{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T23:28:09Z","timestamp":1792193289418,"version":"4.4.0"},"posted":{"date-parts":[[2026,3,2]]},"group-title":"Urology","reference-count":24,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T00:00:00Z","timestamp":1772409600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.medrxiv.org\/about\/FAQ#license"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,3,2]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                <jats:sec>\n                  <jats:title>Background and Objective<\/jats:title>\n                  <jats:p>Risk stratification in localized prostate cancer relies primarily on Grade group (GG). In GG2-4 disease, risk assignment depends on the proportions of pattern 3 and pattern 4. We hypothesized that total pattern 4 length on biopsy would better predict oncologic outcome than GG, percent pattern 4, and multivariable models (\u201cnomograms\u201d) based on clinical variables.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We identified 2499 patients with GG2-4 prostate cancer on biopsy who underwent radical prostatectomy. Discrimination for predictors was calculated for adverse pathologic stage (seminal vesicle invasion or lymph node invasion) and biochemical recurrence (BCR).<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Key Findings and Limitations<\/jats:title>\n                  <jats:p>Total pattern 4 length for the case demonstrated the highest discrimination for adverse pathologic stage in comparison with GG (AUC 0.779 vs 0.658; p&lt;0.0001), percent pattern 4 (0.719), and a model including prostate-specific antigen level, clinical stage, GG, PI-RADS score, and number of positive cores (0.762). Results were similar for BCR, with total pattern 4 length outperforming GG (C-index 0.716 vs 0.662), percent pattern 4 (0.695), and the clinical model (0.699). Neither mm of pattern 3 nor the clinical model added discrimination to total mm of pattern 4.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusions and Clinical Implications<\/jats:title>\n                  <jats:p>Total length of Gleason pattern 4 on biopsy best predicts oncologic outcome in GG2-4 prostate cancer. Other common clinicopathologic variables do not further aid discrimination. Further research is warranted to determine the optimal method for quantifying pattern 4 before incorporation into risk stratification algorithms.<\/jats:p>\n                  <jats:list list-type=\"bullet\">\n                    <jats:list-item>\n                      <jats:p>\n                        <jats:bold>What does the study add?<\/jats:bold>\n                        : Patients with Grade group 2-4 prostate cancer constitute both the largest group and the one in which treatment decision-making is most difficult. For such patients, total length of Gleason pattern 4 on biopsy predicted oncologic outcomes better than Grade group or multivariable models including the standard predictors of stage, grade, PSA, PI-RADS and number of positive cores. Neither mm of pattern 3 nor the standard predictors add discrimination once total length of pattern 4 is known.\n                      <\/jats:p>\n                    <\/jats:list-item>\n                    <jats:list-item>\n                      <jats:p>\n                        <jats:bold>Patient Summary<\/jats:bold>\n                        : Treatment decisions in prostate cancer are often determined by the ratio of pattern 4 to pattern 3 disease. We showed that, in GG2-4 disease, using the total amount of pattern 4 for the case better predicts risk and therefore provides a better basis for treatment decisions.\n                      <\/jats:p>\n                    <\/jats:list-item>\n                  <\/jats:list>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Take Home Message<\/jats:title>\n                  <jats:p>In Grade group 2-4 prostate cancer, total Gleason pattern 4 length for the case is a stronger predictor of adverse pathologic stage and biochemical recurrence than Grade group and other standard clinical variables. Further research is warranted to determine the optimal method for quantifying pattern 4 before incorporation into risk stratification algorithms.<\/jats:p>\n                <\/jats:sec>","DOI":"10.64898\/2026.02.27.26347289","type":"posted-content","created":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T15:05:26Z","timestamp":1772463926000},"source":"Crossref","is-referenced-by-count":3,"title":["Total Gleason Pattern 4 Length Outperforms Grade Group and Clinical Models in Predicting Oncologic Outcomes in Grade Group 2-4 Prostate Cancer"],"prefix":"10.64898","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9902-6603","authenticated-orcid":false,"given":"Nicholas A.","family":"Pickersgill","sequence":"first","affiliation":[{"name":"Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sean A.","family":"Fletcher","sequence":"additional","affiliation":[{"name":"Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nate","family":"Aiken","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa J.","family":"Assel","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicole","family":"Liso","sequence":"additional","affiliation":[{"name":"Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7593-1016","authenticated-orcid":false,"given":"Victor 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