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McKone EL, Sutton EA, Johnson GB, Phillips RM. Application of Advanced Imaging to Prostate Cancer Diagnosis and Management: A Narrative Review of Current Practice and Unanswered Questions. J Clin Med 2024; 13:446. [PMID: 38256579 PMCID: PMC10816977 DOI: 10.3390/jcm13020446] [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: 12/15/2023] [Revised: 01/06/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
Major advances in prostate cancer diagnosis, staging, and management have occurred over the past decade, largely due to our improved understanding of the technical aspects and clinical applications of advanced imaging, specifically magnetic resonance imaging (MRI) and prostate-cancer-specific positron emission tomography (PET). Herein, we review the established utility of these important and exciting technologies, as well as areas of controversy and uncertainty that remain important areas for future study. There is strong evidence supporting the utility of MRI in guiding initial biopsy and assessing local disease. There is debate, however, regarding how to best use the imaging modality in risk stratification, treatment planning, and assessment of biochemical failure. Prostate-cancer-specific PET is a relatively new technology that provides great value to the evaluation of newly diagnosed, treated, and recurrent prostate cancer. However, its ideal use in treatment decision making, staging, recurrence detection, and surveillance necessitates further research. Continued study of both imaging modalities will allow for an improved understanding of their best utilization in improving cancer care.
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Affiliation(s)
| | - Elsa A. Sutton
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Geoffrey B. Johnson
- Department of Radiology, Nuclear Medicine Division, Mayo Clinic, Rochester, MN 55905, USA
| | - Ryan M. Phillips
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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2
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Englman C, Barrett T, Moore CM, Giganti F. Active Surveillance for Prostate Cancer: Expanding the Role of MR Imaging and the Use of PRECISE Criteria. Radiol Clin North Am 2024; 62:69-92. [PMID: 37973246 DOI: 10.1016/j.rcl.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Multiparametric magnetic resonance (MR) imaging has had an expanding role in active surveillance (AS) for prostate cancer. It can improve the accuracy of prostate biopsies, assist in patient selection, and help monitor cancer progression. The PRECISE recommendations standardize reporting of serial MR imaging scans during AS. We summarize the evidence on MR imaging-led AS and provide a clinical primer to help report using the PRECISE criteria. Some limitations to both serial imaging and the PRECISE recommendations must be considered as we move toward a more individualized risk-stratified approach to AS.
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Affiliation(s)
- Cameron Englman
- Department of Radiology, University College London Hospital NHS Foundation Trust, 3rd Floor, Charles Bell House, 43-45 Foley Street, London, W1W7TY, UK; Division of Surgery & Interventional Science, University College London, 3rd Floor, Charles Bell House, 43-45 Foley Street, London, W1W7TY, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Box 218, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK; Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Box 218, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Caroline M Moore
- Division of Surgery & Interventional Science, University College London, 3rd Floor, Charles Bell House, 43-45 Foley Street, London, W1W7TY, UK; Department of Urology, University College London Hospital NHS Foundation Trust, 3rd Floor, Charles Bell House, 43-45 Foley Street, London, W1W7TY, UK
| | - Francesco Giganti
- Department of Radiology, University College London Hospital NHS Foundation Trust, 3rd Floor, Charles Bell House, 43-45 Foley Street, London, W1W7TY, UK; Division of Surgery & Interventional Science, University College London, 3rd Floor, Charles Bell House, 43-45 Foley Street, London, W1W7TY, UK.
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3
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Bhanji Y, Mamawala M, de la Calle CM, Landis P, Epstein JI, Simopoulos DN, Macura KJ, Pavlovich CP. Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) Magnetic Resonance Imaging Scoring to Predict Clinical Outcomes in Active Surveillance for Grade Group 1 Prostate Cancer. Urology 2023; 180:194-199. [PMID: 37536582 DOI: 10.1016/j.urology.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To determine whether radiological change on serial multiparametric magnetic resonance imaging scored using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) Scoring system predicts grade reclassification (GR) at surveillance biopsy in men on active surveillance (AS) with Grade Group 1 (GG1) prostate cancer (PCa). METHODS We retrospectively reviewed records of 255 men with low-risk PCa on AS with magnetic resonance imaging (MRI)-informed diagnostic and confirmatory biopsies and studied the subset who had surveillance biopsies (n = 163) within 6months of an interval MRI. RESULTS We studied 309 PRECISE scores in 255 men. 14% demonstrated radiological progression (PRECISE 4-5) on interval MRI performed within 24months, compared to 34% of those whose interval MRI was performed at a >3-year interval (P = .002). 28% (46/163) of men undergoing surveillance biopsy experienced GR to ≥ GG2 PCa. There was no significant increase in the rate of GR with increasing PRECISE score (PRECISE 1-2: 24%, PRECISE 3: 23%, PRECISE 4-5: 38%; P = .11). There was a significant increase in the rate of GR with increasing PI-RADS score (P < .05). On multivariable analysis, a PI-RADS score of 4-5 was significantly associated with GR compared to men who had a highest PI-RADS ≤3 (OR=1.98 [95% CI: 1.45-3.09, P = .01]). CONCLUSION In a low-risk AS cohort with limited follow-up, a patient's highest PI-RADS rather than their PRECISE score on interval MRI was predictive of GR on surveillance biopsy.
