Prostate cancer upgrading with serial prostate magnetic resonance imaging and repeat biopsy in men on active surveillance: are confirmatory biopsies still necessary?

Abstract

Objectives To investigate whether serial prostate magnetic resonance imaging (MRI) may guide the utility of repeat targeted (TBx) and systematic biopsy (SBx) when monitoring men with low‐risk prostate cancer (PCa) at 1‐year of active surveillance (AS). Patients and Methods We retrospectively included 111 consecutive men with low‐risk (International Society of Urological Pathology [ISUP] Grade 1) PCa, who received protocolled repeat MRI with or without TBx and repeat SBx at 1‐year of AS. TBx was performed in Prostate Imaging‐Reporting and Data System (PI‐RADS) score ≥3 lesions (MRI‐positive men). Upgrading defined as ISUP Grade ≥2 PCa (I), Grade ≥2 with cribriform growth/intraductal carcinoma PCa (II), and Grade ≥3 PCa (III) was investigated. Upgrading detected by TBx only (not by SBx) and SBx only (not by TBx) was investigated in MRI‐positive and ‐negative men, and related to radiological progression on MRI (Prostate Cancer Radiological Estimation of Change in Sequential Evaluation [PRECISE] score). Results Overall upgrading (I) was 32% (35/111). Upgrading in MRI‐positive and ‐negative men was 48% (30/63) and 10% (5/48) ( P < 0.001), respectively. In MRI‐positive men, there was upgrading in 23% (seven of 30) by TBx only and in 33% (10/30) by SBx only. Radiological progression (PRECISE score 4–5) in MRI‐positive men was seen in 27% (17/63). Upgrading (I) occurred in 41% (seven of 17) of these MRI‐positive men, while this was 50% (23/46) in MRI‐positive men without radiological progression (PRECISE score 1–3) ( P = 0.534). Overall upgrading (II) was 15% (17/111). Upgrading in MRI‐positive and ‐negative men was 22% (14/63) and 6% (three of 48) ( P = 0.021), respectively. In MRI‐positive men, there was upgrading in three of 14 by TBx only and in seven of 14 by SBx only. Overall upgrading (III) occurred in 5% (five of 111). Upgrading in MRI‐positive and ‐negative men was 6% (four of 63) and 2% (one of 48) ( P = 0.283), respectively. In MRI‐positive men, there was upgrading in one of four by TBx only and in two of four by SBx only. Conclusion Upgrading is significantly lower in MRI‐negative compared to MRI‐positive men with low‐risk PCa at 1‐year of AS. In serial MRI‐negative men, the added value of repeat SBx at 1‐year surveillance is limited and should be balanced individually against the harms. In serial MRI‐positive men, the added value of repeat SBx is substantial. Based on this cohort, SBx is recommended to be performed in combination with TBx in all MRI‐positive men at 1‐year of AS, also when there is no radiological progression.

Diagnostic Accuracy and Prognostic Value of Serial Prostate Multiparametric Magnetic Resonance Imaging in Men on Active Surveillance for Prostate Cancer

“…Lastly, the improved sensitivity could be accounted for by a substantial rate (38%) of PI-RADS score increase between MRI1 and MRI2. Our findings are concordant with another recent study demonstrating that men with serially positive findings on MRI are more likely to experience biopsy upgrade and that a substantial number of these upgrades occur outside of the targeted lesion [18].…”

What to expect from a non-suspicious prostate MRI? A review

“…In a recent retrospective study including 111 patients on active surveillance, 48 had a non-suspicious mpMRI and a significant cancer was detected by systematic transrectal biopsy in 5 (10%) [31].…”

Guy’s and St Thomas NHS Foundation active surveillance prostate cancer cohort: a characterisation of a prostate cancer active surveillance database

“…Due to the non-invasive nature, MRI has sparked interest in its serial use during followup of men on AS in many healthcare systems and from 2014, NICE guidelines encouraged the use of mpMRI as part of AS follow-up to detect disease progression and drive repeat biopsies [12]. However findings in studies investigating the role of serial MRI for AS monitoring are contradictory [23][24][25]. The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) panel have developed recommendations in AS active surveillance, TP trans-perineal, TRUS trans-rectal ultrasound, MRI magnetic resonance imaging, SD standard deviation, IQR interquartile range effort to highlight clearer thresholds identifying radiologically significant disease progression [26].…”