MP56-12: Age and Gleason Score upgrading between prostate biopsy and radical prostatectomy. Is this still true in the MRI era?

Armando Stabile, Jeffrey Karnes, Giovanni Motterle, Giorgio Gandaglia, Vito Cucchiara, Simone Scuderi, Francesco Barletta, Nicola Fossati, Carlo Bravi, Elio Mazzone, Daniele Robesti, Marco Moschini, Aldo Rizzo, Giuseppe Rosiello, Pierre I Karakiewicz, Francesco Pellegrino, Riccardo Leni, Giorgio Brembilla, Antonio Esposito, Francesco Montorsi, Francesco De Cobelli, Alberto Briganti

Introduction: The risk of Gleason score (GS) upgrading between biopsy and radical prostatectomy (RP) is known to be higher in elderly men. We hypothesized that the introduction of MRI has improved the diagnostic accuracy in older men reducing the risk of upgrading at RP.

Methods: We selected 7831 men who underwent RP at a single tertiary referral center before the introduction of MRI for diagnostic purposes (i.e. before year 2013). We then selected 453 men who received a systematic plus targeted biopsy for a positive MRI (PIRADS>=3) and  receiving a subsequent RP at two tertiary referral centers between 2013 and 2019. The study outcome was to compare the relationship between age and the probability of upgrading at RP across the two populations (MRI vs no MRI cohort). Upgrading was defined as an increase in GS at final pathology compared to biopsy. We used two multivariable logistic regression analyses predicting the risk of upgrading using age, PSA, prostate volume, clinical stage, GS (6 vs 7 vs >=8), number of positive cores for both models and PIRADS score only in the MRI cohort. Non-parametric loess function was used to explore the relationship between age and rate of upgrading in the two cohorts

Results: Median age and rate of upgrading were 65 yrs and 66 yrs and 16% and 37% in the MRI and no MRI cohort, respectively. In the MRI cohort, GS was the only independent predictor of upgrading (GS 7 OR: 0.03; GS>=8 OR: 0.10; p<0.0001) while age was not (p=0.4). In the no MRI cohort, age (OR: 1.03), PSA (OR: 1.02), prostate volume (OR: 0.98), clinical stage (T2 OR: 1.53; T3 OR: 1.80), GS (GS 7 OR: 0.11; GS>=8 OR: 0.13) and number of positive cores (OR: 1.03) were independent predictors of upgrading (all p<0.01). Figure 1 shows as the overall rate of upgrading was higher in the no MRI cohort for men aged>50 yrs. The probability of upgrading slightly decreased with age in the MRI cohort while it significantly increased in the no MRI cohort

Conclusions: We showed that use of mp-MRI has obliterated the association between older age and increased risk of upgrading mainly due to improved diagnostic approaches in this group of men. Therefore, it is likely that the effect of age and Gleason score upgrading reported in previous studies in elderly men was due to misdiagnosis and lead-time bias in the preMRI era in this patient group Source of

Funding: none