Adverse Pathological Findings in Needle Biopsy Gleason Score 6 Prostate Cancers with Low and Intermediate Preoperative PSA Levels Following Radical Prostatectomy (original) (raw)

2012, Anticancer Research

Aim: We retrospectively analyzed the risk associated with undergrading Gleason score 6 (GS6) prostate cancer (PCa) at biopsy, in patients with preoperative PSA levels of 2-3,99 and 4-10 ng/ml. Patients and Methods: A total of 674 patients with needle biopsy-diagnosed GS6 PCa, who underwent radical prostatectomy (RP) between 1995 and 2011, were evaluated. Patients were stratified by preoperative PSA levels into low PSA (2-3,99 ng/ml) and an intermediate PSA of 4-10 ng/ml. Subsequently, the percentage of patients with extracapsular disease (pathological stage ≥pT3a) and/or positive surgical margins was determined among those whose RP GS was still 6 and compared to undergraded cases. Results: Out of 674 patients with needle biopsy-diagnosed GS6 PCa, 36.2% had no difference between biopsy and RP GS while 11.4% had been overgraded and 52.4% of patients were undergraded at biopsy. Stratified according to preoperative PSA levels, there was a significantly higher incidence of undergrading in the intermediate PSA group. Among those with ≥pT3a tumors, 74.1 % were undergraded in needle biopsy, out of which 67.7% had intermediate PSA levels and 32.3% low PSA levels. Among patients with R1 resections 75.1 % were underdiagnosed, out of which 75.9% had intermediate PSA levels. Stratifying these data according to preoperative PSA levels, ≥pT3a tumors and R1 resection were found significantly more often in the intermediate-PSA group. Conclusion: The incidence of adverse pathological findings, including extraprostatic extension and positive surgical margins, is significantly higher in patients with undergraded biopsy GS6. Low preoperative PSA levels improved the correlation between primary and final GS and led to the reduction of unfavorable pathological findings. Prostate cancer (PCa) is the leading cancer in occurrence in men and the second most common cause of cancer-related mortality among male patients. Well-established risk factors for PCa development are race, advanced age and heredity (1, 2). Moreover, a history of prostatitis or sexually transmitted disease is known to increase the risk for developing PCa (1, 2). Since 1993, screening of men for PCa is a well-established tool in Tyrol in Austria that has significantly reduced the PCa mortality rate in Tyrol (3, 4). The diagnostic workup of patients includes measurement of prostate-specific antigen (PSA) and digital rectal examination, followed by a transrectal ultrasoundguided biopsy in suspicious cases (4). Prostate biopsy consequently results in a determination of histopathological Gleason score (GS), one of the critical predictors of prognostic outcome and therapeutic options in patients (5). In general, the Gleason grading system is the standard histological classification for grading adenocarcinoma of the prostate on core biopsy and operative specimens (5). The GS is the sum of the two most common patterns of tumor growth found in radical prostatectomy (RP) specimens (5). Concerning needle biopsy specimens since 2005, the worst grade is incorporated in the GS grading, even if comprising less than grade 5 of cancer (5). Several studies attempted to compare GS of biopsy and RP with conflicting results (6-8). For example, Zam et al. demonstrated good pathological correlation between needle biopsies and their RP in a cohort of 100 patients (9). However, Berg et al. recently found complete agreement between primary and final GS in 76.9% in a total of 365 patients (10). Data from Oliveira et al. showed that 77.9% of cases had the same GS, while 19.5% were undergraded in biopsy (11). Therapeutically, undergrading of PCa often results in improper assessment of the disease and its treatment, consequently also influencing patient prognosis. It has been 5481