Prostate-specific antigen density is a good predictor of upstaging and upgrading, according to the new grading system. The keys we are seeking may be already in our pocket

Objective To analyze the performance of prostate-specific antigen density (PSAD) as a predictor of upstaging and prognostic grade group (PGG) upgrading. Materials and Methods We retrospectively evaluated data on men with prostate cancer (PCa) treated with robot-assisted laparoscopic radical prostatectomy (RALP) at our center in 2014-2015. Preoperative PSAD was calculated. Bioptic and pathologic PGGs were also considered in the analysis. We defined upgrading as any increase in PGG after RALP; upstaging was the pathologic diagnosis of a clinically unsuspected stage ≥3a PCa. Results Data on 379 patients were analyzed. Upgrading was found in 41.4% of the patients; 29% of the patients were upstaged. On multivariable analysis, core involvement and PSAD were found to be predictors of upgrading (odds ratio [OR] 1.017, 95% confidence interval [CI] 1.001-1.034, P =.039; and OR 3.638, 95% CI 1.084-12.207, P =.001, respectively). Furthermore, core involvement and PSAD were predictors of upstaging (OR 1.020, 95% CI 1.020-1.034, P =.003; and OR 5.656, 95% CI 1.285-24.894, P =.022, respectively). PSAD showed areas under the curve of 0.712 (95% CI 0.645-0.780, P =.000) and 0.628 (95% CI 0.566-0.689, P =.000) for the prediction of upgrading and upstaging, respectively. In a subpopulation of 90 patients theoretically eligible for active surveillance, 14% were found upstaged and 17% were upgraded. PSAD showed areas under the curve of 0.894 (95% CI 0.808-0.97, P =.000) and 0.689 (95% CI 0.539-0.840, P =.021) for the prediction of upgrading and upstaging, respectively. Conclusion PSAD is a valuable predictor of upgrading and upstaging in men with PCa who were candidates for surgery and is accurate in selecting patients for AS.