SIGNIFICANCE OF TERTIARY PATTERN 5 IN PROSTATE NEEDLE BIOPSIES WITH GLEASON SCORE OF 3+4 OR 4+3 PROSTATE CANCER: PATHOLOGIC CORRELATION FOLLOWING RADICAL PROSTATECTOMY

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THE JOURNAL OF UROLOGY®

2080 PERCENTAGE OF POSITIVE CORES STRONGLY INFLUENCES THE RATE OF GLEASON SUM AGREEMENT BETWEEN PROSTATE BIOPSY AND RADICAL PROSTATECTOMY. Firas Abdollah*, Vincenzo Scattoni, Alberto Briganti, Diego Angiolilli, Federico Dehò, Marco Roscigno, Nazareno Suardi, Andrea Gallina, Massimo Freschi, Claudio Doglioni, Patrizio Rigatti, Francesco Montorsi, Milano, Italy INTRODUCTION AND OBJECTIVE: The aim of this study was to evaluate the influence of the percentage of positive cores (PPC) on Gleason grade agreement between biopsy and radical prostatectomy (RP). METHODS: The study cohort included 2422 patients treated with RP for clinically localized prostate cancer at a single European institution between January 2002 and May 2008. Of these, 1974 (81.5%) had complete pre-operative clinical and biopsy data. Pathological evaluation was performed by three expert uro-pathologists. For the aim of this study four outcomes were considered: Gleason sum concordance (GSC) between biopsy and RP, biopsy Gleason sum downgrading (GSD) and upgrading (GSU) as well as biopsy Gleason sum significant upgrading (GSSU) defined as a shift from either biopsy Gleason sum 2-6 to 7 or higher, or biopsy Gleason sum 7 to 8-10 at RP. Univariable and multivariable logistic regression analyses addressed the association between PPC and the aforementioned outcomes after controlling for patient age at surgery, pre-operative PSA, clinical stage, primary and secondary biopsy Gleason score. RESULTS: Mean age at surgery was 65.1 yrs (median: 65.8; range 41.4-82). Mean PSA at biopsy was 8.8 ng/ml (median 6.9 ng/ml; range: 0.3-50). Mean number of cores taken was 15.7 (median: 14; range 2-24 ). Mean number of positive cores was 6.5 (median 6; range 1-24). Mean PCC was 43.6% (median: 35.7%; range 4-100%). Biopsy Gleason sum was a6 in 65.9% (1300), 7 in 27% (532) and q8 in 7.1% (142) of patients, respectively. Pathological Gleason sum was a6 in 38.7% (764), 7 in 50.5% (996) and q8 in 10.8% (214) of patients, respectively. The rates of GSC, GSD, GSU and GSSU were 45% (883), 13% (266), 42% (825/1974) and 35% (689) respectively. At multivariable analysis, PPC was a significant predictor of GSC (OR=0.45; p=0.008), GSD (OR=0.22; p=0.001), GSU (OR=6.6; p<0.001) and GSSU (OR=4.4; p<0.001; Table 1) after accounting for pre-operative predictors. CONCLUSIONS: The percentage of positive cores represents an important significant predictor of Gleason sum agreement between biopsy and RP. Increasing percentage of positive cores is indeed associated with higher probability of Gleason score upgrading and significant upgrading. Source of Funding: None

2081 SIGNIFICANCE OF TERTIARY PATTERN 5 IN PROSTATE NEEDLE BIOPSIES WITH GLEASON SCORE OF 3+4 OR 4+3 PROSTATE CANCER: PATHOLOGIC CORRELATION FOLLOWING RADICAL PROSTATECTOMY Rajal B Shah*, Stephanie Daignault, LP Kunju, David P Wood, Jr, John T Wei, Ann Arbor, MI INTRODUCTION AND OBJECTIVE: The International Society of Urologic Pathologists recommends biopsy Gleason score (GS) of 3+4 or 4+3 prostate cancer (PCA) with tertiary pattern 5 be classified as GS of 8 or 9, respectively so that it can be incorporated in the current PCA nomograms for management decisions. However, the scientific data supporting this recommendation and the overall significance of tertiary pattern 5 in prostate needle biopsy (NBX) is largely unknown. METHODS: Prostate NBXs with Gleason score 7 (both 3+4 and 4+3) with tertiary Gleason pattern 5 (third least common pattern of any amount recognizable at low power) were identified to determine the prognostic significance of tertiary pattern 5 and reporting recommendation. For control population NBXs with GS 7 without tertiary pattern 5 and GS 8-10 were included. For all groups only those patients who underwent subsequent radical prostatectomy as a definitive treatment were included