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Affiliation(s)
- Yasin Bhanji
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mufaddal Mamawala
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Claire M de la Calle
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patricia Landis
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan I Epstein
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Demetrios N Simopoulos
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katarzyna J Macura
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christian P Pavlovich
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
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Kalalahti I, Vasarainen H, Erickson AM, Siipola A, Tikkinen KAO, Rannikko A. Does Protocol Make a Difference? Comparison of Two Prostate Cancer Active Surveillance Cohorts: A Non-protocol-based Follow-up and a Protocol-based Contemporary Follow-up. EUR UROL SUPPL 2021; 34:33-40. [PMID: 34934965 PMCID: PMC8655388 DOI: 10.1016/j.euros.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/30/2022] Open
Abstract
Background Active surveillance (AS) is the preferred option for initial management for low-risk prostate cancer (PC). Although many AS protocols exist, there is little evidence to support one over another. Objective To assess whether there is difference in overall (OS), prostate cancer–specific (CSS), metastasis-free (MFS), or treatment-free (TFS) survival between a strict (Prostate cancer Research International: Active Surveillance [PRIAS]) and a loose (European Randomized study of Screening for Prostate Cancer [ERSPC]) AS protocol. Design, setting, and participants This study included two cohorts of men (n = 518) with low-risk, localized, Gleason score ≤7 PC. The ERSPC cohort included 241 men followed for 9.5 yr (median) with a non–protocol-based follow-up. The PRIAS cohort included 277 men followed for 5 yr (median) with a strict protocol. Outcome measurements and statistical analysis OS, CSS, MFS, and TFS were compared by the Kaplan-Meier method, competing risk analysis, and Cox proportional hazard regression. Results and limitations As expected, due to the difference in median follow-up time between the cohorts, a difference in the absolute number of events was seen. However, no difference in any of the survival outcomes was evident in the Kaplan-Meier or competing risks analysis. Furthermore, in Cox proportional hazard regression analysis, cohort (ERSPC vs PRIAS) was not associated with any of the outcomes. Results are limited by the retrospective study design, limited statistical power, and inability to match the cohorts for predictive factors. Conclusions There was no difference in survival outcomes between a non–protocol-based follow-up and a protocol-based contemporary AS follow-up of patients with low-risk PC. However, a longer follow-up is needed. Patient summary We compared survival outcomes of two cohorts of patients with low-risk prostate cancer: a strict and a loose follow-up protocol. We found no differences in survival measures between the cohorts.
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Affiliation(s)
- Inari Kalalahti
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Hanna Vasarainen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Andrew M Erickson
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Arttu Siipola
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Antti Rannikko
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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5
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Caglic I, Sushentsev N, Gnanapragasam VJ, Sala E, Shaida N, Koo BC, Kozlov V, Warren AY, Kastner C, Barrett T. MRI-derived PRECISE scores for predicting pathologically-confirmed radiological progression in prostate cancer patients on active surveillance. Eur Radiol 2021; 31:2696-2705. [PMID: 33196886 PMCID: PMC8043947 DOI: 10.1007/s00330-020-07336-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/16/2020] [Accepted: 07/23/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the predictive value and correlation to pathological progression of the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system in the follow-up of prostate cancer (PCa) patients on active surveillance (AS). METHODS A total of 295 men enrolled on an AS programme between 2011 and 2018 were included. Baseline multiparametric magnetic resonance imaging (mpMRI) was performed at AS entry to guide biopsy. The follow-up mpMRI studies were prospectively reported by two sub-specialist uroradiologists with 10 years and 13 years of experience. PRECISE scores were dichotomized at the cut-off value of 4, and the sensitivity, specificity, positive predictive value and negative predictive value were calculated. Diagnostic performance was further quantified by using area under the receiver operating curve (AUC) which was based on the results of targeted MRI-US fusion biopsy. Univariate analysis using Cox regression was performed to assess which baseline clinical and mpMRI parameters were related to disease progression on AS. RESULTS Progression rate of the cohort was 13.9% (41/295) over a median follow-up of 52 months. With a cut-off value of category ≥ 4, the PRECISE scoring system showed sensitivity, specificity, PPV and NPV for predicting progression on AS of 0.76, 0.89, 0.52 and 0.96, respectively. The AUC was 0.82 (95% CI = 0.74-0.90). Prostate-specific antigen density (PSA-D), Likert lesion score and index lesion size were the only significant baseline predictors of progression (each p < 0.05). CONCLUSION The PRECISE scoring system showed good overall performance, and the high NPV may help limit the number of follow-up biopsies required in patients on AS. KEY POINTS • PRECISE scores 1-3 have high NPV which could reduce the need for re-biopsy during active surveillance. • PRECISE scores 4-5 have moderate PPV and should trigger either close monitoring or re-biopsy. • Three baseline predictors (PSA density, lesion size and Likert score) have a significant impact on the progression-free survival (PFS) time.
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Affiliation(s)
- Iztok Caglic
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Nikita Sushentsev
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
- Cambridge Urology Translational Research and Clinical Trials Office, University of Cambridge, Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Evis Sala
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Nadeem Shaida
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Brendan C Koo
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Vasily Kozlov
- Department of Public Health and Healthcare Organisation, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anne Y Warren
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Pathology, Addenbrooke's Hospital, Cambridge, UK
| | - Christof Kastner
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Tristan Barrett
- CamPARI Prostate Cancer Group, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK.
