Gleason score discrepancies between prostate biopsy and radical prostatectomy in prostate cancer patients: a...

Prostate cancer (PCa) is one of the leading malignancies in males worldwide. Accurate assessment of Gleason scores (GSs) preoperatively is critical for making appropriate treatment decisions. However, GS discrepancies between biopsy and post-surgery pathology are common. This study aimed to evaluate the incidence of GS upgrading and downgrading and to identify related clinical and pathological factors. Understanding the clinical and pathological factors associated with GS upgrading and downgrading is essential to enhance predictive accuracy and optimize PCa management.

This study retrospectively analyzed 218 PCa patients diagnosed by transperineal prostate biopsy and subsequent treated with radical prostatectomy from January 2021 to February 2024. Patients were categorized into upgrading, downgrading, or concordant groups based on GS comparisons. Univariate analysis was adopted to identify predictive factors.

Among the 218 patients included in this study, 80 (36.7%) exhibited pathological upgrading postoperatively, 39 (17.9%) showed pathological downgrading, and 99 (45.4%) maintained consistent pathological results. Pathological upgrading was more frequently observed in patients with a biopsy GS 3+3 (P<0.001) and was associated with the total number of biopsy cores (P=0.043). In contrast, pathological downgrading was more common in patients with biopsy GS 4+3, 5+3, 3+5, or 4+4 (P=0.03) and correlated with the number of positive biopsy cores (P=0.03) and the positive core percentage (P=0.02). Most discrepancies involved ±1 grade group shifts (89, 40.8%), with ≥2 grade group changes occurring in only 13.8% of cases. For patients with GS 3+3 in biopsy, univariate analysis revealed that prostate-specific antigen (PSA), PSA density (PSAD), and the total number of biopsy cores were factors influencing pathological upgrading. Furthermore, 7 (9.8%) of upgraded GS 3+3 cases presented with locally advanced PCa vs. 0% in non-upgraded patients.

These findings highlight significant limitations of pre-surgery biopsy-based grading evaluation. The high rate of upgrading or downgrading suggests current risk stratification systems may underestimate or overestimate clinical impact. This study identified several variables that may assist clinicians in accurately determining the true pathological GS of PCa. This may help to optimize clinical-decisions and improving cancer-specific outcomes in Chinese PCa patients.