Related Experiment Video
Updated: Aug 7, 2026
A New Technique for Treating Low-risk Prostate Cancer—Super Active Surveillance
Published on: November 7, 2025
FIB-4 is associated with Gleason grade group upgrading after radical prostatectomy: a comparison of inflammatory and
Osman Köse1, Hakan Tekinaslan2, Kürsad Dönmez3
1Department of Urology, İzmir Kâtip Çelebi University, Faculty of Medicine, Atatürk Training and Research Hospital, İzmir, Turkey. oskose@gmail.com.
Purpose:
Gleason grade group upgrading from biopsy to radical prostatectomy (RP) may reveal clinically significant prostate cancer that was underestimated at biopsy, particularly among men selected for active surveillance (AS). We compared the discriminative performance of 13 routinely available blood-derived indices for upgrading and assessed whether the Fibrosis-4 (FIB-4) index provided additional information beyond standard clinical variables.
Methods:
We retrospectively reviewed 599 men with gradable biopsy and RP pathology. Major upgrading, the primary endpoint, was defined as an increase of ≥ 2 ISUP grade groups; any upgrading was defined as any increase. Ten inflammatory indices and three AST/ALT-based indices, including the De Ritis ratio, APRI, and FIB-4, were evaluated using the Mann-Whitney U test, logistic regression, and receiver operating characteristic analysis. AS-eligible men were defined as biopsy ISUP grade group 1, PSA < 10 ng/mL, and clinical stage ≤ T2a.
Results:
Upgrading occurred in 43.7% of patients, and major upgrading in 15.5%. Inflammatory indices showed no clinically meaningful discrimination, whereas AST/ALT-based indices consistently demonstrated better discrimination. FIB-4 was independently associated with both any upgrading (OR 1.75) and major upgrading (OR 2.10) after adjustment for PSA, the number of positive biopsy cores, and biopsy ISUP grade group. For major upgrading, adding FIB-4 to the clinical model increased the AUC from 0.589 to 0.711 (ΔAUC + 0.122; DeLong p = 0.0003), and this incremental association persisted after age was included in the base model. Among 258 AS-eligible men, PSA did not discriminate between patients with and without major upgrading, whereas the De Ritis ratio and FIB-4 showed the strongest discrimination.
Conclusion:
Among routinely available blood-derived indices, the clinically relevant signal for Gleason upgrading after RP appeared to be concentrated in AST/ALT-based markers rather than inflammatory indices. FIB-4 was independently associated with upgrading and may provide incremental risk information in active surveillance-eligible men. These findings warrant prospective validation incorporating PSA density and imaging-based risk assessment.
