International Society of Uro-Pathology (ISUP) grade group 2 prostate cancer (GG2 PCa) with suspicion of extraprostatic extension (EPE) on preoperative multiparametric MRI (mpMRI) presents a paradox: an histologically favorable intermediate-risk tumor with aggressive imaging features. We aimed to characterize this population, and identify predictors of pathological upgrading, downstaging, and oncological outcomes after robot-assisted radical prostatectomy (RARP).
We analyzed data from 150 patients across 8 European centers with MRI-targeted biopsy-confirmed GG2 PCa and mpMRI-suspected EPE (icT3a), stratified by EPE score, who underwent RARP between 2019 and 2024. Primary endpoint was predictors of pathological upgrading (GG ≥ 3); secondary endpoints included downstaging (pT2), surgical margins, and biochemical recurrence (BCR)-free survival.
Patients were divided by EPE score: low (1-2, n = 87) and high (3, n = 38). Pathological upgrading occurred in 36% (55/150), including 10% to GG 4-5. High EPE score was the only significant predictor. Conversely, 46% (69/150) were downstaged to pT2, with low EPE score as main predictor. Positive surgical margins were observed in 30% (45/150). At a median follow-up of 28 months (IQR 17-43), 5-year BCR-free survival was 67% (95% CI 53-85). Posterior/apical EPE on MRI and cT3a stage were linked to higher BCR risk.
GG2 PCa with mpMRI-suspected EPE is heterogeneous, showing risks of both upgrading and organ-confined disease. EPE score was the main predictor of both. Despite imaging suspicion, RARP outcomes remained favorable.
Urologic oncology. 2026 May 29 [Epub ahead of print]
Norbert De Brek, Arthur Peyrottes, Romain Diamand, Guillaume Ploussard, Marco Oderda, Raquel Matos Da Silva Maia, Alberto Sasia, Alexandre Fourcade, Claire Siebert, Daniel Benamran, Vincent Benard, Katerina Rysankova, Arnaud Méjean, Marc-Olivier Timsit, Charles Dariane
Department of urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France. Electronic address: ., Department of urology, Saint Louis Hospital, Paris, France. Electronic address: ., Department of Urology, Jules Bordet Institute, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium. Electronic address: ., Clinique la Croix du Sud, 31130 Quint-Fonsegrives, Oncopole Claudius Regaud, Toulouse, France. Electronic address: ., Department of Surgical Sciences, Urology Unit, Molinette Hospital, University of Torino, Italy. Electronic address: ., Department of Urology, Jules Bordet Institute, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium. Electronic address: ., Department of Surgical Sciences, Urology Unit, Molinette Hospital, University of Torino, Italy. Electronic address: ., Department of Urology, Centre hospitalier universitaire de Brest, France. Electronic address: ., Department of Urology, Centre hospitalier universitaire de Brest, France. Electronic address: ., Division of Urology, Geneva University Hospitals, Geneva, Switzerland. Electronic address: ., Division of Urology, Geneva University Hospitals, Geneva, Switzerland. Electronic address: ., Department of Urology, University Hospital Ostrava, Czech Republic. Electronic address: ., Department of urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France. Electronic address: ., Department of urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France. Electronic address: ., Department of urology, Hôpital européen Georges-Pompidou, AP-HP, Paris, France; U1151 Inserm, INEM, Necker, Paris, France. Electronic address: .