fold the number of men eligible according to the cut-off used. The risk of unfavourable disease (defined as pT3-4 stage and/or a Gleason score≥8) remained between 15% to 19.2% when a PSA density cut-off of 15 ng/ml/gr was used. The risk of overall unfavourable disease was significantly higher in men with a cancer involvement ≥3 mm in initial biopsy compared with men who fulfilled these most stringent biopsy criteria (27.3%, vs 13.5%, respectively; p=0.023). The 3-year biochemical RFS was 91.5% and was not affected by the 3 different AS definitions. Conclusions:Even with the use of a 21-core biopsy protocol, the rate of unfavourable disease on RP specimens remains still elevated in men eligible for AS. Patients must be informed of this risk of misclassification which is about 20% in men who fulfil the less stringent biopsy criteria.

Heterogeneity in D׳Amico classification–based low-risk prostate cancer: Differences in upgrading and upstaging according to active surveillance eligibility

“…According to the current findings, these high rates of reclassification at repeat biopsy might still underestimate the risk of Gleason score 4 involvement within AS patients. However, El Hajj et al [9] and Ploussard et al [25] recorded higher rates of pathological stage pT3a within AS candidates who opted for RP than the current study did (14.3%-18.8% vs. 6.3%). Conversely, the rates of pathological stage pT3b were comparable to the current study (1.8% vs. 1.6%).…”

“…Similarly, the rate of either intermediate-or high-risk characteristics at final pathology were comparable between the results obtained in the study by El Hajj et al [9] and that of the current study (50% vs. 56%). Moreover, we recorded lower rates of positive surgical margins, when AS candidates underwent RP (7.4% vs. 18%-19.6%) [9,25].…”

Prostate Cancer: Can Multiparametric MR Imaging Help Identify Patients Who Are Candidates for Active Surveillance?

“…A major concern is that results of random 12-core biopsies do not accurately reflect the aggressiveness of the disease. Indeed, even extended biopsy protocols can miss cancers with unfavorable features, leading to improper selection for AS (17). Multiparametric magnetic resonance (MR) imaging, including both anatomic and functional sequences, has been shown to be effective for the detection and local staging of prostate cancer (18); however, multiparametric MR imaging currently is not included in the decision-making algorithms or criteria for AS.…”

MR Imaging–Transrectal US Fusion for Targeted Prostate Biopsies: Implications for Diagnosis and Clinical Management

“…Even with the strictest criteria and the acquisition of 20 or more cores at biopsy, 20% of patients are misclassified as having low-risk disease (ie, biopsy fails to demonstrate the more aggressive component of the disease, so it is inappropriately recommended that the patient not undergo definitive therapy) (48). Reclassification seems to occur primarily owing to undersampling of the more aggressive tumor (Fig 8) rather than progression of indolent cancer (49,50).…”