Upgrading and Downgrading of Prostate Needle Biopsy Specimens: Risk Factors and Clinical Implications
Received 19 May 2006; accepted 24 October 2006.
Objectives
The prostate biopsy Gleason grade frequently differs from the radical prostatectomy (RP) grade. Given the critical role that needle biopsy plays in treatment decisions, we sought to determine the risk factors for upgrading and downgrading the prostate biopsy specimen.
Methods
We determined the significant predictors of upgrading (worse RP grade than biopsy grade) and downgrading (better RP grade than biopsy grade) among 1113 men treated with RP from 1996 to 2005 within the Shared Equal Access Regional Cancer Hospital (SEARCH) database who had undergone at least sextant biopsy. The Gleason sum was examined as a categorical variable of 2 to 6, 3+4, and 4+3 or greater.
Results
Overall, the disease of 299 men (27%) was upgraded and 123 (11%) was downgraded, and 691 men (62%) had identical biopsy and pathologic Gleason sum groups. Upgrading was associated with adverse pathologic features (P ≤0.001) and the risk of biochemical progression (P = 0.001). Downgrading was associated with more favorable pathologic features (P ≤0.01) and a decreased risk of progression (P = 0.04). On multivariate analysis, greater prostate-specific antigen levels (P <0.001), more biopsy cores with cancer (P = 0.001), and obesity (P = 0.003) were all significantly and positively associated with upgrading. In contrast, biopsy Gleason sum 3+4 (P = 0.001) and obtaining eight or more biopsy cores (P = 0.01) were associated with a lower likelihood of upgrading.
Conclusions
Men whose disease was upgraded were at a greater risk of adverse pathologic features and biochemical progression. Men with “high-risk” cancer (greater prostate-specific antigen levels, more positive cores, and obese) were more likely to have their disease category upgraded, and obtaining more biopsy cores reduced the likelihood of upgrading.
⁎Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
†Division of Urologic Surgery, Departments of Surgery and Pathology and Duke Prostate Center, Duke University School of Medicine, Durham, North Carolina
‡Urology Section, Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, California
§Department of Urology, University of California, San Francisco, School of Medicine, San Francisco, California
¶Department of Urology, University of Alabama at Birmingham, Birmingham, Alabama
∥Department of Urology, San Diego Naval Hospital, San Diego, California
#Urology Section, Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
⁎⁎Department of Urology, University of California, Los Angeles, School of Medicine, Los Angeles, California
††Department of Surgery, Augusta Veterans Affairs Medical Center, Augusta, Georgia
‡‡Section of Urology, Medical College of Georgia, Augusta, Georgia
§§Department of Urology, Stanford University School of Medicine, Palo Alto, California
¶¶Urology Section, Department of Surgery, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
Reprint requests: Stephen J. Freedland, M.D., Division of Urology, Box 3850 DUMC, Duke University School of Medicine, Durham, NC 27710.
This study was supported by the Department of Veterans Affairs, National Institutes of Health grant R01CA100938 (W.J. Aronson), National Institutes of Health Specialized Programs of Research Excellence grant P50 CA92131-01A1 (W. J. Aronson), the Georgia Cancer Coalition (M. K. Terris), Department of Defense, Prostate Cancer Research Program (S. J. Freedland), and the American Urological Association Foundation/Astellas Rising Star in Urology Award (S. J. Freedland).
The views and opinions of, and endorsements by the authors do not reflect those of the U.S. Army or the U.S. Department of Defense.
ABSTRACT