Radical Prostatectomy Outcomes in Patients with PI-RADS 5 Lesions and Favorable Prostate Cancer - Beyond the Abstract

The integration of multiparametric MRI (mpMRI) into prostate cancer diagnostics has improved the detection of clinically significant disease but has also created new management challenges. One of the most debated scenarios concerns patients with biopsy-proven favorable prostate cancer (Grade Group [GG] 1–2) who harbor a PI-RADS 5 lesion on MRI. While histology may support active surveillance (AS), imaging suggests a high likelihood of aggressive disease.

In our study, we evaluated pathological and oncological outcomes in men with PI-RADS 5 lesions and GG 1–2 prostate cancer treated with radical prostatectomy in a contemporary MRI-driven diagnostic setting. Approximately two-thirds of patients had favorable pathology at final histology, whereas one-third harbored adverse or aggressive features, including upgrading to higher grade groups or locally advanced disease. These findings confirm that PI-RADS 5 lesions are associated with a meaningful risk of pathological upgrading, even in patients initially classified as low or favorable intermediate risk.

Biopsy Grade Group emerged as the key determinant of risk. Patients with GG 2 at biopsy were significantly more likely to harbor adverse or aggressive pathology than those with GG 1. In contrast, MRI features such as suspected extraprostatic extension and PSA density did not independently predict unfavorable pathology. From an oncological perspective, biochemical recurrence was driven by final aggressive pathology rather than preoperative clinical or imaging parameters.

These results have important implications for active surveillance. A PI-RADS 5 lesion alone should not be viewed as an absolute contraindication to AS. Carefully selected patients with GG 1 disease and reassuring confirmatory testing may still be suitable candidates for surveillance, provided that follow-up is rigorous and MRI-informed. Conversely, the combination of PI-RADS 5 and GG 2 represents a higher-risk profile and should prompt a thorough discussion regarding definitive treatment.

In summary, our findings support a risk-adapted approach in this challenging subgroup. Histological grade remains the cornerstone of decision-making, while MRI findings should be considered risk modifiers rather than sole drivers of treatment. Balancing imaging, pathology, and clinical judgment is essential to avoid both overtreatment and undertreatment in the modern MRI era.

Written by: Anne-Laure Charvet,1 Thibaut Long Depaquit,1 Hector Bened,2 Harry Toledano,1,3 David Chemouni,2 Laurent Daniel,4 Cyrille Bastide,1 Michael Baboudjian1

  1. Department of Urology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France.
  2. Department of Radiology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France.
  3. Department of Urology, Centre Hospitalier de Martigues, Martigues, France.
  4. Department of Pathology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France.
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