PREDICTORS OF A CLINICALLY SIGNIFICATIVE PROSTATE CARCINOMA IN PATIENTS WHO UNDERWENT TO RADICAL PROSTATECTOMY BUT WERE AFFECTED BY A CANCER SUITABLE FOR ACTIVE SURVEILLANCE

• Published in: Anticancer research Vol. 38; no. 4; p. 2500
• Main Authors: Di Franco, Carmelo Agostino, Giliberto, Giovanni, Porru, Daniele, Cebrelli, Tiziano, Rovereto, Bruno
• Format: Journal Article
• Language: English
• Published: Athens International Institute of Anticancer Research 01.04.2018
• Subjects: Age; Biopsy; Cancer; Cancer surgery; Cores; Density; Diagnostic systems; Disease control; Guidelines; Health risks; Identification methods; Laparoscopy; Life expectancy; Life span; Mathematical analysis; Multivariate analysis; Patients; Prostate cancer; Prostate carcinoma; Prostate-specific antigen; Prostatectomy; Reclassification; Risk factors; Robotic surgery; Surveillance; Upgrading; Urological surgery; Urology
• ISSN: 0250-7005; 1791-7530

Background/Aim: Active surveillance (AS) represents a therapeutic alternative to an immediate radical treatment in patients affected by localized prostate cancer, with favorable prognosis and long life expectancy. Sometimes, discrepancy between biopsy and prostatectomy specimen, in terms of Gleason Score and pathological stage, risks addressing a low-risk patient to a radical treatment and its related effects. The aim of this work was to evaluate the correlation between biopsy and surgical specimen after radical prostatectomy, in patients affected by low-risk prostate cancer suitable for AS, and moreover, to identify predictive factors of clinically significant disease. Materials and Methods: This is a retrospective, non-randomized, study. A cohort of 461 consecutive patients who underwent to radical prostatectomy between 2010 and 2017 in a single centre were evaluated. Data about age, preoperative prostate-specific antigen (PSA), number of bioptic cores, number of positive bioptic cores, percentage of positive biopsy cores, biopsy and pathological Gleason Score, clinic and pathological stage, prostate volume at the operative specimen, PSA density, and positive surgical margins were recorded for each patient. Prostatic volume was calculated with ellipsoid formula. Then, 135 patients suitable for AS were selected based on the European Association of Urology (EAU) guidelines 2017. The upstaging and the upgrading to clinical significant disease after radical prostatectomy was defined as “reclassification of the disease”, while the upstaging ≥ pT3a and/or the upgrading ≥ Gleason Score 4+3 was defined as “unfavorable disease”. All data were collected in Excel database. To identify predictive factors of clinically significant disease we used univariate and multivariate analysis. Results: In a cohort of 461 patients, overall upgrading and uspstaging rate was 60.3% and 39.9%, respectively. Both upstaging and upgrading was observed in 36% of patients, whereas in 24.3% of cases we had only upgrading to Gleason Score >7. Multivariate analysis on 461 patients showed that PSA density and percentage of positive biopsy cores correlated with upstaging and upgrading risk, whereas the age correlated only with upgrading. In 135 patients suitable for AS, upgrading and upstaging rate was 38.5% and 29.6%, respectively. Both upgrading and upstaging was reported in 23.7% of patients, only upgrading in 14.8%, while 55.6% of patients had no reclassification after radical prostatectomy. Gleason Score was 4+3 in 11.1% patients of the 135 suitable for AS. Multivariate analysis in “AS cohort” showed that age and PSA density correlated with upstaging risk, whereas upgrading risk is associated only to age. Conclusion: In patients suitable for AS, on the basis of parameters suggested by EAU Guidelines 2017, around 40- 50% of patients are indeed affected by a clinically significant prostate cancer. Higher age and higher PSA density were identified as predictive factors of clinically significant disease. There are certain limitations of this study: retrospective design, different pathologist, prostatectomy performed in open retropubic, laparoscopy and robot-assisted way. We suggest, that in the presence of factors suggesting a clinically significant disease, other diagnostic studies (e.g. multiparametric RMN) should be performed before starting an AS program.