Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
Cancer. 2013 Nov 15;119(22):3992-4002. doi: 10.1002/cncr.28303. Epub 2013 Sep 4.
Many patients with low-risk prostate cancer (PC) who are diagnosed with Gleason score 6 at biopsy are ultimately found to harbor higher grade PC (Gleason ≥ 7) at radical prostatectomy. This finding increases risk of recurrence and cancer-specific mortality. Validated clinical tools that are available preoperatively are needed to improve the ability to recognize likelihood of upgrading in patients with low-risk PC.
More than 30 clinicopathologic parameters were assessed in consecutive patients with Gleason 6 PC upon biopsy who underwent radical prostatectomy. A nomogram for predicting upgrading (Gleason ≥ 7) on final pathology was generated using multivariable logistic regression in a development cohort of 431 patients. External validation was performed in 2 separate cohorts consisting of 1151 patients and 392 patients. Nomogram performance was assessed using receiver operating characteristic curves, calibration, and decision analysis.
On multivariable analysis, variables predicting upgrading were prostate-specific antigen density using ultrasound (odds ratio [OR] = 229, P = .003), obesity (OR = 1.90, P = .05), number of positive cores (OR = 1.23, P = .01), and maximum core involvement (OR = 0.02, P = .01). On internal validation, the bootstrap-corrected predictive accuracy was 0.753. External validation revealed a predictive accuracy of 0.677 and 0.672. The nomogram demonstrated excellent calibration in all 3 cohorts and decision curves demonstrated high net benefit across a wide range of threshold probabilities. The nomogram demonstrated areas under the curve of 0.597 to 0.672 for predicting upgrading in subsets of men with very low-risk PC who meet active surveillance criteria (all P < .001), allowing further risk stratification of these individuals.
A nomogram was developed and externally validated that uses preoperative clinical parameters and biopsy findings to predict the risk of pathological upgrading in Gleason 6 patients. This can be used to further inform patients with lower risk PC who are considering treatment or active surveillance.
许多经活检诊断为 Gleason 评分 6 的低危前列腺癌（PC）患者，在接受根治性前列腺切除术时最终被发现存在更高等级的 PC（Gleason≥7）。这一发现增加了复发和癌症特异性死亡的风险。需要术前使用经过验证的临床工具来提高识别低危 PC 患者升级可能性的能力。
对经活检诊断为 Gleason 6 PC 且接受根治性前列腺切除术的连续患者进行了 30 多项临床病理参数评估。在一个包含 431 例患者的开发队列中，使用多变量逻辑回归生成预测最终病理升级（Gleason≥7）的列线图。在两个独立的队列中进行了外部验证，包括 1151 例患者和 392 例患者。使用接收者操作特征曲线、校准和决策分析评估列线图的性能。
多变量分析中，预测升级的变量包括超声前列腺特异性抗原密度（比值比 [OR] = 229，P =.003）、肥胖（OR = 1.90，P =.05）、阳性核心数（OR = 1.23，P =.01）和最大核心受累（OR = 0.02，P =.01）。内部验证中，bootstrap 校正后的预测准确性为 0.753。外部验证显示预测准确性分别为 0.677 和 0.672。列线图在所有 3 个队列中均表现出良好的校准，决策曲线在广泛的阈值概率范围内显示出较高的净收益。列线图在满足主动监测标准的低危 PC 患者亚组中预测升级的曲线下面积为 0.597 至 0.672（所有 P 值均<.001），从而可以进一步对这些个体进行风险分层。
开发并外部验证了一个列线图，该列线图使用术前临床参数和活检发现来预测 Gleason 6 患者发生病理升级的风险。这可以帮助进一步告知考虑治疗或主动监测的低危 PC 患者。
