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735 Background: Sarcomatoid dedifferentiation in Renal Cell Carcinoma (sRCC) is well known to be a subtype with poor prognosis with a high rate of synchronous metastases at presentation. Nonetheless, outcomes in a contemporary cohort of patients with localized sRCC are not well characterized in a population-based study. We sought to determine the clinical characteristics, temporal trends in prevalence, and survival outcomes in patients with localized sarcomatoid RCC. Methods: From 2004-2019, all 440,230 cases of RCC in patients ≥18 years were extracted from the National Cancer Database; of these, 3.3% (14,713) had sarcomatoid dedifferentiation. Trend analyses were conducted using Cochran-Armitage test of trend. Multivariable Cox Proportional-Hazards regression was used to determine the impact of clinical and pathologic characteristics on all cause mortality (ACM) in patients with non-metastatic sRCC. Actuarial Overall Survival (OS) was computed with Kaplan-Meier analysis (KMA), with sub-analysis performed for patients with AJCC Prognostic Stages I-III (Stage). Clear cell was reference histology for all analyses. Holm adjustment for multiple comparisons was applied when necessary. Results: Sarcomatoid dedifferentiation increased from 1.9% in 2004 to 4.1% in 2019, average annual percentage change (AAPC) 0.060 (p1 site. On Cox regression for non-metastatic sRCC, ACM was associated with age (HR 1.02, p

430 Background: Molecular features of testicular germ cell tumors (GCT) in various clinical states (pre- vs post-chemotherapy, localized versus metastatic) may inform treatment options for patients with recurrence after definitive therapy. In his study, we describe molecular features and potential therapeutic targets in a cohort of patients with testicular GCT. Methods: We retrospectively examined clinicopathologic and next-generation sequencing (NGS) data from 27 patients with GCT. Tumors were sequenced using the Tempus|xT solid tumor assay, which includes DNA sequencing of 595-648 genes at 500x coverage and RNA sequencing for all human coding genes. Tumor mutational burden (TMB) was measured for all tumors and PD-L1 levels were assessed qualitatively by 22C3 pharmDx immunohistochemistry assay in 8 patients. All genetic variants detected were quantified and analyzed to identify potentially actionable targets. Results: We identified 13 (48%) stage I GCT, 11 (41%) stage II, and 3 (11%) stage III. There were 7 seminomas and 20 nonseminomas. 12 tumor specimen resections were obtained from orchiectomy, and 15 from retroperitoneal lymph node dissection (RPLND), of which, 8 were chemotherapy-naïve and 7 were post-chemotherapy. Chemo-naïve RPLND histology showed a combination of teratoma, seminoma, and mixed GCT, while post-chemo histology revealed 6 teratomas and 9 benign pathologies. The median TMB for the cohort was 0.75 mutations/megabase. Somatic mutations were identified in 55% of patients and most commonly within: KRAS (25.9%), KIT (11.1%), and PIK3CB (7.4%). PD-L1 expression was observed in 75% of the tumors measured (60% positivity at stage I and 100% positivity at stage III). Microsatellite stability was stable in 18 tumors tested. DNA alterations- [single base pair substitutions, insertions, and deletions]- in KRAS (GTPase) proto-oncogenes were detected in 7 tumors and tyrosine kinase receptor gene variants (KIT, P1K3CB) were found at similar frequencies across disease stages. Whole transcriptome NGS RNA expression assays were performed on 21 untreated specimens revealing overexpression of MTOR (33%), MAPK1(14%), and MET (8.0%). Actionable targets with FDA-approved therapies in other organ tissues were detected in 11 patients (40.7%). Incidental germline mutations, including MSH6, RB1, and MSH2, were identified in 9 patients though all were variants of unknown significance. Conclusions: In our study, a significant proportion of patients had potentially actionable molecular targets across the disease spectrum. The identified genetic alterations provide a genomic landscape for risk stratification, future therapies, and molecularly informed treatment paradigms for GCT patients.