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Lee CH, Tan TW, Tan CH. Multiparametric MRI in Active Surveillance of Prostate Cancer: An Overview and a Practical Approach. Korean J Radiol 2021; 22:1087-1099. [PMID: 33856136 PMCID: PMC8236356 DOI: 10.3348/kjr.2020.1224] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 12/26/2022] Open
Abstract
MRI has become important for the detection of prostate cancer. MRI-guided biopsy is superior to conventional systematic biopsy in patients suspected with prostate cancer. MRI is also increasingly used for monitoring patients with low-risk prostate cancer during active surveillance. It improves patient selection for active surveillance at diagnosis, although its role during follow-up is unclear. We aim to review existing evidence and propose a practical approach for incorporating MRI into active surveillance protocols.
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Affiliation(s)
- Chau Hung Lee
- Department of Radiology, Tan Tock Seng Hospital, Singapore
| | - Teck Wei Tan
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Cher Heng Tan
- Department of Radiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
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Sandeman K, Eineluoto JT, Pohjonen J, Erickson A, Kilpeläinen TP, Järvinen P, Santti H, Petas A, Matikainen M, Marjasuo S, Kenttämies A, Mirtti T, Rannikko A. Prostate MRI added to CAPRA, MSKCC and Partin cancer nomograms significantly enhances the prediction of adverse findings and biochemical recurrence after radical prostatectomy. PLoS One 2020; 15:e0235779. [PMID: 32645056 PMCID: PMC7347171 DOI: 10.1371/journal.pone.0235779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/23/2020] [Indexed: 01/21/2023] Open
Abstract
Background To determine the added value of preoperative prostate multiparametric MRI (mpMRI) supplementary to clinical variables and their role in predicting post prostatectomy adverse findings and biochemically recurrent cancer (BCR). Methods All consecutive patients treated at HUS Helsinki University Hospital with robot assisted radical prostatectomy (RALP) between 2014 and 2015 were included in the analysis. The mpMRI data, clinical variables, histopathological characteristics, and follow-up information were collected. Study end-points were adverse RALP findings: extraprostatic extension, seminal vesicle invasion, lymph node involvement, and BCR. The Memorial Sloan Kettering Cancer Center (MSKCC) nomogram, Cancer of the Prostate Risk Assessment (CAPRA) score and the Partin score were combined with any adverse findings at mpMRI. Predictive accuracy for adverse RALP findings by the regression models was estimated before and after the addition of MRI results. Logistic regression, area under curve (AUC), decision curve analyses, Kaplan-Meier survival curves and Cox proportional hazard models were used. Results Preoperative mpMRI data from 387 patients were available for analysis. Clinical variables alone, MSKCC nomogram or Partin tables were outperformed by models with mpMRI for the prediction of any adverse finding at RP. AUC for clinical parameters versus clinical parameters and mpMRI variables were 0.77 versus 0.82 for any adverse finding. For MSKCC nomogram versus MSKCC nomogram and mpMRI variables the AUCs were 0.71 and 0.78 for any adverse finding. For Partin tables versus Partin tables and mpMRI variables the AUCs were 0.62 and 0.73 for any adverse finding. In survival analysis, mpMRI-projected adverse RP findings stratify CAPRA and MSKCC high-risk patients into groups with distinct probability for BCR. Conclusions Preoperative mpMRI improves the predictive value of commonly used clinical variables for pathological stage at RP and time to BCR. mpMRI is available for risk stratification prebiopsy, and should be considered as additional source of information to the standard predictive nomograms.
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Affiliation(s)
- Kevin Sandeman
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Juho T. Eineluoto
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Joona Pohjonen
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Andrew Erickson
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tuomas P. Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petrus Järvinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Henrikki Santti
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anssi Petas
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Matikainen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi Marjasuo
- Department of Diagnostic Radiology, Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anu Kenttämies
- Department of Diagnostic Radiology, Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas Mirtti
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Antti Rannikko
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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8
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Osses DF, Drost FJH, Verbeek JFM, Luiting HB, van Leenders GJLH, Bangma CH, Krestin GP, Roobol MJ, Schoots IG. Prostate cancer upgrading with serial prostate magnetic resonance imaging and repeat biopsy in men on active surveillance: are confirmatory biopsies still necessary? BJU Int 2020; 126:124-132. [PMID: 32232921 PMCID: PMC7383866 DOI: 10.1111/bju.15065] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives 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 1‐year of active surveillance (AS). Patients and Methods We retrospectively included 111 consecutive men with low‐risk (International Society of Urological Pathology [ISUP] Grade 1) PCa, who received protocolled repeat MRI with or without TBx and repeat SBx at 1‐year of AS. TBx was performed in Prostate Imaging‐Reporting and Data System (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 ‐negative men, and related to radiological progression on MRI (Prostate Cancer Radiological Estimation of Change in Sequential Evaluation [PRECISE] score). Results Overall upgrading (I) was 32% (35/111). Upgrading in MRI‐positive and ‐negative men was 48% (30/63) and 10% (5/48) (P < 0.001), respectively. In MRI‐positive men, there was upgrading in 23% (seven of 30) by TBx only and in 33% (10/30) by SBx only. Radiological progression (PRECISE score 4–5) in MRI‐positive men was seen in 27% (17/63). Upgrading (I) occurred in 41% (seven of 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 ‐negative men was 22% (14/63) and 6% (three of 48) (P = 0.021), respectively. In MRI‐positive men, there was upgrading in three of 14 by TBx only and in seven of 14 by SBx only. Overall upgrading (III) occurred in 5% (five of 111). Upgrading in MRI‐positive and ‐negative men was 6% (four of 63) and 2% (one of 48) (P = 0.283), respectively. In MRI‐positive men, there was upgrading in one of four by TBx only and in two of four by SBx only. Conclusion Upgrading is significantly lower in MRI‐negative compared to MRI‐positive men with low‐risk PCa at 1‐year of AS. In serial MRI‐negative men, the added value of repeat SBx at 1‐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 1‐year of AS, also when there is no radiological progression.