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for further analysis of pathologic outcomes as an end point. RESULTS: Total 30 cases met the criteria. Pretreatment serum PSA ranged from 1.7 to 42 ng/ml (median 7.4). Number of cores sampled ranged from 6 to 14 and involvement by tertiary pattern 5 from 1 to 3 (average 1). Of 30 cases, 26 underwent radical prostatectomy (RP), 2 combined radiotherapy and androgen deprivation, 1 radiation, and 1 awaiting treatment decision. Of 26 patients with RP, 31% were pT2, 42% T3a, 23 % T3b, 4 % T4, 19 % with lymph node metastasis and 27% had positive surgical margins. Gleason 7 with tertiary 5 were significantly more likely to present with locally advanced caners (pT3/pT4) and lymph node metastasis, compared to Gleason 7 without tertiary 5 (Pa 0.0001). At RP, pattern 5 was seen as primary, secondary and tertiary pattern in 4%, 42%, and 50% of biopsy GS 7 with tertiary 5 cases respectively, remaining 4% had no pattern 5. CONCLUSIONS: Men with prostate cancer having biopsy GS 7 and tertiary pattern 5 had a significantly high risk of adverse pathologic outcomes in comparison to biopsy GS 7 without tertiary 5. Our result justifies the inclusion of tertiary pattern 5 in biopsy as a secondary pattern for prognostic and management decisions. Source of Funding: None

2082 IS THERE AN INDICATION FOR PREOPERATIVE PROSTATE BIOPSY IN PATIENTS UNDERGOING RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER? Christian Thomas*, Christoph Wiesner, Sebastian Melchior, Rolf Gillitzer, Joachim W Thüroff, Mainz, Germany INTRODUCTION AND OBJECTIVE: The aim of this study was to determine indications for preoperative prostate biopsy in patients undergoing radical cystoprostatectomy for bladder cancer. METHODS: In 316 cystoprostatectomy specimen, concomitant prostate cancer (PCA) was diagnosed in 21,5%. PCA was diagnosed preoperatively in 24% (evident PCA), 32% were suspicious of having PCA but not biopsied (suspected PCA) and in 44% PCA was incidental. Patients were stratified into groups of probability to detect intermediate/ high risk PCA by digital-rectal-examination and PSA. The incidence of unfavourable histopathology for each group was determined. RESULTS: 85% of PCAs were organ confined. Gleason scores were favourable (2-6) in 74%. In incidental PCA, tumors were organ confined in 97% . There were no unfavourable Gleason scores (8-10). In the low probability group, 83% of patients had organ confined PCA and only 17% had an unfavourable Gleason score. In the intermediate probability group, PCA was organ confined in 73%, 45% had favourable Gleason scores (2-6) and 55% had an intermediate Gleason score (7). In the high probability group, 29% had a high risk PCA. CONCLUSIONS: When DRE is not suspicious and PSA is < 10ng/ml, most concomitant prostate cancers are organ confined and have favourable or intermediate Gleason scores. As a consequence, patients with low/intermediate probability to detect intermediate/high risk PCA do not require preoperative prostate biopsy, except if nerve sparing surgery is planned. In contrary, all patients should undergo preoperative biopsy for PCA when DRE is suspicious or PSA-levels > 10 ng/ml, because one of three patients had high risk PCA in this group. Source of Funding: None