Does cumulative prostate cancer length ( CCL ) in prostate biopsies improve prediction of clinically insignificant cancer at radical prostatectomy in patients eligible for active surveillance?

Objectives To evaluate if cumulative prostate cancer length ( CCL ) on prostate needle biopsy divided by the number of biopsy cores ( CCL /core) could improve prediction of insignificant cancer on radical prostatectomy ( RP ) in patients with prostate cancer eligible for active surveillance ( AS ). Patients and Methods Patients diagnosed with prostate cancer on extended (≥10 cores) biopsy with an initial prostate‐specific antigen (iPSA) level of <15 ng/mL, clinical stage (cT) ≤ 2a, and highest biopsy Gleason score 3 + 3 = 6 or 3 + 4 = 7 with <3 positive cores who underwent RP were included in the study. The CCL /core and presence of insignificant cancer (organ‐confined, volume <0.5 mL, Gleason score at RP ≤6) were recorded. pT2 prostate cancer with RP Gleason score ≤3 + 4 = 7 and volume <0.5 mL were categorised as low‐tumour‐volume organ‐confined disease ( LV‐OCD ). Results In all, 221 patients met the inclusion criteria: the mean age was 59 years and the median iPSA level was 4.5 ng/mL. The clinical stage was cT1 in 86% of patients; biopsy Gleason score was 3 + 3 = 6 in 67% (group 1) and 3 + 4 = 7 in 33% of patients (group 2). The maximum percentage of biopsy core involvement was <50 in 85%; the median CCL /core was 0.15 mm. Insignificant cancer was found in 27% and LV‐OCD in 44% of patients. Group 2 was associated with higher number of positive cores, maximum percentage core involvement, total prostate cancer length, and CCL /core. Group 1 was more likely to have insignificant cancer (39%) or LV‐OCD (54%) than group 2 (3% and 23%, respectively). Group 2 had significantly higher RP Gleason score and pathological stage. Univariate analysis of group 1 showed that the iPSA level, maximum percentage core involvement, prostate cancer length, and CCL /core were all significantly associated with insignificant cancer and LV‐OCD . For group 2, the number of positive cores (1 vs 2) was also significantly associated with LV‐OCD . On multivariate logistic regression analysis, maximum percentage core involvement of <50, and number of positive cores (1 vs 2) were independent predictors of insignificant cancer in group 1; biopsy Gleason score, maximum percentage core involvement of <50 and prostate cancer length of <3 mm or CCL /core of <0.2 mm were all independent predictors of LV‐OCD in the whole population. The maximum percentage of core involvement of <50 and prostate cancer length of <3 mm or CCL /core of <0.2 mm were also independent predictors of LV‐OCD in group 1 patients. Conclusion In patients eligible for AS , a CCL /core of <0.20 mm was significantly associated with insignificant cancer and LV‐OCD . However, when parameters of cancer burden were considered, CCL /core did not independently add any additional value for predicting insignificant cancer in patients with biopsy G leason score 6. The CCL /core was an independent predictor of LV‐OCD in the whole population and in group 1 patients, although the model including prostate cancer length showed slightly higher area under the receiver operating characteristic curve.