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Affiliation(s)
- Daniël F Osses
- Departments of, Department of, Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank-Jan H Drost
- Departments of, Department of, Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan F M Verbeek
- Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk B Luiting
- Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Chris H Bangma
- Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gabriel P Krestin
- Departments of, Department of, Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Monique J Roobol
- Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ivo G Schoots
- Departments of, Department of, Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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9
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Rosenzweig B, Laitman Y, Zilberman DE, Raz O, Ramon J, Dotan ZA, Portnoy O. Effects of "real life" prostate MRI inter-observer variability on total needle samples and indication for biopsy. Urol Oncol 2020; 38:793.e13-793.e18. [PMID: 32303407 DOI: 10.1016/j.urolonc.2020.03.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/07/2020] [Accepted: 03/19/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE Prostate multiparametric magnetic resonance imaging (mpMRI) improves diagnosis of clinically significant cancer and reduces over-detection of nonsignificant cancer. Disagreement in the interpretation of mpMRI readings is well-known, with a reported discrepancy rate of 10% to 42%. We report the clinical repercussions of this variability on prostate biopsy candidates. MATERIALS AND METHODS Medical records of patients referred from 11 medical centers for MR-guided prostate biopsy (MRGpB) between October, 2017 and January, 2019 were retrospectively analyzed. Patients with at least one prostate imaging reporting and data system (PI-RADS) 3 or greater prostate lesion were selected, and the mpMRI studies (all read by others) were reviewed by our prostate mpMRI reader. Outcomes included changes in PI-RADS score and the subsequent effect on total needle samples and indication for biopsy. RESULTS Eighty-two patients with 128 lesions were suitable for analysis (mean age 66.5 ± 7.1 years, mean PSA 6.8 ± 8.5 ng/ml). Nine (11%) patients had suspicious rectal exams (T2a). Following our prostate mpMRI reader's imaging revisions, the PI-RADS score was downgraded in 66 (52%) lesions, upgraded in 15 (12%), and unchanged in 47 (37%), leaving a total of 84 suspected lesions (kappa = 0.17). Biopsy was deferred in 22 (27%) patients, and an estimated 136.4 (34.4%) samples were avoided (P = 0.0001 for both). There was a trend toward prostate size to correlate with imaging revision and abortion of biopsy (P = 0.06) while enrollment in active surveillance correlated with proof from such outcome (P = 0.007). CONCLUSION These data suggest that high interobserver disagreement in prostate mpMRIs from diverse institutes significantly affects prostate biopsy practice. The clinical consequences of this discord are significant.
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Affiliation(s)
- Barak Rosenzweig
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2013, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
| | - Yael Laitman
- Oncogenetics Unit, Institute of Human Genetics, and Meirav High Risk Clinic, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Dorit E Zilberman
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Orit Raz
- Assuta Ashdod University Hospital, Ashdod, Israel
| | - Jacob Ramon
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Zohar A Dotan
- Department of Urology, Chaim Sheba Medical Center, Ramat Gan, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Orith Portnoy
- The Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Department of Diagnostic Imaging, Chaim Sheba Medical Center, Ramat Gan, Israel
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10
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Confirmatory multiparametric magnetic resonance imaging at recruitment confers prolonged stay in active surveillance and decreases the rate of upgrading at follow-up. Prostate Cancer Prostatic Dis 2020; 23:94-101. [PMID: 31249386 DOI: 10.1038/s41391-019-0160-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/06/2019] [Accepted: 05/12/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND To understand the value of multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies at recruitment on active surveillance (AS) outcomes. MATERIALS AND METHODS This retrospective single-center study enrolled two cohorts of 206 and 310 patients in AS. The latter group was submitted to mpMRI and targeted biopsies at recruitment. Kaplan-meier curves quantified progression-free survival (PFS) and Bioptic-PFS (B-PFS: no upgrading or >3 positive cores) in the two cohorts. Cox-regression analyses tested independent predictors of PFS and B-PFS. In patients submitted to radical prostatectomy (RP) after AS, significant cancer (csPCa) was defined as: GS ≥ 4 + 3 and/or pT ≥ 3a and/or pN+ . Logistic-regression analyses predicted csPCa at RP. RESULTS AND LIMITATIONS Median time follow-up and median time of persistence in AS were 46 (24-70) and 36 (23-58) months, respectively. Patients submitted to mpMRI at AS begin, showed greater PFS at 1- (98% vs. 91%), 3- (80% vs. 57%), and 5-years (70% vs. 35%) follow-up, respectively (all p < 0.01). At Cox-regression analysis only confirmatory mpMRI± targeted biopsy (HR: 0.3; 95% CI 0.2-0.5; p < 0.01) at AS begin was an independent predictor of PFS. Globally, 50 (16%) vs. 128 (62%) and 26 (8.5%) vs. 64 (31%) [all p < 0.01] men in the two groups experienced any-cause and bioptic AS discontinuation, respectively. Patients submitted to confirmatory mpMRI experienced greater 1-(98% vs. 93%), 3-(90% vs. 75%), and 5-years (83% vs. 56%) B-PFS, respectively (all p < 0.01). At Cox-regression analysis, mpMRI±-targeted biopsy at AS begin was associated with B-PFS (HR: 0.3; 95% CI 0.2-0.6; p < 0.01). No differences were recorded in csPCa rates between the two groups (22% vs. 28%; p = 0.47). Limitations of the study are the single-center retrospective nature and the absence of long-term follow-up. CONCLUSIONS Confirmatory mpMRI±-targeted biopsies are associated with higher PFS and B-PFS during AS. However, a non-negligible percentage of patients experience csPCa after switching to active treatment.