609 Background: Disparities in outcomes of renal cell carcinoma (RCC) exist with respect to survival outcomes between different ethnic, and socioeconomic groups. We sought to evaluate disparities in delivery of surgical care between medically underserved (MU) and non-medically underserved (NMU) patients. Methods: We conducted a single-center retrospective analysis of consecutive patients presenting with localized renal cortical neoplasms who underwent surgical excision [Radical (RN) or Partial Nephrectomy (PN)] at an academic tertiary-care referral center. The cohort was divided into MU and NMU groups and descriptive analyses were conducted for demographics and clinical disease characteristics, type of surgery, time to surgery, estimated blood loss, and 30-day total and major complications (Clavien-Dindo, ≥3). Cochran-Armitage trend analysis was conducted to evaluate for surgical trends, and logistic regression multivariable analyses (MVA) were conducted for type of surgery and major complications. Results: 1418 patients were analyzed (MU n=334/NMU n=1084). Comparing MU vs. NMU, no differences were noted for age (p=0.612), Charlson Comorbidity Index (p=0.803), tumor size (p=0.236), or time to surgery (p=0.482). Significantly greater proportions of white patients were noted in NMU (60.6% vs. MU=45.5%, p

418 Background: Chemotherapy for testicular cancer (TC) is highly effective yet associated with significant consequences on long-term health-related quality of life. We evaluate the impact of chemotherapy on anxiety, depression, and suicidality amongst TC survivors. Methods: We conducted a retrospective cohort study of US veterans diagnosed with TC in the Veterans Health Affairs database from 1990-2016. Patients with non-primary germ cell tumor histologies were excluded. Baseline disease characteristics and treatment received were ascertained from the VA Central Cancer Registry. Anxiety or depression was a composite endpoint comprised of diagnosis codes for anxiety, depression, or administration of medications used to treat these diagnoses. Incident suicidality was defined as a diagnosis code for suicidal ideation. Time to event was defined as time from diagnosis to event or censor at the time of last follow-up. Rates of outcomes were reported through cumulative incidences. Associations with outcomes and receipt of chemotherapy were assessed through multivariable Cox regression models. Results: In total, 1684 patients (1174 seminoma, 510 nonseminoma) were included in the cohort. Median age at diagnosis in the cohort was 40 years old. Median follow up time was 7.67 years for surviving patients. 1506 (89.4%) patients were white, 114 (6.8%) were African American, and 64 (3.8%) were another or unknown race. There were 1066 (63.3%) stage I patients, 191 (11.3%) stage II, 198 (11.8%) stage III, and 229 (13.6%) unknown stage patients. 579 (34.4%) patients received chemotherapy. At the time of diagnosis, 104 (6.2%) patients already experienced anxiety or depression. At 10 years, cumulative incidence of the diagnosis of anxiety or depression as 44.1% in the entire cohort. At 10 years, cumulative incidence of the diagnosis of suicidality was 5.5%. On multivariable Cox regression, factors associated with a higher risk of anxiety or depression were older age at diagnosis (Hazard Ratio (HR): 1.11 per standard deviation increase, p=0.01), being unemployed (HR: 1.25, p=0.01), and receipt of chemotherapy (HR: 1.43, p

723 Background: C-reactive protein (CRP) has been demonstrated to be an independent predictor of survival outcomes in renal cell carcinoma (RCC). The use of biomarkers to predict post-surgical complications is not well studied. We sought to investigate predictive factors for major complications following surgery for RCC and delineate their impact on mortality outcomes. Methods: We performed a two-center retrospective analysis of patients who underwent partial (PN) and radical nephrectomy (RN) for RCC. Patients who had complications within 30 days after surgery were identified and the complications were scored using the Clavien-Dindo classification system. Patients were grouped based on whether they experienced 30-day major (Clavien ≥3) complications and whether they had elevated preoperative CRP defined as >5mg/L. Primary outcome was non-cancer mortality (NCM), with secondary outcomes being all-cause (ACM) and cancer-specific (CSM) mortality. Multivariable analyses (MVA) were conducted to evaluate predictors for Clavien ≥3 complications, NCM, CSM, and ACM. Kaplan-Meier analyses (KMA) were performed to compare overall survival (OS), noncancer-specific survival (NCS), and cancer-specific survival (CSS) between patients with non-elevated and elevated preoperative CRP and between patients without and with 30-day Clavien ≥3 complications. Results: A total of 2,234 patients were analyzed [116 (5.2%) experienced Clavien ≥3 complications; median follow up 44 months]. MVA revealed that coronary artery disease (OR 2.37, p=0.005), elevated CRP (OR 2.25, p=0.004), PN (OR 2.79, p

