Role of PSA velocity in predicting pathologic upgrade for Gleason 6 prostate cancer

Pathologic upgrading to Gleason 7 or higher on radical prostatectomy (RP) specimens occurs in many patients with Gleason 6 prostate cancer on preoperative biopsy. We evaluated whether biopsy characteristics and preoperative factors, including preoperative PSA velocity (PSAV), are predictive of pathologic upgrading.

We identified 235 consecutive Gleason 6 prostate cancer patients who underwent biopsies at our institution, had multiple pre-biopsy PSA values, and eventually underwent RP. Preoperative biopsy, clinical characteristics, and PSAV were analyzed to determine the risk of pathologic upgrading or extracapsular extension. These clinical factors were evaluated for association with biochemical recurrence following RP.

Overall, 48% of patients were upgraded to Gleason grade 7 or higher following RP. Median PSAV was 0.61 ng/mL/y, and PSAV was similar between upgraded and non-upgraded patients (1.01 vs. 0.78, P = 0.1). PSA velocity level was not associated with extracapsular disease (P = 0.4). PSA velocity > 1 was associated with biochemical recurrence (HR 3.23, P = 0.01) but this was not statistically significant in a multivariable model. Increasing PSA density (HR 2.18, P < 0.001), bilateral cores positive (HR 1.89, P < 0.05), and any biopsy core involvement > 50% (HR 2.52, P < 0.05) were most associated with pathologic upgrading. On multivariate analysis, only bilateral cancer detection at biopsy (HR 1.90, P < 0.05) significantly predicted upgrading.

PSAV has a limited role in predicting Gleason 6 upgrading. Patients with bilateral cancer detected on transrectal biopsy should be encouraged to have radical local therapy due to high risk of harboring more aggressive disease.