Repeat MRI during active surveillance: natural history of prostatic lesions and upgrading rates

Abstract

Objectives To assess upgrading rates in patients on active surveillance (AS) for prostate cancer (PCa) after serial multiparametric magnetic resonance imaging (mpMRI). Methods We conducted a retrospective analysis of 558 patients. Five different criteria for mpMRI progression were used: 1) a Prostate Imaging Reporting and Data System (PI‐RADS) score increase; 2) a lesion size increase; 3) an extraprostatic extension score increase; 4) overall mpMRI progression; and 5) the number of criteria met for mpMRI progression (0 vs 1 vs 2–3). In addition, two definitions of PCa upgrading were evaluated: 1) International Society of Urological Pathology Grade Group (ISUP GG) ≥2 with >10% of pattern 4 and 2) ISUP GG ≥ 3. Estimated annual percent changes methodology was used to show the temporal trends of mpMRI progression criteria. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of mpMRI progression criteria were also analysed. Multivariable logistic regression models tested PCa upgrading rates. Results Lower rates over time for all mpMRI progression criteria were observed. The NPV of serial mpMRI scans ranged from 90.5% to 93.5% (ISUP GG≥2 with >10% of pattern 4 PCa upgrading) and from 98% to 99% (ISUP GG≥3 PCa upgrading), depending on the criteria used for mpMRI progression. A prostate‐specific antigen density (PSAD) threshold of 0.15 ng/mL/mL was used to substratify those patients who would be able to skip a prostate biopsy. In multivariable logistic regression models assessing PCa upgrading rates, all five mpMRI progression criteria achieved independent predictor status. Conclusion During AS, approximately 27% of patients experience mpMRI progression at first repeat MRI. However, the rates of mpMRI progression decrease over time at subsequent mpMRI scans. Patients with stable mpMRI findings and with PSAD < 0.15 ng/mL/mL could safely skip surveillance biopsies. Conversely, patients who experience mpMRI progression should undergo a prostate biopsy.

Uso da ressonância magnética multiparamétrica na vigilância ativa do câncer de próstata: Uma revisão integrativa

“…A maioria dos estudos analisados definiram PI-RADS ≥3 como positivo para um câncer clinicamente significativo, esse achado também foi observado na meta-análise de Woo et al (2017). É válido salientar que apesar disso, pacientes com PI-RADS ≥3 podem ser incluídos no tratamento por VA, sendo necessário realizar, obrigatoriamente, nesses casos uma biópsia inicial para excluir neoplasia clinicamente significativa, sendo que alguns estudos concluíram que esses pacientes apresentam maior risco de progressão da doença durante a VA e mudança para tratamento curativo (Luzzago et al, 2022;Chu et al, 2022;Liss et al, 2020;Fujihara et al, 2021;Hsiang et al, 2021).…”

Magnetic Resonance Imaging-based Monitoring in Active Surveillance: Are We Ready To Jump on the Bandwagon?

“…Before jumping on the bandwagon of preferential biopsy avoidance, we need substantial evidence of the value of serial MRI scans in monitoring men with MRI-positive findings in daily practice. The PRECISE criteria for follow-up of MRI-suspicious lesions provide a scheme for reporting over time, but the data so far on changes on MRI do not allow avoidance of biopsies with great certainty [8] . Jumping to conclusions for this (in particular) higher-risk population on active surveillance should not be fueled by minimal information or the tendency to confirm one’s beliefs.…”