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Targeted Prostate Biopsy Gleason Score Heterogeneity and Implications for Risk Stratification

Mesko, Shane, BS*; Marks, Leonard, MD; Ragab, Omar, MD; Patel, Shyamal, MD; Margolis, Daniel, A., MD§; Demanes, D., Jeffrey, MD; Kamrava, Mitchell, MD

American Journal of Clinical Oncology: May 2018 - Volume 41 - Issue 5 - p 497–501
doi: 10.1097/COC.0000000000000308
Original Articles: Genitourinary

Objectives: To quantify Gleason score (GS) heterogeneity within multiparametric magnetic resonance imaging (MRI)-targeted prostate biopsies and to determine impact on National Comprehensive Cancer Network (NCCN) risk stratification.

Methods: An Institutional Review Board-approved retrospective study was performed on men who underwent Artemis (MRI-transrectal–ultrasound fusion) targeted biopsy (TB) for suspected prostate cancer between 2012 and 2015. Intratarget heterogeneity was defined as a difference in GS between 2 cores within a single target in patients with ≥2 positive cores. Prostate specific antigen, maximum tumor diameter, apparent diffusion coefficient, MRI suspicion score, prostate volume, systematic biopsy (SB) GS, and T-stage were analyzed for correlation with heterogeneity. Changes in NCCN risk based on high versus low GS on TB, SB alone, and SB+TB were compared.

Results: Fifty-three patients underwent TB of 73 suspected lesions. Seventy percent (51/73) had ≥2 positive cores, thus meeting inclusion criteria for heterogeneity analysis. Fifty-five percent (28/51) of qualifying targets showed GS heterogeneity. None of the evaluated factors showed a significant relationship with heterogeneity. NCCN low-risk, intermediate-risk, and high-risk groups were 30%, 49%, and 21%, respectively, with SB alone. Adding low GS TB to SB resulted in 17%, 55%, 28% in each risk group, while using high GS+SB resulted in 4%, 54%, and 42%. Overall, the addition of TB resulted in higher NCCN risk groups in 38% of cases.

Conclusions: Over half of multiparametric MRI-defined targets demonstrated GS heterogeneity. The addition of high GS from TB leads to risk inflation compared with using SB alone. Further research is needed on how to integrate these findings into current risk stratification models and clinical practice.

*University of California Irvine School of Medicine, Irvine

Departments of Urology

Radiation Oncology

§Radiology, University of California Los Angeles, Los Angeles, CA

M.K.: speaking honorarium from Elekta. The other authors declare no conflicts of interest.

The project described was supported in part by Award Number R01CA158627 from the National Cancer Institute. Additional support was provided by UCLA Clinical and Translational Sciences Institute Grant No. UL1TR000124, the Beckman Coulter Foundation, the Jean Perkins Foundation, and the Steven C. Gordon Family Foundation.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Reprints: Mitchell Kamrava, MD, 200 UCLA, Medical Plaza Suite B265, Los Angeles, CA 90095. E-mail:

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.