Selecting Patients with Favorable Risk, Grade Group 2 Prostate Cancer for Active Surveillance—Does Magnetic Resonance Imaging Have a Role?

Percentage Gleason pattern 4 and PI-RADS score predict upgrading in biopsy Grade Group 2 prostate cancer patients without cribriform pattern

“…In the current study, clinical stage T3, presence of mpMRI PI-RADS 5 lesions and increasing biopsy percentage Gleason pattern 4 were all significant predictors for upgrading to GG ≥ 2 on RP, while biopsy tumor volume and PSA did not have independent value. The potential significance of PI-RADS 5 lesions in biopsy GG2 men was also found by others [ 10 , 19 – 21 ]. Cribriform architecture by definition lacks intervening stroma resulting in high cell density, and is associated with high tumor volume.…”

“…Furthermore, NCCN takes the number of positive cores into account, while the EAU guideline includes men with < 10% Gleason pattern 4 and without CR/IDC. Although some have indicated that presence of PI-RADS 5 lesion on MRI is associated with more aggressive disease, this is not included as a criterium by EAU or NCCN yet [ 19 – 21 ]. In the current study, clinical stage T3, presence of mpMRI PI-RADS 5 lesions and increasing biopsy percentage Gleason pattern 4 were all significant predictors for upgrading to GG ≥ 2 on RP, while biopsy tumor volume and PSA did not have independent value.…”

Selecting Patients with Favorable Risk, Grade Group 2 Prostate Cancer for Active Surveillance—Does Magnetic Resonance Imaging Have a Role? Letter.

“…To the Editor: Stonier et al reviewed 1,117 patients with risk grade group 2 prostate cancer who underwent radical prostatectomy at Memorial Sloan Kettering Cancer Center and found that the absence of positive findings on preoperative multiparametric magnetic resonance imaging may help to stratify patients for active surveillance. 1 We caution that this study reviewed a selective age population of 57 to 66 years old and the study did not characterize patient race. Our recent studies showed that African American race and men older than 70 years are at a higher risk for harboring high-grade disease.…”

Con: Magnetic Resonance Imaging Targeting Leads to Overtreatment of Prostate Cancer

“…8,9 There is even advocacy by some to no longer call Gleason 3þ3 disease cancer, 10 as well as consider offering surveillance to men with Gleason 3þ4 prostate cancer. 7 These changes occurred because understanding of prostate cancer biology has evolved, and as disease behavior in the era of MRI-targeted biopsy-diagnosed disease becomes clearer also, so too can paradigms for treatment recommendations continue to evolve. We would thus explicitly argue that it is a mistake to apply historical risk-stratification and treatment recommendations to contemporary, MRI-inclusive derived diagnosis.…”

“…We and others would argue in fact that with the improved reliability of cancer grading using MRI-targeted prostate biopsy, such improved tumor characterization could even help select patients with favorable intermediate-risk prostate cancer who could be good candidates for active surveillance. 7 Thus, contrary to the original article’s claim, we believe embracing the benefits of prostate MRI could actually decrease overtreatment of prostate cancer.…”