Role of Multiparametric Prostate Magnetic Resonance Imaging before Confirmatory Biopsy in Assessing the Risk of Prostate Cancer Progression during Active Surveillance - Beyond the Abstract

Prostate-specific antigen (PSA) is the standard serum marker for the diagnosis of Prostate Cancer (PCa).1 Owing to the natural history of low-risk PCa2 there is some concern regarding over-diagnosis and over-treatment in low-risk PCa patients.3 Active surveillance (AS) programs try to avoid over-treatment in patients with low-grade and low-volume PCa without losing the correct timing for curative treatment.4 Magnetic resonance imaging (MRI) has evolved as a useful tool to improve the stratification and characterization of PCa candidates for AS.5,6

Considering this background, we aimed to demonstrate the impact of introducing MRI before the confirmatory prostate biopsy in two consecutive cohorts (with and without the use of MRI before the confirmatory biopsy) and to analyze its predictive value in the reclassification rate. Altogether, 170 male patients from a single tertiary-care academic institution who enrolled in an AS program between 2011 and 2019 were included in this study. The cohort was stratified into three different groups according to the use of MRI before a confirmatory biopsy and the presence of a suspicious MRI (PIRADS ≥ 3) (Fig 1).

Distribution of the reclassification pattern at confirmatory biopsy

Figure 1. Distribution of the reclassification pattern at confirmatory biopsy among the cohorts. mpMRI = multiparametric magnetic resonance imaging, PI-RADS = prostate imaging-reporting and data system

The study showed that the patients with a suspicious MRI have a higher chance of reclassification in comparison to patients with a non-suspicious MRI, or even to the patients without MRI before the confirmatory biopsy (Fig 1).

Next, a univariate logistic regression model was performed to determine the risk of reclassification at the confirmatory biopsy with the inclusion of MRI before it, showing a clear increase in the reclassification risk (odds ratio [OR]: 2.41) and particularly if a suspicious lesion were found on the MRI (OR: 5.44). Furthermore, in the multi-parametric analysis, the presence of suspicious findings on MRI (PIRADS score ≥ 3) (OR: 4.72) persisted showing a clear and statistical association with a higher risk of reclassification at the confirmatory biopsy in the cohort that underwent MRI.

When comparing the chance of progression during the follow up within the patients with MRI before biopsy reclassification, the results revealed that the patients with suspicious MRI were at greater risk for moving to an active treatment (Fig 2).

Probability of progression free survival
Figure 2. Probability of progression-free survival according to the results of MRI performed before the confirmatory biopsy.

Finally, when adjusting for main variables in the multi-parametric analysis, the presence of suspicious MRI remained associated with a higher risk of progression to active treatment during the follow-up (hazard ratio [HR]:2.62).

We can conclude that the inclusion of MRI before the confirmatory biopsy is a useful tool to stratify the risk of reclassification and that the presence of suspicious lesions on MRI could be also considered a putative prognostic factor for future reclassification/progression during the follow-up.

Written by: Joseba Salguero, MD, IMIBIC, Twitter: @josalse, and Enrique Gómez-Gómez, MD, FEBU, PhD, Twitter: @enriquegomezgo4, Department of Urology, University Hospital Reina Sofia, Cordoba, Spain


  1. Stamey, Thomas A., Norman Yang, Alan R. Hay, John E. McNeal, Fuad S. Freiha, and Elise Redwine. "Prostate-specific antigen as a serum marker for adenocarcinoma of the prostate." New England Journal of Medicine 317, no. 15 (1987): 909-916.
  2. Albertsen, Peter C., James A. Hanley, and Judith Fine. "20-year outcomes following conservative management of clinically localized prostate cancer." Jama 293, no. 17 (2005): 2095-2101.
  3. Loeb, Stacy, Marc A. Bjurlin, Joseph Nicholson, Teuvo L. Tammela, David F. Penson, H. Ballentine Carter, Peter Carroll, and Ruth Etzioni. "Overdiagnosis and overtreatment of prostate cancer." European urology 65, no. 6 (2014): 1046-1055.
  4. European Association Urology: European Association of Urology Guidelines. 2018 Edition. Volume presented. Arnhem, The Netherlands: European Association of Urology Guidelines Office; 2018.
  5. Kasivisvanathan, Veeru, Francesco Giganti, Mark Emberton, and Caroline M. Moore. "Magnetic Resonance Imaging Should Be Used in the Active Surveillance of Patients with Localised Prostate Cancer." European urology 77, no. 3 (2020): 318.
  6. Pepe, Pietro, Giuseppe Dibenedetto, Ludovica Pepe, and Michele Pennisi. "Multiparametric MRI Versus SelectMDx Accuracy in the Diagnosis of Clinically Significant PCa in Men Enrolled in Active Surveillance." in vivo 34, no. 1 (2020): 393-396.
Read the Abstract