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Impact of cribriform pattern 4 and intraductal prostatic carcinoma on National Comprehensive Cancer Network (NCCN) and Cancer of Prostate Risk Assessment (CAPRA) patient stratification


Pretreatment classification tools are used in prostate cancer to inform patient management. The effect of cribriform pattern 4 (CC) and intraductal carcinoma (IDC) on such nomograms is still underexplored. We analyzed the Cancer of Prostate Risk Assessment (CAPRA) and National Comprehensive Cancer Network (NCCN) risk scores in cases with and without CC/IDC to assess impact on biochemical recurrence (BCR) and metastases/death of prostate cancer (event free survival-EFS) after prostatectomy. A matched biopsy- prostatectomy cohort (2010–2017) was reviewed for CC/IDC. CAPRA and NCCN scores were calculated. CAPRA score 0–2 were deemed “low”, 3–5 “intermediate” and 6–10 “high”. NCCN scores 1–2 “very low/low”, 3 “favorable intermediate”, 4 “unfavorable intermediate”, 5–6 “high/very high”. Cases were stratified by presence of CC/IDC. BCR and EFS probabilities were estimated using the Kaplan-Meier method. Prognostic performance was evaluated using log-rank tests and Harrell’s concordance index. 612 patients with mean age 63.1 years were included with mean follow up of 5.3 (range 0–10.8) years. CC/IDC was noted in 159/612 (26%) biopsies. There were 101 (17%) BCR and 36 (6%) events. CAPRA discriminated three distinct risk categories for BCR (p < 0.001) while only high risk separated significantly for EFS (p < 0.001). NCCN distinguished two prognostic groups for BCR (p < 0.0001) and three for EFS (p < 0.0001). Addition of CC/IDC to CAPRA impacted scores 3–5 for BCR and scores 3–5 and 6–10 for EFS and improved the overall concordance index (BCR: 0.66 vs. 0.71; EFS: 0.74 vs. 0.80). Addition of CC/IDC to NCCN impacted scores 4 and 5–6 and also improved the concordance index for BCR (0.62 vs. 0.68). Regarding EFS, NCCN scores 4 and 5–6 demonstrated markedly different outcomes with the addition of CC/IDC. The CAPRA nomogram allows better outcome stratification than NCCN. Addition of CC/IDC status particularly improves patient stratification for CAPRA scores 3–5, 6–10, and for NCCN scores 4 and 5–6.

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Fig. 1: Intraductal carcinoma on core needle biopsy.
Fig. 2: Recurrence free survival and event free survival graphs of study cohort.
Fig. 3: Impact of IDC/CC inclusion.

Data availability

The datasets used in the current study are available from the authors upon reasonable request.


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This study was presented, in part, at the 2022 United States and Canadian Academy of Pathology meeting on March 22.


This work was supported, in part, by Prostate Cancer Canada grant to T.v.D.K. (Movember Discovery grant D2017-1879).

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Y.Y. collected, analyzed data, and drafted the manuscript. M.R.D. and T.v.D.K designed the study, collected and analyzed data, and revised the manuscript. A.F. and N.F. drafted and revised the manuscript. K.L. contributed with statistical analysis. All authors approved the final version of the manuscript.

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Correspondence to Yanhong Yu.

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The authors declare no competing interests.

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The present study was approved by the research ethics boards of Sunnybrook Health Sciences Centre and the University Health Network (REB 395-2017 and CAPCR 17-5727).

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Yu, Y., Lajkosz, K., Finelli, A. et al. Impact of cribriform pattern 4 and intraductal prostatic carcinoma on National Comprehensive Cancer Network (NCCN) and Cancer of Prostate Risk Assessment (CAPRA) patient stratification. Mod Pathol (2022).

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