Active surveillance (AS) is a well-established strategy for managing prostate cancer (PCa); however, available evidence indicates that approximately 28% of patients may experience progression within the first 5 years. Magnetic resonance imaging (MRI) may help optimize patient selection. This study assessed whether the presence of focal lesions (prostate imaging reporting and data system (PI-RADS) ≥ 3) on baseline MRI is associated with an increased risk of histological progression and AS discontinuation.
We conducted a retrospective study of consecutive patients enrolled in AS at a comprehensive cancer center since 2012, recorded in the Urodata platform, based on a prospectively maintained cohort and including patients meeting European Association of Urology (EAU) criteria for low- or favorable intermediate-risk PCa. Inclusion criteria were diagnostic and confirmatory transperineal biopsies performed with the institution's standard technique, available baseline MRI, and a minimum follow-up of one year. Patients with prior treatment were excluded. Histological progression was defined as an increase in Gleason grade group on follow-up biopsy compared with baseline. Progression at 5 years was evaluated using Kaplan-Meier curves and multivariable Cox proportional hazards models. Patients with PI-RADS ≥ 3 were classified as visible lesions on MRI (MRI+), and those with PI-RADS <3 as no visible lesions on MRI (MRI-).
A total of 105 patients were included, with a median age of 64 years (interquartile range (IQR) 59-70) and a median prostate-specific antigen (PSA) of 5.8 ng/mL (IQR 4.7-8.9). The median interval between initial and confirmatory biopsy was 24 months, and median follow-up was 6 years. Seventy-one patients were classified as MRI+. Baseline characteristics were similar between groups. Five-year progression-free survival was 41% in MRI+ versus 77% in MRI- groups (hazard ratios (HR) 5.5; 95% confidence interval (CI) 2.3-13). Only 28% of patients with PI-RADS 5 remained free of progression at 5 years. Baseline PSA >6 ng/mL and PSA density >0.2 were independently associated with histological progression.
The presence of PI-RADS ≥ 3 lesions on baseline MRI is significantly associated with an increased risk of histological progression and AS discontinuation. MRI may be a key tool for optimizing candidate selection for AS.
Archivos espanoles de urologia. 2026 Jun [Epub]
Raimundo Domínguez Argomedo, Pedro de Pablos-Rodríguez, Paula Pelechano Gómez, María Isabel Martín García, Amaia Arrizabalaga Solano, Victor Rodríguez Part, Manel Beamud Cortés, Ana Calatrava Fons, Cristina Gutiérrez Castañé, Álvaro Gómez-Ferrer Lozano, Ángel García Cortés, José Agustín López Gonzalez, José Luis Domínguez Escrig, Cristian Romero Hinostroza, Eugenio Sánchez Aparisi, Juan Casanova Ramón-Borja
Department of Urology, DIPRECA Hospital, 7510689 Santiago, Chile., Department of Urology, Valencian Institute of Oncology Foundation (FIVO), 46010 Valencia, Spain., Department of Radiology, Valencian Institute of Oncology Foundation (FIVO), 46010 Valencia, Spain., Department of Urology, Miguel Servet University Hospital, 50009 Zaragoza, Aragon, Spain., Department of Pathology, Valencian Institute of Oncology Foundation (FIVO), 46010 Valencia, Spain., Department of Urology, Guillermo Almenara Irigoyen National Hospital, 15082 Lima, Perú.