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Development and External Validation of Multiparametric MRI-Derived Nomogram to Predict Risk of Pathologic Upgrade in Patients on Active Surveillance for Prostate Cancer. AJR Am J Roentgenol 2020; 214:825-834. [PMID: 31913073 DOI: 10.2214/ajr.19.22196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The aim of this study was to create, develop, and externally validate a nomogram that predicts pathologic upgrade in patients on active surveillance (AS) for prostate cancer using commonly available clinical and multiparametric MRI (mpMRI) factors. MATERIALS AND METHODS. A consecutive sample of 300 patients undergoing AS for prostate cancer at the Keimyung University Dongsan Hospital between 2010 and 2016 was used to develop the nomogram. The validation cohort consisted of 150 patients undergoing active surveillance at Kyungpook National University Hospital between 2013 and 2017. The study outcome was the occurrence of pathologic upgrade in AS patients. The relationship between the clinical and mpMRI factors considered and pathologic upgrade was tested using univariate and multivariate logistic regression analyses. The predictive accuracy of the nomogram was determined using the ROC AUC. RESULTS. The overall rate of pathologic upgrade was 25.0% in the developmental cohort and 22.0% in the validation cohort. Significant variables in the models were age, prostate-specific antigen level, biopsy grade group 2, baseline Prostate Imaging Reporting and Data System (PI-RADS) scores of 4 and 5, positive cores on initial biopsy greater than 1, and biopsy cores with 50% or more tumor involvement. The progression seen on mpMRI of PI-RADS score was significantly associated with pathologic upgrade. The nomogram used to predict the risk of pathologic upgrade had a predictive accuracy of 0.78 in the external validation cohort. CONCLUSION. This study developed and externally validated a nomogram that predicts the risk of pathologic upgrade on the basis of commonly used factors. This nomogram may be used to assist management decision making for patients on AS for prostate cancer.
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Chesnut GT, Vertosick EA, Benfante N, Sjoberg DD, Fainberg J, Lee T, Eastham J, Laudone V, Scardino P, Touijer K, Vickers A, Ehdaie B. Role of Changes in Magnetic Resonance Imaging or Clinical Stage in Evaluation of Disease Progression for Men with Prostate Cancer on Active Surveillance. Eur Urol 2019; 77:501-507. [PMID: 31874726 DOI: 10.1016/j.eururo.2019.12.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/10/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Active surveillance (AS) protocols rely on rectal examination, prostate-specific antigen, imaging, and biopsy to identify disease progression. OBJECTIVE To evaluate whether an AS regimen based on magnetic resonance imaging (MRI) or clinical stage changes can detect reclassification to grade group (GG) ≥2 disease compared with scheduled systematic biopsies. DESIGN, SETTING, AND PARTICIPANTS We identified a cohort of men initiated on AS between January 2013 and April 2016 at a single tertiary-care center. Patients completed confirmatory testing and prostate MRI prior to enrollment, then underwent laboratory and physical evaluation every 6 mo, MRI every 18 mo, and biopsy every 3yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS MRI results were evaluated using composite Likert/Prostate Imaging Reporting and Data System v2 scoring. MRI and clinical changes were assessed for association with disease progression. Univariable and multivariable regression models were used to predict upgrading on 3-yr biopsy. RESULTS AND LIMITATIONS At 3yr, of 207 men, 66 (32%) had≥GG2 at biopsy: 55 (83%) with GG2, 10 (15%) with GG3, and one (1.5%) with GG4. Among patients with a 3-yr MRI score of ≥3, 41% had≥GG2 disease, compared with 15% with an MRI score of <3 (p=0.0002). The MRI score increased in 48 men (23%), decreased in 27 (13%), and was unchanged in 132 (64%) men. Increases in MRI score were not associated with reclassification after adjusting for the 3-yr MRI score (p=0.9). Biopsying only for an increased MRI score or clinical stage would avoid 681 biopsies per 1000 men, at the cost of missing ≥GG2 disease in 169 patients. CONCLUSIONS An AS strategy that uses MRI or clinical changes to trigger prostate biopsy avoids many biopsies but misses an unacceptable amount of clinically significant disease. Prostate biopsy for men on AS should be performed at scheduled intervals, regardless of stable imaging or examination findings. PATIENT SUMMARY An active surveillance strategy for biopsy based only on increases in magnetic resonance imaging score or clinical stage will avoid many biopsies; however, it will miss many patients with clinically significant prostate cancer.
