ISUP 2 prostate cancer with suspicion of extraprostatic extension on MRI: Prostatectomy results and oncologic outcomes

Background International Society of Uro-Pathology (ISUP) grade group 2 prostate cancer (GG2 PCa) with suspicion of extraprostatic extension (EPE) on preoperative multiparametric MRI (mpMRI) presents a paradox: an histologically favorable intermediate-risk tumor with aggressive imaging features. We aimed to characterize this population, and identify predictors of pathological upgrading, downstaging, and oncological outcomes after robot-assisted radical prostatectomy (RARP). Materials and Methods We analyzed data from 150 patients across 8 European centers with MRI-targeted biopsy-confirmed GG2 PCa and mpMRI-suspected EPE (icT3a), stratified by EPE score, who underwent RARP between 2019 and 2024. Primary endpoint was predictors of pathological upgrading (GG ≥ 3); secondary endpoints included downstaging (pT2), surgical margins, and biochemical recurrence (BCR)-free survival. Results Patients were divided by EPE score: low (1–2, n = 87) and high (3, n = 38). Pathological upgrading occurred in 36% (55/150), including 10% to GG 4–5. High EPE score was the only significant predictor. Conversely, 46% (69/150) were downstaged to pT2, with low EPE score as main predictor. Positive surgical margins were observed in 30% (45/150). At a median follow-up of 28 months (IQR 17–43), 5-year BCR-free survival was 67% (95% CI 53–85). Posterior/apical EPE on MRI and cT3a stage were linked to higher BCR risk. Conclusions GG2 PCa with mpMRI-suspected EPE is heterogeneous, showing risks of both upgrading and organ-confined disease. EPE score was the main predictor of both. Despite imaging suspicion, RARP outcomes remained favorable.