Pathologic Upgrading in Biopsy Grade Group 1, PI-RADS ≥ 3 Prostate Cancer: Factors Associated With Clinically...

Active surveillance (AS) is standard for most men with biopsy Gleason Grade Group (GG) 1 prostate cancer (PCa). However, some with suspicious magnetic resonance imaging (MRI) findings (PI-RADS ≥ 3) harbor higher-grade disease. We quantified the rate of pathologic upgrading among surgically treated GG1/PI-RADS ≥ 3 patients and identified predictors of clinically significant cancer.

We retrospectively reviewed men undergoing transperineal MRI-ultrasound fusion biopsy at a tertiary center (September 2021-October 2023). Patients with biopsy GG1 and PI-RADS ≥ 3 were grouped by radical prostatectomy (RP) status. In the RP cohort, multivariable Firth logistic regression assessed associations between age, prostate volume, and maximum systematic biopsy core percent involvement (max SBx-core involvement) and upgrading (GG ≥ 2).

Of 1457 biopsy cases, 244 (16.7%) met the inclusion criteria, and 62 (25.4%) underwent RP. RP patients were younger, had smaller prostates, and greater biopsy tumor burden than nonsurgical patients (all P < .05). Among RP patients, 45 of 62 (72.6%) were upgraded to GG ≥ 2. Upgraded cases had smaller prostates (41 vs. 51 mL, P =.031) and higher max SBx-core involvement (50% vs. 40%, P = .044). On multivariable analysis, both remained independent predictors of upgrading.

In biopsy GG1 men with PI-RADS ≥ 3 lesions, upgrading at RP is frequent (73%), underscoring the limitations of biopsy risk classification. Smaller prostate volume and greater tumor involvement on systematic cores provide reproducible, quantitative predictors that may inform counseling and management decisions for this discordant subset.