Identifying Men Who Can Remain on Active Surveillance Despite Biopsy Reclassification to Grade Group 2 Prostate Cancer.

Men on active surveillance (AS) with Grade Group (GG) 1 prostate cancer who reclassify to GG2 on surveillance biopsy often leave AS. We aimed to identify subgroups of men who can safely remain on AS despite preoperative reclassification to GG2.

We studied 249 AS patients with surveillance biopsies classified as GG1 or GG2 who underwent RP. Perineural invasion (PNI), cancer volume, linear length and maximum percentage of Gleason pattern 4 (GP4), and PSA density (PSAD) were evaluated. RP adverse pathology was defined by any of: pN1; ≥pT3; ≥GG2 with ≥20% GP4; intraductal carcinoma; large cribriform glands.

A multivariable logistic regression model incorporating PSAD and PNI stratified RP adverse pathology risk among GG1 and GG2 AS patients. 57% (39/68) of GG1 men reclassified to GG2 while on AS had favorable RP pathology. Those without biopsy PNI and with low PSAD were more likely to have favorable RP pathology.

Most GG1 men who enter AS and subsequently reclassify to GG2 have favorable findings at RP and can remain on AS. Among patients reclassified to GG2, those with low PSAD and without PNI had the lowest risk of RP adverse pathology, comparable to (or below) that of GG1 patients who were not reclassified to GG2 pre-operatively. PSAD and PNI stratify risk in AS patients reclassified to GG2 and if concordant with other clinicopathologic and radiographic findings, can enable more patients to remain on AS. Reclassification to GG2 alone should not disqualify men from remaining on AS.

The Journal of urology. 2023 Apr 12 [Epub ahead of print]

Ezra Baraban, Eric Erak, Aisha Fatima, Amir Akbari, Jianping Zhao, Sean A Fletcher, Yasin Bhanji, Claire M de la Calle, Mufaddal Mamawala, Patricia Landis, Katarzyna J Macura, Christian P Pavlovich, Jonathan I Epstein

Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland., Department of Urology, Johns Hopkins Hospital, Baltimore, Maryland., Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland.