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Light A, Kanthabalan A, Otieno M, Pavlou M, Omar R, Adeleke S, Giganti F, Brew-Graves C, Williams NR, Emara A, Haroon A, Latifoltojar A, Sidhu H, Freeman A, Orczyk C, Nikapota A, Dudderidge T, Hindley RG, Virdi J, Arya M, Payne H, Mitra AV, Bomanji J, Winkler M, Horan G, Moore CM, Emberton M, Punwani S, Ahmed HU, Shah TT. The Role of Multiparametric MRI and MRI-targeted Biopsy in the Diagnosis of Radiorecurrent Prostate Cancer: An Analysis from the FORECAST Trial. Eur Urol 2024; 85:35-46. [PMID: 37778954 DOI: 10.1016/j.eururo.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 08/01/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The role of multiparametric magnetic resonance imaging (MRI) for detecting recurrent prostate cancer after radiotherapy is unclear. OBJECTIVE To evaluate MRI and MRI-targeted biopsies for detecting intraprostatic cancer recurrence and planning for salvage focal ablation. DESIGN, SETTING, AND PARTICIPANTS FOcal RECurrent Assessment and Salvage Treatment (FORECAST; NCT01883128) was a prospective cohort diagnostic study that recruited 181 patients with suspected radiorecurrence at six UK centres (2014 to 2018); 144 were included here. INTERVENTION All patients underwent MRI with 5 mm transperineal template mapping biopsies; 84 had additional MRI-targeted biopsies. MRI scans with Likert scores of 3 to 5 were deemed suspicious. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS First, the diagnostic accuracy of MRI was calculated. Second, the pathological characteristics of MRI-detected and MRI-undetected tumours were compared using the Wilcoxon rank sum test and chi-square test for trend. Third, four biopsy strategies involving an MRI-targeted biopsy alone and with systematic biopsies of one to two other quadrants were studied. Fisher's exact test was used to compare MRI-targeted biopsy alone with the best other strategy for the number of patients with missed cancer and the number of patients with cancer harbouring additional tumours in unsampled quadrants. Analyses focused primarily on detecting cancer of any grade or length. Last, eligibility for focal therapy was evaluated for men with localised (≤T3bN0M0) radiorecurrent disease. RESULTS AND LIMITATIONS Of 144 patients, 111 (77%) had cancer detected on biopsy. MRI sensitivity and specificity at the patient level were 0.95 (95% confidence interval [CI] 0.92 to 0.99) and 0.21 (95% CI 0.07 to 0.35), respectively. At the prostate quadrant level, 258/576 (45%) quadrants had cancer detected on biopsy. Sensitivity and specificity were 0.66 (95% CI 0.59 to 0.73) and 0.54 (95% CI 0.46 to 0.62), respectively. At the quadrant level, compared with MRI-undetected tumours, MRI-detected tumours had longer maximum cancer core length (median difference 3 mm [7 vs 4 mm]; 95% CI 1 to 4 mm, p < 0.001) and a higher grade group (p = 0.002). Of the 84 men who also underwent an MRI-targeted biopsy, 73 (87%) had recurrent cancer diagnosed. Performing an MRI-targeted biopsy alone missed cancer in 5/73 patients (7%; 95% CI 3 to 15%); with additional systematic sampling of the other ipsilateral and contralateral posterior quadrants (strategy 4), 2/73 patients (3%; 95% CI 0 to 10%) would have had cancer missed (difference 4%; 95% CI -3 to 11%, p = 0.4). If an MRI-targeted biopsy alone was performed, 43/73 (59%; 95% CI 47 to 69%) patients with cancer would have harboured undetected additional tumours in unsampled quadrants. This reduced but only to 7/73 patients (10%; 95% CI 4 to 19%) with strategy 4 (difference 49%; 95% CI 36 to 62%, p < 0.0001). Of 73 patients, 43 (59%; 95% CI 47 to 69%) had localised radiorecurrent cancer suitable for a form of focal ablation. CONCLUSIONS For patients with recurrent prostate cancer after radiotherapy, MRI and MRI-targeted biopsy, with or without perilesional sampling, will diagnose cancer in the majority where present. MRI-undetected cancers, defined as Likert scores of 1 to 2, were found to be smaller and of lower grade. However, if salvage focal ablation is planned, an MRI-targeted biopsy alone is insufficient for prostate mapping; approximately three of five patients with recurrent