July 15, 2020

How Accurate Is Needle Biopsy in Patients With High-Grade Prostate Cancer?

New study examines rates of downgrading in patients with aggressive prostate cancer

650×450-Prostate-Cancer

For most cancers, the nuclei of the cancer cell are indicative of how aggressive the malignancy is. In prostate cancer, however, the shape and configuration of the cells that make up each individual gland, rather than the nucleus, provides a better basis for diagnosis.

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Recognizing this, the Gleason scoring system, implemented in the 1970s, assesses both the appearance of the cells — ranging from more to less disordered — and also includes the sum of primary and secondary cell patterns. Often in prostate cancer, more than one pattern is present.

This heterogeneous cell pattern and growth can understandably lead to inaccuracies in prostate biopsies. A needle biopsy may capture a particularly high- or low-grade pattern that does not reflect the true nature of the malignancy. In fact, a closer evaluation of the specimen after prostatectomy may lead physicians to change the patient’s risk category altogether, known as upgrading or downgrading.

Investigators recently led a study to better assess the rate of downgrading in a cohort of patients with high-grade prostate cancer on initial biopsy. They reported their findings in the Journal of Urology.

Eric Klein, MD, Chair of Glickman Urological & Kidney Institute and co-author of the study, remarks, “Accurate risk stratification is critical for treatment planning and management of patient expectations.” He continues, “We hoped to determine how often a high-grade biopsy actually translated to high-grade disease or if it was the result of a sampling error.”

Advertisement

A closer look at the findings

The study examined 1,776 men with localized high risk (PSA >20 ng/ml, Grade Group (GG) 4-5, or clinical stage ≥ T3) or very high risk (primary Gleason pattern 5, more than four biopsy cores with GG 4-5, or two or more HR features) prostate cancer who underwent radical prostatectomy (RP) from 2005 to 2015. Investigators examined patients diagnosed with GG 4 disease at the time of biopsy and had data available for analysis (N = 726).

Of this cohort, 45% of patients (N = 333) were downgraded to GG ≤ 3 after surgery. This is significantly lower than similar studies that have approximated as many as 60% of high-grade cases may be downgraded. Of these, 16% (98/604) of high-risk patients and 7% (8/122) of very high-risk patients (P < 0.01) were downgraded to GG ≤ 2.

Downgraded patients shared the following clinical and oncological traits. The majority of downgraded biopsies had Gleason pattern 4+4 (86.7%), as compared to 3+5 or 5+3 (P = 0.003). On average, they also had lower PSA levels, fewer positive biopsy cores and lower clinical stage. Taken together, this data may give clinicians evidence to predict whether a biopsy is likely to be downgraded following RP.

“In other words, if a patient shows a high-risk or very high-risk cancer on biopsy, there is a good chance that it is, in fact, a high-grade malignancy, and is fine to proceed with a more aggressive treatment plan,” says Dr. Klein.

Advertisement

And while it’s unlikely that a biopsy downgrade from GG 4 to GG 3, for example, would have altered the course of treatment in a significant way, the psychological implications for patients and the difference in prognosis discussions should not be overlooked.

“Our findings affirm that despite some challenges with high-grade prostate cancer biopsy, we can still be relatively confident that the diagnosis is consistent with final pathology,” comments Dr. Klein. “This is just one more way to help manage care for patients and counsel them on treatment.”

Related Articles

Cleveland Clinic physiatrist
March 22, 2024
The Vital Role of Oncology Rehabilitation (Podcast)

New program provides prehabilitation and rehabilitation services to help patients with cancer maintain and regain function

Doctors working on MGUS screening study
March 18, 2024
Pilot Study Aims for Early Identification of Multiple Myeloma Precursor Among Black Patients

First-of-its-kind research investigates the viability of standard screening to reduce the burden of late-stage cancer diagnoses

Hematologist at Cleveland Clinic
March 14, 2024
Advances in Mantle Cell Lymphoma Treatment (Podcast)

Global R&D efforts expanding first-line and relapse therapy options for patients

Physician with patient
March 6, 2024
Targeting Uncontrolled Erythrocytosis in Polycythemia Vera with Rusfertide

Study demonstrates ability to reduce patients’ reliance on phlebotomies to stabilize hematocrit levels

Dr. Jagadeesh at Cleveland Clinic
February 28, 2024
Treating Patient with Systemic T-Cell Lymphoma and Graft-Versus-Host Disease

A case study on the value of access to novel therapies through clinical trials

Doctor measuring patient's waist size
February 26, 2024
Impact of Obesity on GVHD & Transplant Outcomes in Hematologic Malignancies

Findings highlight an association between obesity and an increased incidence of moderate-severe disease

Physician with patient
February 21, 2024
Strategies for Improving Clinical Trial Equity

Cleveland Clinic Cancer Institute takes multi-faceted approach to increasing clinical trial access

How antibody drug conjugates work
February 13, 2024
Real-World Use of Trastuzumab Deruxtecan

Key learnings from DESTINY trials

Ad