Clinical Significance Of Gleason Score,T Stage And PSAD In Predicting PSA Progression After Radical Prostatectomy For Intermediate-risk Prostate Cancer

1.Background and ObjectivesPCa is the most common solid malignancy in many western countries.Although the incidence and mortality rate of the prostate cancer is lower in Asian countries,the incidence has risen in recent years.It is well known that the CUA and EUA PCa risk classification system has been widely applied for the selection of appropriate treatment and the prediction of prognosis for PCa,Even so,significant heterogeneous remained in every given risk group and the established risk stratification system appeared to inefficiently identify patients with advanced pathologic features preoperatively.PSA progression is often a predictor of tumor recurrence.The purpose of this study was to explore the risk factors of PSA progression of intermediate-risk prostate cancer,and identify potential"high-risk" cases based on preoperative and postoperative risk factors,so as to conduct more accurate risk stratification for intermediate-risk prostate cancer patients.2.MethodsWe retrospectively analyzed 357 cases of prostate cancer patients who underwent radical prostatectomy in the first affiliated hospital of Suchow University from September 2013 to September 2018 and met the inclusion criteria.According to the 2019 European guidelines for the diagnosis and treatment of urological diseases,169 had intermediate-risk PCa(clinical stage T2b,or biopsy Gleason score 7,or PSA 10-20 ng/mL),and 188 had high-risk PCa(clinical stage ≥T2c,or biopsy Gleason score 8-10,or PSA>20 ng/mL).Radieal prostatectomy was carried out using the laparoscopic approach.None of the patients in the intermediate-risk group received adjuvant androgen deprivation and all the patients in the high-risk group received adjuvant androgen deprivation.T test and chi-square test were used to compare the differences in the clinical characters between patients in intermediate-risk group and those in the high-risk group.PSA progression was defined as two consecutive rises in PSA level ≥0.2 ng/mL after RP.PSAD was defined as the ratio of preoperative serum PSA level(ng/mL)to transrectal ultrasound-estimated prostate volumae(cm3).Postoperative PSA-free survival rates were calculated using the Kaplan-Meier method with a log-rank statistie being used to compare the PSA-free survival rates among the groups or subgroups.To identify independent prognosis factors,univariate analysis was carried out using the following variables:patient age,biopsy primary Gleason pattern,preoperative PSA level,prostate volume,PSA density,percent of positive biopsies and positive surgical margins.3.Results1)There were statistically significant differences in PSA,PSAD,percent of positive biopsies,biopsy primary Gleason pattern and clinical T stage between the intermediate-risk and high-risk groups.2)The results of univariate analysis showed that PSAD,biopsy primary Gleason pattern and clinical T stage were important risk factors for PSA progression in patients with intermediate-risk PCa(P=0.021、0.026 and 0.021,respectively).The results of multivariate analysis were consistent with the results of univariate analysis.Independent risk factors of PSA progression in patients with intermediate-risk PCa included PSAD>0.15 ng/mL/cm3(HR=2.204,95%Cl 1.02-4.78,P=0.036),biopsy primary Gleason pattern was 4(HR=2.539,95%Cl 1.25～5.17,P=0.010),clinical staging T2b(HR=2.336,95%CI 1.14～4.79,P=0.021.3)There was no statistically significant differences in PSA progression survival rate between the patients who met T2a+PSAD>0.22 ng/mL/cm3 or G3+PSAD>0.37 ng/mL/cm3 or G4+PSAD>0.15ng/ml/cm3 or T2b+PSAD>0.15 ng/mL/cm3 and the high-risk group.Patients with intermediate-risk PCa who met G4+PSAD>0.37 ng/mL/cm3 was almost the same as that in the high-risk group.4.ConclusionsBased on the influences of various factors on BCR rate of intermediate and high-risk PCa,the following conclusions are drawn:1.PSAD,biopsy primary Gleason pattern,and clinical T stage,as independent risk factors,could be used to classify the risk of intermediate-risk PCa.2.Patients with intermediate-risk PCa who met some conditions may have a similar prognosis in the high-risk group,especially those with G4+PSAD>0.37 ng/mL/cm3 whose PSA-free survival curve was almost the same as that in the high-risk group.These patients may need early postoperative intervention and individual treatment.