cancer found on an MRI-targeted biopsy alone harboured further tumours in unsampled quadrants. Systematic sampling of the whole gland should be considered in addition to an MRI-targeted biopsy to capture both MRI-detected and MRI-undetected disease. PATIENT SUMMARY After radiotherapy, magnetic resonance imaging (MRI) is accurate for detecting recurrent prostate cancer, with missed cancer being smaller and of lower grade. Targeting a biopsy to suspicious areas on MRI results in a diagnosis of cancer in most patients. However, for every five men who have recurrent cancer, this targeted approach would miss cancers elsewhere in the prostate in three of these men. If further focal treatment of the prostate is planned, random biopsies covering the whole prostate in addition to targeted biopsies should be considered so that tumours are not missed.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abi Kanthabalan
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Marjorie Otieno
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Francesco Giganti
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Chris Brew-Graves
- Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Norman R Williams
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Amr Emara
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Athar Haroon
- Department of Nuclear Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK; Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arash Latifoltojar
- Division of Medicine, Faculty of Medicine, University College London, London, UK; Department of Radiology, Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Harbir Sidhu
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Ashok Nikapota
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard G Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Jaspal Virdi
- Department of Urology, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Manit Arya
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Heather Payne
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Anita V Mitra
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mathias Winkler
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gail Horan
- Department of Oncology, Queen Elizabeth Hospital, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Caroline M Moore
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK.
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Adams ES, Deivasigamani S, Mottaghi M, Huang J, Gupta RT, Polascik TJ. Evaluation of Recurrent Disease after Radiation Therapy for Patients Considering Local Salvage Therapy: Past vs. Contemporary Management. Cancers (Basel) 2023; 15:5883. [PMID: 38136427 PMCID: PMC10741753 DOI: 10.3390/cancers15245883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/14/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
Recurrent prostate cancer after primary treatment with radiation therapy is a common problem. Patients with localized recurrence may benefit from salvage therapy, but careful patient selection is crucial because not all patients will benefit from local salvage therapy, and salvage therapy has increased morbidity compared to primary treatments for prostate cancer. This review aims to provide an overview of the evaluation of patients with recurrent disease after radiation therapy and how it is continuing to evolve with increasing data on outcomes, as well as improving technologies and techniques. Our enhanced understanding of treatment outcomes and risk stratification has influenced the identification of patients who may benefit from local salvage treatment. Advances in imaging and biopsy techniques have enhanced the accuracy of locating the recurrence, which affects treatment decisions. Additionally, the growing interest in image-targeted ablative therapies that have less morbidity and complications than whole-gland therapies for suitable patients influences the evaluation process for those considering focal salvage therapy. Although significant changes have been made in the diagnostic evaluation of patients with recurrent disease after radiation therapy, it remains unclear whether these changes will ultimately improve patient outcomes.
