Presentation: Dr. Rouviere provided a nice argument for the continued use of MRI and imaging, and they are doing a good job selecting patients for treatment. However, he made sure to not argue to MRI in lieu of prostate biopsies.
Long-term adherence to AS protocols requires trust (between physician and patient that aggressive tumor is not being missed) and protocols compatible with long-term follow-up (ie infrequent biopsies).
1. Can mpMRI improve patient selection for AS?
- Schoots I, Curr Opin Urol, 2017 – systematic review of 8 studies of mpMRI prior to confirmatory biopsy
- Re-classification rate on confirmatory biopsy was 32% - but 8% were only on targeted biopsy, while 11% were on systematic biopsy alone
- mpMRI and targeted biopsy cannot be exluded: account for 24% increased detection of higher grade cancer
- but, systematic biopsy was doing pretty well by itself!
- 2018 EAU guidelines: perform mpMRI prior to systematic +/- targeted confirmatory biopsy (Strong recommendation)
2. Can mpMRI improve detection of clinically significant PCa during AS follow-up?
- Schoots I, Curr Opin Urol, 2017 – systematic review of 3 studies of mpMRI at the start of AS and before each follow-up biopsy.
- Progression at mpMRI was associated with 35-70% upgrading on following biopsy
- Stable disease on mpMRI was still associated with 16-32% upgrading on following biopsy!
Unfortunately, this just means mpMRI has low specificity but high sensitivity. Better definitions of mpMRI progression are needed.
3. Combining mpMRI and clinical data?
- Clinical data and mpMRI provide independent information, so they can complement each other
- Nassiri JUrol 2017
- 206 men on AS after fusion biopsy
- On MV analysis, the only predictors of progression were Grade group 2 at the time of diagnosis, PSA density >= 0.15, and MRI PIRADS 5
- University of Lyon cohort – 365 patients on AS
- PSA density + MRI exceeded MRI alone in terms of improving specificity and sensitivity
- Adding MRI to clinical data provides better initial staging
1. Obvious benefit prior to confirmatory biopsy, as patient is being evaluated for AS. Hence, strongly recommend prior to a systematic+targeted confirmatory biopsy
2. However, the role of mpMRI in AS follow-up is less clear. For now, a negative mpMRI does not exclude progression of disease.
Presented by: O. Rouviere, Lyon, France
Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark