From Biopsy to Pathology: A Retrospective Cohort Study of Predictors of Gleason Score Upgrading in Grade Group 1 Prostate Cancer.

Background/Aim: This study aimed to identify pre-treatment predictors of Gleason score (GS) upgrading in patients with biopsy-confirmed Grade Group 1 (GS 3+3) prostate cancer (PCa) - those typically considered candidates for active surveillance according to National Comprehensive Cancer Network guidelines - so as to refine risk stratification and avoid under-treatment. Patients and Methods: A retrospective analysis was conducted on patients with biopsy-proven GS 3+3 PCa who underwent radical prostatectomy (RP) at a tertiary referral center between 2010 and 2023. Preoperative clinical, pathological, and biochemical data were collected, including prostate-specific antigen (PSA) levels, PSA density, prostate volume (PV). Multivariable logistic regression was used to identify independent predictors of GS upgrading. Collinearity among PSA, PV, and PSA density was assessed using variance inflation factors and correlation matrix analysis. These findings highlight the limitations of biopsy-based grading in accurately assessing tumor aggressiveness. Conclusion: GS upgrading is common in patients initially diagnosed with GS 3+3 PCa and is associated with pre-treatment clinical factors, including PSA density and smaller PV. Identifying these predictors preoperatively may improve risk stratification and guide personalized treatment strategies. Future research should focus on integrating genomic and molecular markers to increase the predictive accuracy and optimize patient management.