Preoperative characteristics of men with unfavorable high-Gleason prostate cancer at radical prostatectomy

Introduction: Some men with Gleason sum 8-10 prostate cancer (PC) at RP have favorable outcomes: Biochemical recurrence free (BFS) and prostate cancer-specific survival (CSS) are improved for such men with pT2 or pT3a disease compared with pT3b or N1 disease at radical prostatectomy (RP). We examine biopsy characteristics of men with high-grade PC at RP to better select those who may benefit from surgery. Materials and Methods: A total of 1,174 men from our Institutional Database (1982-2010) had Gleason 8-10 cancer at RP. Their demographic and prostate biopsy characteristics were compared among those with disease defined as favorable (pT2 or pT3a) vs. unfavorable (pT3b or N1). Logistic regression was used to determine predictors of unfavorable disease. Kaplan-Meier analysis was used to determine survival outcomes. Results: Biopsy data were available for 1,157 men (median cores 12 [2-20]); 779 (66.4%) favorable, 394 (33.6%) unfavorable; 102 (8.7%), 515 (44.1%), and 552 (47.2%) were low, intermediate, and high-risk. For favorable and unfavorable cases, 10-year BFS was 40.0% and 5.7% (P < 0.001) and CSS was 84.9% and 60.3% (P < 0.001). Multivariate logistic regression revealed that PSA ≥ 20 and perineural invasion (PNI) at biopsy increased the likelihood of unfavorable, high-grade disease. Considering PSA ≥ 20 and PNI as adverse features, 23.7%, 40.1%, and 71.4% of patients with none, 1, or 2 adverse features had unfavorable, high-Gleason PC (P < 0.001). Conclusions: High-Gleason PC was not uniformly associated with poor outcomes after RP, though men with unfavorable (pT3b/N1) disease fared poorly. Preoperative predictors of high-Gleason, unfavorable disease in a cohort of predominantly intermediate and high-risk patients were PSA ≥ 20 and PNI.