EAU 2017: MRI as a follow up tool in active surveillance: results from an MRI-defined active surveillance cohort

London, England (UroToday.com) Active surveillance (AS) has become a mainstay of therapy for low-volume, low-risk prostate cancer, and in some institutions, it is also utilized for low-volume intermediate risk disease. However, the introduction of multiparametric MRI (mpMRI) has significantly changed our evaluation of the prostate, both in men with elevated PSA (undiagnosed prostate cancer) and in men on active surveillance.

In this study, the authors at UCL (London), who have a long-history with the use of mpMRI, highlight the findings of their mpMRI-based active surveillance regimen. This is a single-center experience.

In their AS regimen, the utilize mpMRI heavily. Below, they highlight the stratification process for follow-up MRI’s – based on the presence or absence of a lesion on the initial MRI’s.

chart 18

Limitations / Discussion Points:
The inclusion criteria were men who met the NICE guidelines for active surveillance (Gleason
score 3+3 or 3+4, PSA< 20ng/ml) and had an mpMRI at UCLH. Biopsies (MRI-targeted, transperineal) were performed for the following reasons: a lesion was discordant with the
original histology, progression on mpMRI, or according to a change in other factors (eg an
increase in PSA density). It should be noted that even without a lesion on baseline MRI, all men usually received another MRI every 3 years.

A recommendation for active treatment was discussed based on mpMRI features and in those men who showed other high risk features (Gleason 8 disease, or any nodal or metastatic disease).

Of this AS cohort, 387 men met inclusion criteria and were initiated on AS between 2004 and 2015. Of the 387, 64 (17%) had Gleason 3+4 prostate cancer. By the time of analysis, 294 men remained on AS (median time 5 years); 64 men went on to active treatment.

No prostate cancer related death occurred in the cohort. The 5-year treatment free survival was 85.1% and 78.3% for men without and with lesions on baseline mpMRI, respectively (p=0.024). The 5-year treatment free survival was 86.3% and 60.8% in patients with Gleason 3+3 and 3+4, respectively (p<0.001).

Ultimately, the authors conclude that a lesion on mpMRI and Gleason 3+4 disease predict worse outcomes. However, the Gleason 3+4 finding is not unsurprising, and many institutions would not consider them for AS. It would have been cleaner for the authors to only consider the Gleason 6 patients. More detail regarding their MRI findings (besides just lesion presence/absence) would be helpful guide future management – per the presenter, they are looking into this now.

Regardless, the use of mpMRI will likely be an important part of many institutions’ AS protocols.

Speaker(s): Adam Retter

Co-Authors: Giganti F., Kirkham A., Allen C., Punwani S., Emberton M., Moore C.

1. University College London Hospital, Dept. of Radiology, London, United Kingdom
2. University College London Hospital, Dept. of Urology, London, United Kingdom

Written By: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the #EAU17 - March 24-28, 2017- London, England

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