Repeat biopsy remains central to active surveillance (AS) because upgrading and tumor burden may change management.
This retrospective paired workflow study included 38 men and 47 repeat biopsy sessions (2023-2025), comprising 846 biopsy cores and 871 H&E slides. Whole-slide imaging (WSI) and conventional microscopy were compared after a washout interval. QuPath was used only for pathologist-guided tumorlength and greatest percentage of cancer (GPC) documentation.
On the first eligible repeat biopsy, upgrading to ISUP Grade Group (GG) 2 occurred in 7/38 men (18.4%; 95% CI, 7.7- 34.3). No GG3, cribriform morphology, or intraductal carcinoma was identified. Protocol-linked reclassification occurred in 11/38 men (28.9%). Slide-level cancer-detection agreement was 856/871 (98.3%; kappa = 0.91), and raw patient-level agreement for upgrading was 36/38 (94.7%; kappa = 0.80). After adjudication, no upgraded patient remained missed. QuPathsupported measurement was interpretable in 79/101 positive core-level assessments (78.2%), with excellent agreement (ICC = 0.98) and shorter median measurement time (41 s vs 78 s).
WSI reproduced management-relevant conventional microscopy outputs in repeat AS biopsies. Its value was organizational and documentary, not autonomous cancer detection or grading.
Archivio italiano di urologia, andrologia : organo ufficiale [di] Societa italiana di ecografia urologica e nefrologica. 2026 Jun 15 [Epub ahead of print]
Ludovica Pepe, Mara Curduman, Pietro Pepe, Vincenzo Fiorentino
Anatomic Pathology Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina; PhD Program in Translational Molecular Medicine and Surgery, Department of Biomedical Sciences, Dental Sciences and Morpho-functional Imaging, University of Messina., Pathology Unit, Cannizzaro Hospital, Catania., Urology Unit, Cannizzaro Hospital, Catania.