Predictors of pathological upgrading in low-risk gleason grade group 1 prostate cancer on prostate biopsy: the role of clinical and tumor-specific factors.

OBJECTIVE: Gleason Grade Group (GG) 1 prostate cancer (PCa) with PSA <10 ng/dL is considered low risk or very low risk disease per NCCN risk stratification. Management recommendation for these patients is typically active surveillance. We sought to determine risk factors for pathological upgrading in men with GG1 on prostate biopsy who elected robotic radical prostatectomy (RALP).

MATERIALS AND METHODS: A retrospective review of men with GG1 PCa who underwent RALP was performed. Final pathology specimens were examined for the following endpoints: final Gleason score, positive margin (PSM) status, presence of perineural invasion (PNI), presence of variant histology.

RESULTS: 874 men underwent MRI-fusion prostate biopsy between January 2021 and August 2024. Of the 874 men, 198 had GG1 prostate cancer with PSA <10ng/dL, of which 164 underwent RALP. On multivariate analysis, there was no correlation between number of positive biopsy cores and pathological upgrading. Significant predictors for upgrading or other adverse pathological features were abnormal digital rectal exam (DRE), PSA >6ng/dL, PIRADS score of 5, MPS2.0 score >8.1%, presence of atypical small acinar proliferation (ASAP) or intraductal carcinoma (IDC) on biopsy.

CONCLUSION: Men with GG1 prostate cancer on prostate biopsy and PSA >6 ng/dL, PIRADS 5 lesion on mpMRI, abnormal DRE, MPS2.0 score >8.1%, and presence of any IDC or ASAP on biopsy are more likely to have disease upgrading and adverse pathological features such as PSM on final pathology at the time of RALP. These men should be counseled on their unique risks, with prioritization of early intervention.