Prostate biopsy upgrading and its implications on treatment modality and outcomes in men treated with radical prostatectomy or permanent seed implantation at UT M.D. Anderson Cancer Center, 2000-2001

Introduction: Radical prostatectomy and permanent seed implantation are among the standard of care treatment options for men with low or intermediate risk prostate cancer. Pathologic upgrading of Gleason score from biopsy to radical prostatectomy specimen has been previously described, but the meaning for men undergoing permanent seed implantation is unclear. The purpose of this study is to compare the biochemical recurrence-free survival and prostate cancer specific survival outcomes of a cohort of patients whose disease was upgraded between outside institution biopsy to UT MD Anderson Cancer Center biopsy, or between biopsy to radical prostatectomy Gleason score, to those patients who were not upgraded. Methods: A retrospective cohort was assembled using data from 387 men with clinical T1-T2b, prostate-specific antigen (PSA) level < 20 ng/mL, and Gleason score (GS) 6-7 disease on biopsy treated with either radical prostatectomy (n=294) or permanent seed implantation (n=93) at the UT MD Anderson Cancer Center during 2000-2001. No patient in the radical prostatectomy or permanent seed implantation group received adjuvant external beam radiation therapy. We compared the 5-year biochemical recurrence-free survival between the upgraded and non-upgraded patients using the outside biopsy Gleason score, UT MD Anderson Cancer Center centrally reviewed Gleason score, and radical prostatectomy Gleason score using Kaplan-Meier estimates. The prostate cancer specific survival was compared between men who had full pathologic evaluation for upgrading (radical prostatectomy) versus those who only had a biopsy. 3 Results: The median follow-up time was 7.2 years for the radical prostatectomy group and 7.6 years for the permanent seed implantation group. There was no statistically significant difference in mean PSA level between men treated with radical prostatectomy (6.2 ng/mL) and permanent seed implantation (6.6 ng/mL), and the most common clinical stage was T1c for both groups. For patients presenting with outside pathologic review, upgrading from Gleason 6 to Gleason 7 occurred in 43 men treated with radical prostatectomy (14.6%) and 16 men treated with permanent seed implantation (17.2%). For men treated with radical prostatectomy, 132 men had subsequent upgrading from MD Anderson biopsy Gleason score to radical prostatectomy Gleason score (44.9%). In the radical prostatectomy group, the biochemical recurrence-free survival at 5 years was 93.2% in men with concordance between the outside Gleason score and MD Anderson central review Gleason score, and 95.3% for men with an upgrading from Gleason 6 to 7 (p=0.60). In the permanent seed implantation monotherapy group, the 5 year biochemical recurrence-free survival rate was 91.6% in men with concordant Gleason score, and 100% in men with upgrading from Gleason 6 to Gleason 7 (P=0.40). Conclusions: In this retrospective cohort analysis with central pathology review at a tertiary cancer center, we found no differences in biochemical recurrence-free survival rates or prostate cancer specific survival for men who are upgraded versus not upgraded. We are currently evaluating these findings in a prospective cohort of permanent seed implantation monotherapy in men with intermediate risk localized disease.Master of Public Healt