Prostate cancer upgrading with serial prostate MRI scans and repeat biopsy in men on active surveillance: are confirmatory biopsies still necessary?

To investigate whether serial prostate magnetic resonance imaging (MRI) may guide the utility of repeat targeted (TBx) and systematic biopsy (SBx) when monitoring men with low-risk prostate cancer (PCa) at one-year in active surveillance (AS).

We retrospectively included 111 consecutive men with low-risk (ISUP grade 1) PCa, who received protocolled repeat MRI with or without TBx and repeat SBx at one-year AS. TBx was performed in PI-RADS score ≥3 lesions (MRI-positive men). Upgrading defined as ISUP grade ≥2 PCa (I), grade ≥2 with cribriform growth/intraductal carcinoma PCa (II), and grade ≥3 PCa (III) was investigated. Upgrading detected by TBx only (not by SBx) and SBx only (not by TBx) was investigated in MRI-positive and MRI-negative men, and related to radiological progression on MRI (PRECISE score).

Overall upgrading (I) was 32% (35/111). Upgrading in MRI-positive and MRI-negative men was 48% (30/63) and 10% (5/48) (p <0.001), respectively. In MRI-positive men, upgrading was in 23% (7/30) by TBx only and in 33% (10/30) by SBx only. Radiological progression (PRECISE score 4-5) in MRI-positive men was observed in 27% (17/63). Upgrading (I) occurred in 41% (7/17) of these MRI-positive men, while this was 50% (23/46) in MRI-positive men without radiological progression (PRECISE score 1-3) (p =0.534). Overall upgrading (II) was 15% (17/111). Upgrading in MRI-positive and MRI-negative men was 22% (14/63) and 6% (3/48) (p =0.021), respectively. In MRI-positive men, upgrading was 21% (3/14) by TBx only and 50% (7/14) by SBx only. Overall upgrading (III) was 5% (5/111). Upgrading in MRI-positive and MRI-negative men was 6% (4/63) and 2% (1/48) (p =0.283), respectively. In MRI-positive men, upgrading was 25% (1/4) by TBx only and 50% (2/4) by SBx only.

Upgrading is significantly lower in MRI-negative compared to MRI-positive low-risk PCa men at one-year surveillance. In serial MRI-negative men, the added value of repeat SBx at one-year surveillance is limited and should be balanced individually against the harms. In serial MRI-positive men, the added value of repeat SBx is substantial. Based on this cohort, SBx is recommended to be performed in combination with TBx in all MRI-positive men at one-year surveillance, also when there is no radiological progression.

BJU international. 2020 Mar 31 [Epub ahead of print]

Daniƫl F Osses, Frank-Jan H Drost, Jan F M Verbeek, Henk B Luiting, Geert J L H van Leenders, Chris H Bangma, Gabriel P Krestin, Monique J Roobol, Ivo G Schoots

Erasmus University Medical Center, Department of Radiology & Nuclear Medicine, Rotterdam, The Netherlands., Erasmus University Medical Center, Department of Urology, Rotterdam, The Netherlands., Erasmus University Medical Center, Department of Pathology, Rotterdam, The Netherlands.

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