Gleason Score 3 + 4 (Grade Group 2) Prostate Cancer on Biopsy and Postoperative Pathological Upgrading: A Systematic...

Area of Science:

• Urology
• Oncology
• Pathology

Background:

• Active surveillance is a treatment option for intermediate-risk prostate cancer (PCa) patients.
• Clinical heterogeneity of needle biopsy (Bx) 3+4 diagnosis creates uncertainty for active surveillance.
• Upgrading of Bx 3+4 at radical prostatectomy (RP) is a critical concern impacting treatment decisions.

Purpose of the Study:

• To investigate pathological upgrading from Bx 3+4 to adverse RP pathology.
• To assess the impact of upgrading on oncological outcomes.
• To identify predictors of upgrading in Bx 3+4 prostate cancer.

Main Methods:

• A systematic literature search was conducted up to February 2025.
• Meta-analyses were performed on data from 48 studies including 63,119 patients with matched Bx 3+4 and RP pathology.
• Independent predictors for upgrading were identified.

Main Results:

• The incidence of Bx 3+4 upgrading to RP ≥ 4+3 was 23.4%.
• Age, clinical T stage (cT), PI-RADS, greatest percentage of cancer in biopsy (GPC), and number of positive cores were significant predictors of upgrading.
• No significant differences in upgrading rates were observed between systematic biopsy (SBx) and MRI-targeted biopsy (TBx) methods, or between transrectal (TR) and transperineal (TP) approaches.

Conclusions:

• Upgrading from Bx 3+4 to adverse RP pathology occurs in 23.4% of cases.
• Patients with upgraded disease may experience significantly worse biochemical recurrence-free survival.
• Biopsy methods do not significantly impact the rate of upgrading from Bx 3+4 to RP ≥ 4+3.