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

Abstract

PurposeTo 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≤6, PSA≤10 ng/mL, and ≤2 positive biopsy cores).Materials and MethodsBetween 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.ResultsTumor 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).ConclusionsPSA 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.

The use of prostate specific antigen density to predict clinically significant prostate cancer

“…The tendency of PSAD to detect clinically significant prostate cancer has been shown in several clinical scenarios. For instance, the integration of PSAD into active surveillance protocols can be associated with improved enrollment criteria and a reduced rate of upgrading and reclassification down to 17.5% 11 , 12 .…”

Prostate Cancers Detected by Magnetic Resonance Imaging–Targeted Biopsies Have a Higher Percentage of Gleason Pattern 4 Component and Are Less Likely to Be Upgraded in Radical Prostatectomies

“…Although several studies show a positive correlation, 12,48,49 other studies do not find a correlation between Gleason upgrading and tumor volume. 50,51 Our study shows that Gleason upgrading is inversely correlated with cancer volume measurementincluding greatest length and percentage of tumor in any cancer core, and greatest length and percentage of tumor in any cancer core with GP 4-implying that a GS 7 PCa with a smaller volume on standard biopsy is more likely to be upgraded at RP. The possible explanation for this finding is that a PCa with a small volume may not be adequately sampled by the standard sextant biopsy.…”

Expanded criteria for active surveillance in prostate cancer: a review of the current data

“…One method of determining these cutoffs would be to generate receiver operating characteristic (ROC) curves for each parameter to define values that maximize sensitivity and specificity for clinically significant versus insignificant prostate cancer. Furthermore, by combining these ROC curves with number needed to treat and number needed to harm analyses, physicians and patients can have maximally informed discussions about the risks and benefits of treatment versus AS ( 23 , 24 ).…”