Histologic upgrading in patients eligible for active surveillance on saturation biopsy

We evaluated the risk of histologic upgrading and upstaging in patients who met strict active surveillance (AS) criteria on saturation biopsy and elected to undergo radical prostatectomy.

A retrospective review was conducted of 362 consecutive, individual patients who underwent transrectal ultrasound guided saturation biopsy (32 cores) between 2006 and 2013. Thirty-one patients (9%) were eligible for AS based on Hopkins criteria for very low risk (VLR): stage T1c, prostate-specific antigen (PSA) density ≤ 0.15 ng/mL2, Gleason ≤ 6, ≤ 2 cores and ≤ 50% core. Twenty patients (64%) elected radical prostatectomy, 2 (7%) elected radiation treatment and 9 (29%) elected AS (n = 9, 29%). Radical prostatectomy results were used to evaluate for upgrading and upstaging.

Patient and saturation biopsy characteristics were similar amongst radical prostatectomy, radiation and AS patients. Mean age was 63 years (range 50-75) and 27 patients (87%) had a prior negative biopsy. Median time to prostatectomy was 3 months (range 1-46). Upgrading (Gleason ≥ 7) was identified in 40% (n = 8) of patients: Gleason 3+4 (n = 7) and Gleason 4+3 (n = 1). Upstaging (≥ T3) was not identified. Mean follow up was 47 months (range 11-99) for all patients. No patient developed biochemical recurrence or required salvage treatment.

Despite increased prostate sampling, patients who met strict AS criteria on saturation biopsy were at high risk for Gleason upgrading, but fortunately at low risk for upstaging and biochemical recurrence. Patients contemplating AS based on saturation biopsy results should be counseled appropriately. MRI-TRUS fusion biopsy may be an alternative to saturation biopsy until proven otherwise.