734 Background: T1a renal cell carcinoma (RCC) is associated with excellent cure rates. However, a small fraction present with metastasis. We sought to determine the clinical characteristics, variables associated with synchronous metastasis, and survival outcomes in patients with pT1a and cT1a RCC using the National Cancer Database (NCDB). We secondarily evaluated whether surgery impacted risk of all cause mortality in cT1a RCC with synchronous lung and bone metastasis. Methods: From 2004 to 2019, all cases of RCC in patients age ≥18 were extracted from NCDB. pT1a and cT1a RCC were characterized as those 1) with no metastasis at diagnosis, 2) with synchronous metastasis [pT1aNxM1 at diagnosis]. Impact of surgery on all cause mortality was not evaluated for cT1a with synchronous metastasis to liver and brain due to low sample sizes. Results: The table describes selected characteristics of the cohorts. On multivariable logistic regression, diagnosis of pT1a with synchronous metastasis was associated with age (OR 1.02), male sex (OR 1.64), tumor size (OR 1.84), cN1 (OR 1.08), sarcomatoid (OR 5.50), tumor grade (OR 2.84) (p1 site (HR 2.48, p=0.032), and inversely with radical (HR 0.42, p

736 Background: Lymph node positivity in Renal Cell Carcinoma (RCC) is associated with worsened oncologic outcomes. However, the actual prognostic significance of node positivity is poorly understood. Currently, American Joint Committee on Cancer (AJCC) Stage III RCC includes both node-positive pN1 and node-negative pN0 disease. We hypothesize that (1) there is a threshold in number of pathologic node positivity that distinguishes favorable risk from poor risk nodal disease, and (2) current categorization of pN1 can be subdivided into pN1 and pN2 based this threshold. We tested our hypothesis using the National Cancer Database (NCDB). Methods: From 2004-2019, all cases of RCC were queried in patients age ≥18. Patients with pathologic node positive disease and without synchronous metastasis were selected for analysis to minimize confounding from metastatic burden. Multivariable Cox Proportional-Hazards regression tested association between number of pathologically positive lymph nodes and all-cause mortality (ACM), adjusting for clinical and pathologic co-variables. Receiver Operator Characteristic (ROC) Curve analyses employing the concordance probability method evaluated performance of potential cut-points for pN2 node-positivity. Kaplan-Meier analyses (KMA) compared these thresholds against overall survival (OS) in non-metastatic Stage IV RCC. Results: 28,590 patients with above criteria were identified, of which 13.6% had pN1. On multivariable analyses, increased pathologic node positivity was associated with increased hazard of ACM (HR 1.19, 95% Confidence Interval [CI] 1.17-1.20, p

644 Background: Pathological upstaging to pT3a disease can occur after the surgical treatment of clinical T1 and T2 Renal Cell Carcinomas (RCCs), and this upstaging has been previously shown to be associated with poorer outcomes. With an intent to delve deeper into the disparateness in outcomes of pT3a disease, we investigated the survival of patients with an initial clinical stage of cT1, cT2 and cT3a. Methods: Using the National Cancer Database (NCDB), patients with RCC were categorized by pathological and clinical staging of RCC according to the American Joint Committee on Cancer Guidelines (AJCC). The primary outcome was measured as overall survival (OS) at the end of follow up. Five-year survival rates and Kaplan-Meier Analysis assessed the differences between cT1 → pT3a, cT2 → pT2, cT2 → pT3a, and cT3a → pT3a. Multivariable cox regression (MVA) assessed predictors OS with age, sex, ethnicity, Charlson Score, socioeconomic status, geography, tumor size histology and grade, lymph node metastasis, surgical margins, and surgery type (partial versus radical nephrectomy) as covariates. Results: 53908 patients were analyzed (10789 cT1 → pT3a, 22183 cT2 → pT2, 9676 cT2 → pT3a, 11260 cT3a → pT3a, mean follow up 62.3 months). Of all pT3a patients, 64.5% were upstaged from cT1-2. MVA for OS demonstrated Hispanic ethnicity to be protective (hazard ratio [HR]=0.88, P

