Improving the prediction of Gleason score upgrading: The role of prostate-specific antigen density

Conservative therapies, such as active surveillance, can be appropriate treatment for low-risk prostate cancer. The aim of this study was to analyze the frequency of Gleason score (GS) upgrading in patients with a low-grade GS. We reviewed our prospectively maintained database of patients with prostate cancer that underwent radical prostatectomy within the time frame of 2004–2015. Potential predictors of upgrading in patients with GS 3 + 3 were studied. Of the 342 patients in our database, 125 had GS 3 + 3. Biopsy GS and surgical GS were identical in 71 (56.8%) patients with GS 3 + 3, whereas 54 (43.2%) patients had an upgrade. The GS was upgraded to 7 in 70% of those patients and to ≥8 in 30%. We found a statistically significant correlation between postoperative upgrade and the preoperative prostate-specific antigen density (PSAD) value (p < 0.001), prostate volume (p = 0.004), and patient age ≥70 years (p = 0.011). We estimated an optimal PSAD cutoff point of 0.17 ng/ml² through ROC analysis, with an AUC of 0.675 (p = 0.001). It is our opinion that every hospital center offering active surveillance should carry out a continuous review of upgrading and related risk factors.