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Affiliation(s)
- Gregory T Chesnut
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Emily A Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Benfante
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Fainberg
- Department of Urology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Taehyoung Lee
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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The Use of MRI and PET Imaging Studies for Prostate Cancer Management: Brief Update, Clinical Recommendations, and Technological Limitations. Med Sci (Basel) 2019; 7:medsci7080085. [PMID: 31387208 PMCID: PMC6723334 DOI: 10.3390/medsci7080085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023] Open
Abstract
Multi-parametric magnetic resonance imaging (mpMRI) and positron emission tomography (PET) using prostate-specific membrane antigen (PSMA) targeting ligands have been adopted as a new standard of imaging modality in the management of prostate cancer (PCa). Technological advances with hybrid and advanced computer-assisted technologies such as MR/PET, MR/US, multi-parametric US, and robotic biopsy systems, have resulted in improved diagnosis and staging of patients in various stages of PCa with changes in treatment that may be considered “personalized”. Whilst newer clinical trials incorporate these novel imaging modalities into study protocols and as long-term data matures, patients should be made aware of the potential benefits and harm related to these technologies. Published literature needs to report longer-term treatment efficacy, health economic outcomes, and adverse effects. False positives and negatives of these imaging modalities have the potential to cause harm and the limitations of these technologies should be appreciated. The role of a multi-disciplinary team (MDT) and a shared-decision-making model are important to ensure that all aspects of the novel imaging modalities are considered.
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Scheltema MJ, Chang JI, Stricker PD, van Leeuwen PJ, Nguyen QA, Ho B, Delprado W, Lee J, Thompson JE, Cusick T, Spriensma AS, Siriwardana AR, Yuen C, Kooner R, Hruby G, O'Neill G, Emmett L. Diagnostic accuracy of 68Ga-prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) and multiparametric (mp)MRI to detect intermediate-grade intra-prostatic prostate cancer using whole-mount pathology: impact of the addition of 68Ga-P. BJU Int 2019; 124 Suppl 1:42-49. [DOI: 10.1111/bju.14794] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Matthijs J. Scheltema
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Prostate Cancer Centre; Darlinghurst NSW Australia
- Amsterdam UMC; Department of Urology; Amsterdam The Netherlands
| | - John I. Chang
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Prostate Cancer Centre; Darlinghurst NSW Australia
| | - Phillip D. Stricker
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Prostate Cancer Centre; Darlinghurst NSW Australia
| | - Pim J. van Leeuwen
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Prostate Cancer Centre; Darlinghurst NSW Australia
- Antoni van Leeuwenhoek Nederlands Kanker Instituut; Amsterdam The Netherlands
| | - Quoc A. Nguyen
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
| | - Bao Ho
- St Vincent's Hospital Nuclear Medicine and PET Department; Darlinghurst NSW Australia
| | | | - Jonathan Lee
- St Vincent's Hospital Nuclear Medicine and PET Department; Darlinghurst NSW Australia
| | - James E. Thompson
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Prostate Cancer Centre; Darlinghurst NSW Australia
| | - Thomas Cusick
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
| | | | - Amila R. Siriwardana
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Prostate Cancer Centre; Darlinghurst NSW Australia
| | - Carlo Yuen
- St Vincent's Clinic; Darlinghurst NSW Australia
| | - Raji Kooner
- St Vincent's Clinic; Darlinghurst NSW Australia
| | - George Hruby
- Genesis Cancer Care; St Vincent's Hospital; Darlinghurst NSW Australia
| | | | - Louise Emmett
- Garvan Institute of Medical Research and The Kinghorn Cancer Centre; Darlinghurst NSW Australia
- St Vincent's Hospital Nuclear Medicine and PET Department; Darlinghurst NSW Australia
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The Association of the Long Prostate Cancer Expressed PDE4D Transcripts to Poor Patient Outcome Depends on the Tumour's TMPRSS2-ERG Fusion Status. Prostate Cancer 2019; 2019:8107807. [PMID: 31275657 PMCID: PMC6582815 DOI: 10.1155/2019/8107807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/10/2019] [Accepted: 04/21/2019] [Indexed: 11/17/2022] Open
Abstract
Objectives To investigate the added value of assessing transcripts for the long cAMP phosphodiesterase-4D (PDE4D) isoforms, PDE4D5 and PDE4D9, regarding the prognostic power of the ‘CAPRA & PDE4D7' combination risk model to predict longitudinal postsurgical biological outcomes in prostate cancer. Patients and Methods RNA was extracted from both biopsy punches of resected tumours (606 patients; RP cohort) and diagnostic needle biopsies (168 patients; DB cohort). RT-qPCR was performed in order to determine PDE4D5, PDE4D7, and PDE4D9 transcript scores in both study cohorts. By RNA sequencing, we determined the TMPRSS2-ERG fusion status of each tumour sample in the RP cohort. Kaplan-Meier survival analyses were then applied to correlate the PDE4D5, PDE4D7 and PDE4D9 scores with postsurgical patient outcomes. Logistic regression was then used to combine the clinical CAPRA score with PDE4D5, PDE4D7, and PDE4D9 scores in order to build a ‘CAPRA & PDE4D5/7/9' regression model. ROC and decision curve analysis was used to estimate the net benefit of the ‘CAPRA & PDE4D5/7/9' risk model. Results Kaplan-Meier survival analysis, on the RP cohort, revealed a significant association of the PDE4D7 score with postsurgical biochemical recurrence (BCR) in the presence of the TMPRSS2-ERG gene rearrangement (logrank p<0.0001), compared to the absence of this gene fusion event (logrank p=0.08). In contrast, the PDE4D5 score was only significantly associated with BCR in TMPRSS2-ERG fusion negative tumours (logrank p<0.0001 vs. logrank p=0.4 for TMPRSS2-ERG+ tumours). This was similar for the PDE4D9 score although less pronounced compared to that of the PDE4D5 score (TMPRSS2ERG- logrank