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

• Published in: BJU international Vol. 129; no. 4; pp. 524 - 533
• Main Authors: Luzzago, Stefano, Piccinelli, Mattia Luca, Mistretta, Francesco A., Bianchi, Roberto, Cozzi, Gabriele, Di Trapani, Ettore, Cioffi, Antonio, Catellani, Michele, Fontana, Matteo, Jannello, Letizia Maria Ippolita, Botticelli, Francesco Maria Gerardo, Marvaso, Giulia, Alessi, Sarah, Pricolo, Paola, Ferro, Matteo, Matei, Deliu‐Victor, Jereczek‐Fossa, Barbara A., Fusco, Nicola, Petralia, Giuseppe, Cobelli, Ottavio, Musi, Gennaro
• Format: Journal Article
• Language: English
• Published: England Wiley Subscription Services, Inc 01-04-2022
• Subjects: active surveillance; Biopsy; EPE score; Humans; Image-Guided Biopsy - methods; Magnetic resonance imaging; Magnetic Resonance Imaging - methods; Male; multiparametric magnetic resonance imaging; Neoplasm Grading; PCSM; PI‐RADS score; Prostate; Prostate - diagnostic imaging; Prostate - pathology; prostate biopsy; Prostate cancer; ProstateCancer; Prostatic Neoplasms - diagnostic imaging; Prostatic Neoplasms - pathology; Regression analysis; Retrospective Studies; Surveillance; uroonc; Watchful Waiting; EPE score; prostate biopsy; uroonc; PI-RADS score; multiparametric magnetic resonance imaging; PCSM; ProstateCancer; active surveillance
• ISSN: 1464-4096; 1464-410X
• DOI: 10.1111/bju.15623

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.