Clinical Research Papers:

Low serum total testosterone level as a predictor of upstaging and upgrading in low-risk prostate cancer patients meeting the inclusion criteria for active surveillance

Matteo Ferro _, Giuseppe Lucarelli, Dario Bruzzese, Giuseppe Di Lorenzo, Sisto Perdonà, Riccardo Autorino​‌, Francesco Cantiello, Roberto La Rocca, Gian Maria Busetto, Amelia Cimmino, Carlo Buonerba, Michele Battaglia, Rocco Damiano, Ottavio De Cobelli, Vincenzo Mirone and Daniela Terracciano

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Oncotarget. 2017; 8:18424-18434. https://doi.org/10.18632/oncotarget.12906

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Matteo Ferro1,*, Giuseppe Lucarelli2,*, Dario Bruzzese3, Giuseppe Di Lorenzo4, Sisto Perdonà5, Riccardo Autorino6, Francesco Cantiello7, Roberto La Rocca8, Gian Maria Busetto9, Amelia Cimmino10, Carlo Buonerba4, Michele Battaglia2, Rocco Damiano7, Ottavio De Cobelli1,11,12, Vincenzo Mirone8 and Daniela Terracciano13

1 Department of Urology, European Institute of Oncology, Via Ripamonti, Milan, Italy

2 Department of Emergency & Organ Transplantation - Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy

3 Department of Public Health, University of Naples ‘Federico II’, Naples, Italy

4 Department of Clinical Medicine, Medical Oncology Unit, University of Naples ‘Federico II’, Naples, Italy

5 Department of Urology, “Istituto Nazionale Tumori Fondazione Giovanni Pascale - IRCCS”, Naples, Italy

6 University Hospitals Urology Institute, Cleveland, OH, USA

7 Division of Urology, Magna Graecia University, Catanzaro, Italy

8 Department of Urology, University of Naples ‘Federico II’, Naples, Italy

9 Department of Urology, “La Sapienza” University, Rome, Italy

10 Institute of Genetics and Biophysics “A. Buzzati Traverso”, National Research Council, Naples, Italy

11 University of Milan, Milan, Italy

12 University of Medicine Iuliu Hatieganu, Cluj-Napoca, Romania

13 Department of Translational Medical Sciences, University of Naples ‘Federico II’, Naples, Italy

* These authors have contributed equally to this study

Correspondence to:

Matteo Ferro, email:

Giuseppe Lucarelli, email:

Amelia Cimmino, email:

Keywords: testosterone, prostate cancer, active surveillance, upgrading, upstaging

Received: June 13, 2016 Accepted: October 14, 2016 Published: October 25, 2016


Active surveillance (AS) is currently a widely accepted treatment option for men with clinically localized prostate cancer (PCa). Several reports have highlighted the association of low serum testosterone levels with high-grade, high-stage PCa. However, the impact of serum testosterone as a predictor of progression in men with low-risk PCa has been little assessed.

In this study, we evaluated the association of circulating testosterone concentrations with a staging/grading reclassification in a cohort of low-risk PCa patients meeting the inclusion criteria for the AS protocol but opting for radical prostatectomy.

Radical prostatectomy (RP) was performed in 338 patients, eligible for AS according to the following criteria: clinical stage T2a or less, PSA<10ng/ml, two or fewer cancer cores, Gleason score (GS)≤6 and PSA density<0.2 ng/mL/cc. Reclassification was defined as upstaging (stage>pT2) and upgrading (GS≥7; primary Gleason pattern 4) disease. Unfavorable disease was defined as the occurrence of pathological stage>pT2 and predominant Gleason score 4. Total testosterone was measured before surgery.

Low serum testosterone levels (<300 ng/dL) were significantly associated with upgrading, upstaging, unfavorable disease and positive surgical margins. The addition of testosterone to a base model, including age, PSA, PSA density, clinical stage and positive cancer involvement in cores, showed a significant independent influence of this variable on upstaging, upgrading and unfavorable disease.

In conclusion, our results support the idea that total testosterone should be a selection criterion for inclusion of low-risk PCa patients in AS programs and suggest that testosterone level less than 300 ng/dL should be considered a discouraging factor when a close AS program is considered as treatment option

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