p<0.0001 vs. TMPRSS2ERG+ logrank p<0.005). In order to predict BCR after primary treatment, we undertook ROC analysis of the logistic regression combination model of the CAPRA score with the PDE4D5, PDE4D7, and PDE4D9 scores. For the DB cohort, this demonstrated significant differences in the AUC between the CAPRA and the PDE4D5/7/9 regression model vs. the CAPRA and PDE4D7 risk model (AUC 0.87 vs. 0.82; p=0.049) vs. the CAPRA score alone (AUC 0.87 vs. 0.77; p=0.005). The CAPRA and PDE4D5/7/9 risk model stratified 19.2% patients of the DB cohort to either ‘no risk of biochemical relapse' (NPV 100%) or the ‘start of any secondary treatment (NPV 100%)', over a follow-up period of up to 15 years. Decision curve analysis presented a clear, net benefit for the use of the novel CAPRA & PDE4D5/7/9 risk model compared to the clinical CAPRA score alone or the CAPRA and PDE4D7 model across all decision thresholds. Conclusion Association of the long PDE4D5, PDE4D7, and PDE4D9 transcript scores to prostate cancer patient outcome, after primary intervention, varies in opposite directions depending on the TMPRSS2-ERG genomic fusion background of the tumour. Adding transcript scores for the long PDE4D isoforms, PDE4D5 and PDE4D9, to our previously presented combination risk model of the combined ‘CAPRA & PDE4D7' score, in order to generate the CAPRA and PDE4D5/7/9 score, significantly improves the prognostic power of the model in predicting postsurgical biological outcomes in prostate cancer patients.
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Hsiang W, Ghabili K, Syed JS, Holder J, Nguyen KA, Suarez-Sarmiento A, Huber S, Leapman MS, Sprenkle PC. Outcomes of Serial Multiparametric Magnetic Resonance Imaging and Subsequent Biopsy in Men with Low-risk Prostate Cancer Managed with Active Surveillance. Eur Urol Focus 2019; 7:47-54. [PMID: 31147263 DOI: 10.1016/j.euf.2019.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 04/11/2019] [Accepted: 05/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Outcomes of serial multiparametric magnetic resonance imaging (mpMRI) and subsequent biopsy in monitoring prostate cancer (PCa) in men on active surveillance (AS) have not been defined clearly. OBJECTIVE To determine whether changes in serial mpMRI can predict pathological upgrade among men with grade group (GG) 1 PCa managed with AS. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of men with GG1 on AS with at least two consecutive mpMRI examinations during 2012-2018 who underwent mpMRI/ultrasound fusion or systematic biopsies. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Progression on serial mpMRI was evaluated as a predictor of pathological upgrading to GG≥2 on a follow-up biopsy using clinical, pathological, and imaging factors in binary logistic regression. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were determined. RESULTS AND LIMITATIONS Of 122 patients, 29 men (23.8%) experienced pathological upgrade on the follow-up biopsy. Progression on mpMRI was not associated with pathological upgrade. The sensitivity, specificity, PPV, and NPV of mpMRI progression for predicting pathological upgrade were 41.3%, 54.8%, 22.2%, and 75%, respectively. Age (odds ratio [OR] 1.17, p=0.006), Prostate Imaging Reporting and Data System (PI-RADS) score on initial mpMRI (4-5 vs ≤3, OR 7.48, p=0.01), number of positive systematic cores (OR 1.84, p=0.03), number of positive targeted cores (OR 0.44, p=0.04), and maximum percent of targeted core tumor involvement (OR 1.04, p=0.01) were significantly associated with pathological upgrade. CONCLUSIONS We did not observe an association between mpMRI progression and pathological upgrade; however, a PI-RADS score of 4-5 on initial mpMRI was predictive of subsequent pathological progression. The continued use of systematic and fusion biopsies appears necessary due to risks of reclassification over time. PATIENT SUMMARY Progression on serial multiparametric magnetic resonance imaging during active surveillance (AS) is not associated with progression on the follow-up biopsy. Both systematic and fusion biopsies are necessary to sufficiently capture progression during AS.
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Affiliation(s)
- Walter Hsiang
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Kamyar Ghabili
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Jamil S Syed
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Justin Holder
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Kevin A Nguyen
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | | | - Steffen Huber
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
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Glass AS, Dall'Era MA. Use of multiparametric magnetic resonance imaging in prostate cancer active surveillance. BJU Int 2019; 124:730-737. [PMID: 30740876 DOI: 10.1111/bju.14705] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To review the role of multiparametric magnetic resonance imaging (mpMRI) for active surveillance (AS) of prostate cancer. MATERIALS AND METHODS We performed a comprehensive search of Medline and Embase databases for relevant articles in the English language. Search terms included 'prostate cancer', 'active surveillance' or 'monitoring', 'expectant management', and 'MRI'. We also reviewed practice guidelines from recognized international associations or societies involved in prostate cancer care. Articles were selected by both authors for relevance to the subject matter. RESULTS The ability of mpMRI to visualize primarily high-grade tumours within the prostate may improve risk stratification for men considering AS for prostate cancer. Multiple mostly single-institution studies have found that the addition of mpMRI and a targeted biopsy strategy can improve AS patient selection over standard TRUS biopsy alone. The high negative predictive value of mpMRI may allow men to avoid early repeat biopsy and may offer the possibility to tailor biopsy strategies. The presence of a radiographically positive lesion on mpMRI at baseline is predictive of higher likelihood of radiographic progression over time while on AS. CONCLUSIONS MRI has shown promise in both patient selection and monitoring for men who undergo AS for prostate cancer. There are multiple barriers to the widespread use of mpMRI for AS including quality, cost and access to care.