615 Background: A significant portion of patients presenting with clinically localized stage 1-2 renal cell carcinoma are pathologically upstaged to Stage 3 following surgical intervention. This is due to previously undetected extension into the renal venous system, perirenal or renal sinus fat, or collecting system. Improved detection of potential T3 upstaging may prompt changes in disease management, which may impact patient survival. We sought to compare pathologically upstaged and non-upstaged T3a RCC cases to identify characteristics of upstaged masses, predictors of T3a disease, and impact on oncological outcomes. Methods: We conducted a single center retrospective analysis of patients with pathologic T3a RCC who underwent surgical intervention. The cohort was divided into a group of patients with masses not preoperatively identified as cT3a (upstaged, cT1-cT2/pT3a) and a group of patients with masses preoperatively identified as cT3a (non-upstaged, cT3a/pT3a) for descriptive and outcomes analyses. We sought to delineate proportion of under-diagnosed pT3a RCC, location of upstaged disease, and predictors of upstaging. Primary outcome was overall survival (OS) and secondary outcome was recurrence-free survival (RFS). Multivariate analyses (MVA) were performed to identify predictors of T3a invasion site and outcomes. Kaplan Meier survival analyses (KMA) were performed to compare survival outcomes. Results: We analyzed 185 patients, of which 120 (64.9%) were upstaged and 65 (35.1%) were non-upstaged. When compared to non-upstaged masses, upstaged masses were significant for smaller size (6.8 vs 8.2 cm, p=0.008), lower RENAL score (8.7 vs 9.9, p

395 Background: Radical nephrectomy (RN) is a mainstay of management of localized renal cancer larger than 4 cm in size. RN is associated with renal functional decline, however impact of age on functional decline is unclear. We investigated impact of age on post RN function, focusing on decline to moderate and severe chronic kidney disease (CKD). Methods: This was a retrospective analysis of the International Marker Consortium for Renal Cancer (INMARC) registry of patients who underwent RN. Primary outcome was development of de novo CKD stage IIIB [estimated glomerular filtration rate (eGFR)30). Patients clinical characteristics were stratified by age groups (70 years old). Multivariable logistic regression analysis (MVA) was utilized to identify risk factors with renal functional decline to different CKD stages. Kaplan-Meier analysis (KMA) was utilized to evaluate functional outcomes with respect to the different age groups. Results: Overall, 2,436 patients were analyzed (≤50 years, n=513; 50-70 years, n=1,344; >70, n=579; median follow up 31.9 months). On MVA, increasing age was independently associated with increased risk of development of CKD Stage IIIb [compared to ≤50 years (referent), 50-70 years, OR 3.35, p70 years OR 7.7, p70 years OR 9.4, p70 years was independently associated with increased risk of development of CKD Stage IV [OR 1.96, p=0.027]. In addition, male (OR 1.49, p= 0.036), increasing BMI (OR 1.03, p=0.003), diabetes mellitus (OR 2.69, p 70 years 37.06%, p70 years 55.5%, p70 years 81.2%, p< 0.001). Conclusions: Increasing age is an independent risk factor for progressive and clinically significant renal functional decline after radical nephrectomy. Prioritization for nephron sparing management should be considered whenever safe and feasible in elderly patients to reduce potential risk of sequelae of functional decline.

394 Background: Studies have discussed the prognostic use of C-reactive protein (CRP) and De Ritis ratio (AST/ALT or AAR) in the evaluation of renal malignant masses. Elevated pre-treatment CRP has been shown to be associated with non-cancer mortality. Additionally increased preoperative AAR has been found to be a prognostic factor for overall survival. With studies showing the ethnic disparities in mortality rate in certain underserved ethnic groups, there is a need for investigation into possible ethnic differences. Our aim is to evaluate the association between these elevated preoperative markers and all-cause mortality (ACM) and cancer specific mortality (CSM) among ethnic groups. Methods: Retrospective review of the International Marker Consortium for Renal Cancer (INMARC) was performed. Patients with renal malignancies who underwent partial or radical nephrectomy (PN, RN) were included. Patients were grouped according to ethnicity and African American (AA), White, Asian, and Hispanic ethnic groups were selected for descriptive, survival and multivariable analysis of outcomes. A Cox-regression multivariable analysis (MVA) was performed for each group. The primary outcome was overall survival and cancer specific survival from time of surgery to last follow-up, which was evaluated using Kaplan-Meyer Analysis (KMA). Results: A total of 4,810 patients were analyzed (627 AA, 2,344 White, 462 Hispanic, 1,094 Asian). Preoperative CRP and AAR were considered elevated if above 5 mg/L and 1.26, respectively. Descriptive analysis showed significant differences in age, diabetes mellitus status, hypertension status, tumor size, surgery type (PN vs. RN), preoperative CRP, preoperative AAR, ACM and CSM between ethnicities (p-value

