Incidence of upgrading and upstaging in patients with low-volume Gleason score 3+4 prostate cancers at biopsy: finding a new group eligible for active surveillance.

INTRODUCTION: The aim of this study was to identify patients with low-volume Gleason score 3+4 (GS3+4) prostate cancer (PCa) who may be candidates for active surveillance (AS) by analyzing the incidence of upgrading and upstaging following radical prostatectomy (RP). PATIENTS AND METHODS: Of 907 patients who underwent RP at our institute over the last 5 years, 66 men diagnosed with low-volume GS3+4 PCa at needle biopsy were identified. The incidence of upstaging and upgrading was assessed. RESULTS: The overall rate of upgrading and upstaging was 31.8 and 25.6%, respectively. Preoperative PSA levels were significantly higher in patients who were upgraded (p = 0.015). The optimal preoperative PSA cutoff level for the prediction of upgrading was 4.73 ng/ml (sensitivity 85.7%, specificity 57.8%). Patients with <15% of maximum cores positive had significantly lower upstaging rate than those with >15% of maximum cores positive (p = 0.035). Clinical stage and number of positive cores had marginal association with upgrading and upstaging statistically (p = 0.061 and 0.081, respectively). CONCLUSIONS: In patients with low-volume GS3+4 PCa at biopsy, underestimation may be effectively avoided when we select patients with PSA <4.73 and % maximum cancer involvement on positive cores <15%.