EURURO Vol. 72 No. 3

Prostate Cancer

Adverse Disease Features in Gleason Score 3 + 4 ‘‘Favorable

Intermediate-Risk’’ Prostate Cancer: Implications for Active

Surveillance

Alessandro Morlacco

a ,

John C. Cheville

b ,

Laureano J. Rangel

c ,

Derek J. Gearman

a ,

R. Jeffrey Karnes

a , *

Department of Urology, Mayo Clinic, Rochester, MN, USA;

Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA;

Department of

Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA

E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 4 4 2 – 4 4 7

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Article info

Article history:

Accepted August 18, 2016

Associate Editor:

Giacomo Novara

Keywords:

Prostate cancer

Active surveillance

Eligibility

Gleason score

Gleason 3 + 4

Radical prostatectomy

Upgrade

Downgrade

Unfavorable disease

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Abstract

Background:

According to a recent National Comprehensive Cancer Network (NCCN)

guidelines update, patients with Gleason score (GS) 3 + 4 prostate cancer (PCa) and

‘‘favorable intermediate-risk’’ (FIR) characteristics might be offered active surveillance

(AS). However, the risk of unfavorable disease features and its prediction in this subset of

patients is not completely understood.

Objective:

To identify the risk of unfavorable disease and potential predictors of adverse

outcomes among GS 3 + 4 FIR PCa patients.

Design, setting, and participants:

The study included patients with biopsy GS 3 + 4 and

otherwise fulfilling the NCCN low-risk definition (prostate-specific antigen [PSA]

ng/ml, cT2a or lower) undergoing radical prostatectomy (RP) from 2006 to 2014 at a

single institution.

Outcome measurements and statistical analysis:

Complete information on PSA, PSA

density (PSAD), clinical stage, percentage of positive cores, percentage of maximum

surface specimen involvement, and RP pathology were available. GS upgrade and

downgrade, non–organ-confined and non–specimen-confined disease, unfavorable dis-

ease (pT3–T4 and/or pN1 and/or a pGS 4 + 3) were the outcomes. Statistical analysis

included descriptive statistics and multivariable logistic regression.

Results and limitations:

A total of 156 patients (13.1%) experienced GS upgrade; 201

(16.9%) were downgraded. Overall, 205 men (17.2%) harbored non–organ-confined

disease, and 295 (24.8%) had unfavorable disease. Age (odds ratio [OR]: 1.06), percentage

surface involvement (OR: 1.01), and PSAD (OR: 1.83) were the only significant predictors

of upgrade. Age (OR: 1.05), clinical stage (OR: 1.74), percentage of positive cores

50%

(OR 1.57), percentage of surface area (OR: 1.02), and perineural invasion (OR: 1.89) were

significant predictors of unfavorable disease at RP. The retrospective design is a limita-

tion.

Conclusions:

AS is a possible option for a subset of men with FIR GS 3 + 4. However,

clinical models alone have a limited role in GS upgrade prediction, and alternative tools

warrant further investigation.

Patient summary:

Patients with Gleason score 3 + 4 at biopsy, low prostate-specific

antigen, and low stage might consider the option of active surveillance, but the use of

clinical information alone might be not adequate for thorough risk-adapted counseling.

* Corresponding author. Mayo Clinic, Gonda Building 7-130, 200 First Street SW, Rochester, MN

55905, USA. Tel. +1 507 266 9968; Fax: +1 507 284 4951.

E-mail address:

Karnes.R@mayo.edu

(R.J. Karnes).

http://dx.doi.org/10.1016/j.eururo.2016.08.043

0302-2838/