196 Background: The utility of prostate-specific antigen velocity (PSAV) to predict clinical progression in patients with localized prostate cancer (PC) on active surveillance remains unclear, and in African American (AA) patients on active surveillance remains undefined. Methods: We performed a cohort analysis using the national US Veterans Affairs Informatics and Computing Infrastructure (VINCI). We identified 5296 patients diagnosed with localized prostate cancer (PC) from 2001 to 2015 managed with active surveillance. Follow-up extended through March 31, 2020. We defined low-risk PC as ISUP grade group 1 (GG1) clinical tumor stage ≤ 2A, and PSA level ≤ 10 ng/dl; and active surveillance as no definitive treatment within the first year after diagnosis with at least one additional staging biopsy after diagnostic biopsy. The primary outcome was grade progression on repeat biopsy/prostatectomy defined as GG2 or GG3. The secondary outcome was incident metastases. Cumulative incidence functions and multivariable Cox proportional hazards models were used to test associations between PSAV and outcomes. Results: The final cohort included 3919 Non-Hispanic White patients (NHW) (74%) and 1377 AA (26%) patients. GG2 progression on repeat biopsy occurred in 2062 (38.9%) patients, with a cumulative incidence (CI) of 43.2 % and GG3 progression occurred in 728 (13.7%) patients, with a CI of 18% at seven years. Fifty-four (0.8%) patients developed metastases, with a CI of 1.4% at ten years. In unadjusted analyses, compared to NHW patients, AA patients were significantly more likely to progress to GG2 (52.8% vs 39.8%, p

281 Background: We aimed to determine whether insurance expansions implemented through the Patient Protection and Affordable Care Act (ACA) were associated with changes in insurance coverage status, stage at diagnosis, and overall survival for patients with renal cell carcinoma (RCC). Methods: We identified patients 40 to 64 years old diagnosed with RCC between 2010 and 2016 in the National Cancer Database. States were categorized as participating on time in Medicaid expansion or not participating. We stratified patients into advanced cancer (stage III + IV) and localized cancer (stage I + II) groups. We stratified patients into low, middle, and high income groups. Stage trend and insurance trend analysis were performed to based on income status amongst patients living in expansion and non-expansion states. Absolute percentage change (APC) was calculated for insurance status and stage migration. Cox Regression Multivariable Analysis was conducted to assess risk of all-cause mortality (ACM) for patients before and after the implementation of the ACA, adjusting for insurance status, income, education, age, race, ethnicity, comorbidity, and living in an expansion state. Results: We identified 78,099 patients who met inclusion criteria. Following implementation of ACA, APC of patients with insurance increased in both Medicaid and non-expansion states by 4.0% and 2.10% (p

489 Background: To compare the rate of hospital based outcomes in patients with urologic malignancies who underwent surgery as part of treatment in academic and community hospitals. Methods: We reviewed the Vizient Clinical Database from September 2014 to December 2017. Vizient is a member-driven health services organization that includes ~99% of academic hospitals (AH) and more than 40 community hospitals (CH). This is a comparative database comprised of administrative billing. Data include patient demographics, readmission rates, costs, LOS, case mix index (CMI) and mortality. Patients aged ≥ 18 were included and ICD-9 and ICD-10 codes were used to identify patients with urologic malignancies who underwent surgical treatment. Chi square and student t-tests were used to compare categorical and continuous variables, respectively. Results: We identified a total of 37,628 cases. There were 33,290 (88%) procedures performed in AH and 4,330 (12%) in CH. These included radical prostatectomy (RP) 18,540, radical nephrectomy (rNx) 8,059, partial nephrectomy (pNx) (5,287), radical cystectomy (4,421), radical nephroureterectomy (rNu) (1,006), and partial cystectomy (321). There were no significant differences in 30-day readmission rates or mortality for any procedure between AH and CH. LOS was significantly lower (P

