Introduction

No previous study calculated tumor volume (TV) at pathology in patients enrolled in active surveillance (AS) programs who are eventually treated with radical prostatectomy (RP). We assessed pathological characteristics in these patients as compared to those found in patients eligible for AS but chosen to undergo immediate RP

Methods

Between 2009 and 2016, 235 consecutive patients were enrolled into our AS program for low-risk PCa according to the PRIAS criteria. During AS, 88 (37.4%) patients were switched to active treatment because of rising PSA, pathological upgrading (Gleason>6 or >2 positive cores) or patient preference. Of these, 48 patients (55%) were submitted to RP at our center. We examined the pathological characteristics of RP in these patients. TV was calculated as prostate weight x percentage of cancer at whole mount pathology. Finally, we compared these figures with those found in the pathological examination of 274 consecutive patients who could have been considered eligible for AS at the time of diagnosis that were instead submitted to immediate RP

Results

Median time from AS entry to RP (n=48) was 14 months (IQR: 11-25.5). Median TV in patients treated with RP after AS was 3.4 ml vs. 2.07 ml in immediate RP patients (p=0.002). In patients who progressed during AS and then received RP (n=48), 38 (79.2%), 11 (22.9%), 2 (4.2%), and 3 (6.3%) had Gleason score >6, extracapsular extension (ECE), seminal vesicles invasion (SVI) and nodal invasion (LNI), respectively. In patients submitted to immediate RP, 85 (30.9%), 13 (4.7%), 1 (0.4%) and 0 (0%) had Gleason score >6, ECE, SVI and LNI, respectively. Patients initially managed with AS had higher rates of Gleason >6 (7.7% vs. 35.4%), ECE (22.9 vs. 4.7%), SVI (4.2 vs. 0.4%), LNI (6.3 vs. 0%) and higher (all p<0.001). However, when the rates of adverse pathology of patients who progressed during AS (n=48) were recalculated on the total number of patients who entered the AS program (n=235), these figures were virtually identical to those of patients submitted to immediate RP (all p: n.s.), suggesting that time on AS did not worsen pathological outcomes.

Conclusions

Patients initially managed with AS seem to show higher rates of adverse pathology compared to similar patients treated with immediate RP. However, when applied to the overall population of AS patients, the rate of upstaging and upgrading at diagnosis remained stable during AS. The findings of adverse pathology at RP seem to be more related to initial misclassification instead of real clinical progression

Funding

none