title: Upgrading and downgrading of prostate cancer from biopsy to radical prostatectomy: incidence and predictive factors using the modified Gleason grading system and factoring in tertiary grades.
abstract: BACKGROUND
  Prior studies assessing the correlation of Gleason score (GS) at needle biopsy and corresponding radical prostatectomy (RP) predated the use of the modified Gleason scoring system and did not factor in tertiary grade patterns.
  
  
  OBJECTIVE
  To assess the relation of biopsy and RP grade in the largest study to date.
  
  
  METHODS
  A total of 7643 totally embedded RP and corresponding needle biopsies (2004-2010) were analyzed according to the updated Gleason system.
  
  
  METHODS
  All patients underwent prostate biopsy prior to RP.
  
  
  METHODS
  The relation of upgrading or downgrading to patient and cancer characteristics was compared using the chi-square test, Student t test, and multivariable logistic regression.
  
  
  CONCLUSIONS
  A total of 36.3% of cases were upgraded from a needle biopsy GS 5-6 to a higher grade at RP (11.2% with GS 6 plus tertiary). Half of the cases had matching GS 3+4=7 at biopsy and RP with an approximately equal number of cases downgraded and upgraded at RP. With biopsy GS 4+3=7, RP GS was almost equally 3+4=7 and 4+3=7. Biopsy GS 8 led to an almost equal distribution between RP GS 4+3=7, 8, and 9-10. A total of 58% of the cases had matching GS 9-10 at biopsy and RP. In multivariable analysis, increasing age (p<0.0001), increasing serum prostate-specific antigen level (p<0.0001), decreasing RP weight (p<0.0001), and increasing maximum percentage cancer/core (p<0.0001) predicted the upgrade from biopsy GS 5-6 to higher at RP. Despite factoring in multiple variables including the number of positive cores and the maximum percentage of cancer per core, the concordance indexes were not sufficiently high to justify the use of nomograms for predicting upgrading and downgrading for the individual patient.
  
  
  CONCLUSIONS
  Almost 20% of RP cases have tertiary patterns. A needle biopsy can sample a tertiary higher Gleason pattern in the RP, which is then not recorded in the standard GS reporting, resulting in an apparent overgrading on the needle biopsy.
authors.affiliation: Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, USA. jepstein@jhmi.edu
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Epstein
authors.forename: Zhaoyong
authors.initials: Z
authors.lastname: Feng
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Trock
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001707:Biopsy, Needle; D006801:Humans; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D049451:Nomograms; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D012307:Risk Factors
chemical_list: D017430:Prostate-Specific Antigen