477 Background: Micropapillary variants of urothelial cell carcinoma (UCC) are associated with aggressive clinical behavior including an increased risk of regional and distant metastasis. Although neoadjuvant chemotherapy (NAC) improves survival for patients with UCC who achieve a complete pathologic response (pT0), less is known regarding the uptake of this practice in patients with micropapillary variant (MV) or its effect on pathologic response. Methods: We queried the National Cancer Database to identify all patients with a diagnosis of UCC including MV from 2004-2014. We restricted our analysis to patients who underwent radical cystectomy with or without NAC. We compared clinical, demographic, and pathologic characteristics and evaluated time trends associated with use of NAC. Following propensity score matching to balance covariates associated with the receipt of NAC, we used logistic regression models to study the association of NAC use and pT0 rate. Dual analyses were performed among patients with clinical stage II (cT2) disease, as well as the entire cohort (all stages). Results: We identified 102,266 patients, including 101,272 (99.03%) pure UCC and 994 (0.97%) MV. Patients with MV were younger (Median 70 years vs 73 years, p < 0.001), more commonly male (79.0 vs 73.6% p < 0.001), were more commonly treated in academic centers (66.43% vs 44.77%), there was no difference between urban/rural areas. Use of NAC among patients with cT2 increased in the entire cohort from 27% on 2004 to 49.7% in 2014 for UCC, and from 50% to 58% for MV. Among patients with cT2 disease, 38.4% of UCC received NAC and 49% MV received NAC (P < 0.001). Following propensity score matching, receipt of NAC was associated with pT0 for both histological diagnoses (OR 2.13 95% CI: 1.65-2.78 p < 0.001). This effect persisted on restriction to patients with cT2 (OR 3.32, 95% CI: 2.32-4.75, p < 0.001). Conclusions: There has been increased use of NAC among patients with micropapillary variant. Patients with cT2 micropapillary variant were equally like to be achieve a pathologic complete response to NAC as were patients without histologic variants of urothelial cell carcinoma.

485 Background: Approximately 7% of patients with localized upper tract urothelial cancer (UTUC) are treated without definitive therapy. Understanding outcomes and alternative therapy would aid in counseling older patients with co-morbidities. Methods: We utilized the National Cancer Database to identify patients with localized UTUC managed non-surgically between 2004 and 2013. Patient demographics, co-morbidity, tumor grade, and chemotherapy and radiation utilization were recorded. Survival analyses were performed with the Kaplan-Meier method and a cox proportional hazard regression model. Results: We identified 3,157 (10.9%) patients with localized UTUC who did not receive definitive surgery. Median age was 79 years, 55% were males, 79% had government health insurance, and 68% had a CDS of 0. Tumor grade was low (grade 1 or 2) in 632 (36.4%) and high (grade 3 or 4) in 1104 (63.6%). Median overall survival (OS) for the cohort was 2.2 years, significantly shorter for patients with greater co-morbidities. Chemotherapy or radiation was performed in 294 (9.3%) and 197 (6.3%) patients respectively. There were no OS differences for individuals receiving chemotherapy. Of patients who received radiation therapy, the median OS was 1.4 vs 2.0 years, (p

29 Background: To assess the positive predictive value (PPV) of PI-RADS 4 lesions stratified by suspicion for tumor multi-focality. Methods: Between April 2015 and July 2016, 62 biopsy naïve men with at least one PI-RADS 4 lesion underwent mpMRI/US fusion biopsy. Patients were placed into group 1 if they had a single lesion, group 2 if they had an additional PI-RADS 3 or 2 lesion, and group 3 if they had an additional PI-RADS 4 or 5 lesion. Image interpretation was performed prospectively and assessed using PI-RADS version 2. The ANOVA and chi-square tests were used to assess differences between continuous and categorical variables, respectively. Results: Using systematic and targeted biopsy combined, the overall and GS ≥ 7 cancer detection rate for the entire cohort was 80.6% (50/62), and 53.2% (33/62), respectively. There were a total of 88 lesions with 26,14, and 48 lesions in groups 1,2, and 3, respectively. There were no significant differences in mean age, PSA density, race, or lesion location between groups; p = 0.107, p = 0.694, p = 0.511, and p = 0.558, respectively. The PPV for any prostate cancer was 65.4% (17/26), 100% (14/14), and 90% (43/48) for groups 1,2, and 3 respectively (p = 0.005). The PPV for GS ≥ 7 was 42% (11/26), 50% (7/14), and 75% (36/48) for groups 1,2, and 3, respectively (p = 0.001). Conclusions: Our data indicate that the PPV for a PI-RADS category assessment score of 4 may be influenced by tumor multi-focality on imaging. Further assessment with increased sample size will be useful to confirm our initial results.