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Affiliation(s)
- Allison S Glass
- Department of Urology, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Marc A Dall'Era
- Department of Urology, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
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Gallagher KM, Christopher E, Cameron AJ, Little S, Innes A, Davis G, Keanie J, Bollina P, McNeill A. Four-year outcomes from a multiparametric magnetic resonance imaging (MRI)-based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies. BJU Int 2019; 123:429-438. [PMID: 30113755 PMCID: PMC7379595 DOI: 10.1111/bju.14513] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To report outcomes from a multiparametric (mp) magnetic resonance imaging (MRI)-based active surveillance programme that did not include performing protocol biopsies after the first confirmatory biopsy. PATIENTS AND METHODS All patients diagnosed with Gleason 3 + 3 prostate cancer because of a raised PSA level who underwent mpMRI after diagnosis were included. Patients were recorded in a prospective clinical database and followed up with PSA monitoring and repeat MRI. In patients who remained on active surveillance after the first MRI (with or without confirmatory biopsy), we investigated PSA dynamics for association with subsequent progression. Comparison between first and second MRI scans was undertaken. Outcomes assessed were: progression to radical therapy at first MRI/confirmatory biopsy and progression to radical therapy in those who remained on active surveillance after first MRI. RESULTS A total of 211 patients were included, with a median of 4.2 years of follow-up. The rate of progression to radical therapy was significantly greater at all stages among patients with visible lesions than in those with initially negative MRI (47/125 (37.6%) vs 11/86 (12.8%); odds ratio 4.1 (95% CI 2.0-8.5), P < 0.001). Only 1/56 patients (1.8%) with negative initial MRI scans who underwent a confirmatory systematic biopsy had upgrading to Gleason 3 + 4 disease. PSA velocity was significantly associated with subsequent progression in patients with negative initial MRI (area under the curve 0.85 [95% CI 0.75-0.94]; P <0.001). Patients with high-risk visible lesions on first MRI who remained on active surveillance had a high risk of subsequent progression 19/76 (25.0%) vs 9/84 (10.7%) for patients with no visible lesions, despite reassuring targeted and systematic confirmatory biopsies and regardless of PSA dynamics. CONCLUSION Men with low-risk Gleason 3 + 3 prostate cancer on active surveillance can forgo protocol biopsies in favour of MRI and PSA monitoring with selective re-biopsy.
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Affiliation(s)
| | - Edward Christopher
- Department of UrologyWestern General HospitalEdinburghUK
- College of Medicine and Veterinary MedicineUniversity of EdinburghEdinburghUK
| | | | - Scott Little
- Department of UrologyWestern General HospitalEdinburghUK
| | - Alasdair Innes
- Department of UrologyWestern General HospitalEdinburghUK
| | - Gill Davis
- Department of UrologyWestern General HospitalEdinburghUK
| | - Julian Keanie
- Department of RadiologyWestern General HospitalEdinburghUK
| | - Prasad Bollina
- Department of UrologyWestern General HospitalEdinburghUK
| | - Alan McNeill
- Department of UrologyWestern General HospitalEdinburghUK
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Stavrinides V, Giganti F, Emberton M, Moore CM. MRI in active surveillance: a critical review. Prostate Cancer Prostatic Dis 2018; 22:5-15. [PMID: 30115960 DOI: 10.1038/s41391-018-0077-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/18/2018] [Accepted: 07/19/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Recent technological advancements and the introduction of modern anatomical and functional sequences have led to a growing role for multiparametric magnetic resonance imaging (mpMRI) in the detection, risk assessment and monitoring of early prostate cancer. This includes men who have been diagnosed with lower-risk prostate cancer and are looking at the option of active surveillance (AS). The purpose of this paper is to review the recent evidence supporting the use of mpMRI at different time points in AS, as well as to discuss some of its potential pitfalls. METHODS A combination of electronic and manual searching methods were used to identify recent, important papers investigating the role of mpMRI in AS. RESULTS The high negative predictive value of mpMRI can be exploited for the selection of AS candidates. In addition, mpMRI can be efficiently used to detect higher risk disease in patients already on surveillance. CONCLUSION Although there is an ongoing debate regarding the precise nature of its optimal implementation, mpMRI is a promising risk stratification tool and should be considered for men on AS.
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Affiliation(s)
- Vasilis Stavrinides
- Division of Surgery and Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, W1W 7TS, London, UK.
| | - Francesco Giganti
- Division of Surgery and Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, W1W 7TS, London, UK.,Department of Radiology, University College London Hospitals NHS Trust, 235 Euston Road, NW1 2BU, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, W1W 7TS, London, UK.,Department of Urology, University College London Hospitals NHS Trust, 235 Euston Road, NW1 2BU, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, W1W 7TS, London, UK.,Department of Urology, University College London Hospitals NHS Trust, 235 Euston Road, NW1 2BU, London, UK
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