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Affiliation(s)
- Eric S. Adams
- Department of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | | | - Mahdi Mottaghi
- Section of Urology, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, NC 27710, USA
| | - Jiaoti Huang
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
| | - Rajan T. Gupta
- Department of Urology, Duke University Medical Center, Durham, NC 27710, USA
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Thomas J. Polascik
- Department of Urology, Duke University Medical Center, Durham, NC 27710, USA
- Section of Urology, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, NC 27710, USA
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA
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Marra G, Calleris G, Conte F, Benfant N, Rajwa P, Ahmed M, Abreu A, Cacciamani G, Smith JA, Joniau S, Rodriguez-Sanchez L, Sanchez-Salas R, Cathcart P, Gill I, Karnes RJ, Tilki D, Shariat SF, Touijer K, Gontero P. Recurrent Gleason Score 6 Prostate Cancer After Radiotherapy or Ablation: Should We Observe Them All? Results from a Large Multicenter Salvage Radical Prostatectomy Consortium. Eur Urol Focus 2023:S2405-4569(23)00194-3. [PMID: 37704503 DOI: 10.1016/j.euf.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Salvage radical prostatectomy (sRP) yields poor functional outcomes and relatively high complication rates. Gleason score (GS) 6 prostate cancer (PCa) has genetic and clinical features showing little, if not absent, metastatic potential. However, the behavior of GS 6 PCa recurring after previous PCa treatment including radiotherapy and/or ablation has not been investigated. OBJECTIVE To evaluate the oncological outcomes of sRP for radio- and/or ablation-recurrent GS 6 PCa. DESIGN, SETTING, AND PARTICIPANTS Retrospective data of sRP for recurrent PCa after local nonsurgical treatment were collected from 14 tertiary referral centers from 2000 to 2021. INTERVENTION Prostate biopsy before sRP and sRP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A survival analysis was performed for pre-sRP biopsy and sRP-proven GS 6. Concordance between PCa at pre-sRP biopsy and sRP histology was assessed. RESULTS AND LIMITATIONS We included GS 6 recurrent PCa at pre-sRP biopsy (n = 142) and at sRP (n = 50), as two cohorts. The majority had primary radiotherapy and/or brachytherapy (83.8% of GS 6 patients at pre-sRP biopsy; 78% of GS 6 patients at sRP) and whole-gland treatments (91% biopsy; 85.1% sRP). Biopsy GS 6 10-yr metastasis, cancer-specific survival (CSS), and overall survival (OS) were 79% (95% confidence interval [CI] 61-89%), 98% (95-99%), and 89% (78-95%), respectively. Upgrading at sRP was 69%, 35.5% had a pT3 stage, and 13.4% had positive nodes. The sRP GS 6 10-yr metastasis-free survival, CSS, and OS were 100%, 100%, and 90% (95% CI 58-98%) respectively; pT3 and pN1 disease were found in 12% and 0%, respectively. Overall complications, high-grade complications, and severe incontinence were experienced by >50%, >10%, and >15% of men, respectively (in both the biopsy and the sRP cohorts). Limitations include the retrospective nature of the study and absence of a centralized pathological review. CONCLUSIONS GS 6 sRP-proven PCa recurring after nonsurgical primary treatment has almost no metastatic potential, while patients experience relevant morbidity of the procedure. However, a significant proportion of GS 6 cases at pre-sRP biopsy are upgraded at sRP. In the idea not to overtreat, efforts should be made to improve the diagnostic accuracy of pre-sRP biopsy. PATIENT SUMMARY We investigated the oncological results of salvage radical prostatectomy for recurrent prostate cancer of Gleason score (GS) 6 category. We found a very low malignant potential of GS 6 confirmed at salvage radical prostatectomy despite surgical complications being relatively high. Nonetheless, biopsy GS 6 was frequently upgraded and had less optimal oncological control. Overtreatment for recurrent GS 6 after nonsurgical first-line treatment should be avoided, and efforts should be made to increase the diagnostic accuracy of biopsies for recurrent disease.
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Affiliation(s)
- Giancarlo Marra
- Department of Surgical Sciences and Urology Clinic, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Giorgio Calleris
- Department of Surgical Sciences and Urology Clinic, University of Turin and Città della Salute e della Scienza, Turin, Italy.
| | - Francesca Conte
- Department of Surgical Sciences and Urology Clinic, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Nicole Benfant
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Mohamed Ahmed
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Andre Abreu
- USC Institute of Urology & The Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Giovanni Cacciamani
- USC Institute of Urology & The Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Joseph A Smith
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Lara Rodriguez-Sanchez
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | - Rafael Sanchez-Salas
- Department of Urology, Institut Mutualiste Montsouris and Université Paris Descartes, Paris, France
| | | | - Inderbir Gill
- USC Institute of Urology & The Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Departments of Urology, Weill Cornell Medical College, New York, New York, USA; Department of Urology, University of Texas Southwestern, Dallas, Texas, USA; Research Center for Evidence-Based Medicine, Iranian EBM Center: A Joanna Briggs Institute Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paolo Gontero
- Department of Surgical Sciences and Urology Clinic, University of Turin and Città della Salute e della Scienza, Turin, Italy
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