Stratifying patients with intermediate-risk prostate cancer: Validation of a new model based on MRI parameters and targeted biopsy and comparison with NCCN and AUA subclassifications

Clinically Meaningful Upstaging and Upgrading in Favorable Intermediate-Risk Radical Prostatectomy Patients

INTRODUCTION

In NCCN favorable intermediate-risk (FIR) prostate cancer (PCa) patients treated with radical prostatectomy (RP), we tested the effect of upstaging and upgrading on cancer-specific mortality (CSM).

METHODS

Within the SEER database (2010-2021), upstaging (≥pT3a or pN1) and upgrading (ISUP ≥3) rates in FIR RP patients were tabulated. Kaplan-Meier (KM) plots and multivariable Cox-regression models (CRMs) were fitted.

RESULTS

In 9,037 FIR RP PCa patients, 1,136 (12.6%) exhibited upstaging, 1,341 (14.8%) upgrading, and 377 (4.2%) both vs. 6,937 (76.8%) that did not. Of all upstaged patients, 812 (71.5%) harbored pT3a vs. 324 (28.5%) ≥pT3b/pN1 stage. Of all upgraded patients, 1,077 (80.3%) harbored ISUP 3 vs. 264 (19.7%) ISUP ≥4. Of all upstaged and upgraded patients, 46 (12.2%) exhibited both ≥pT3b/pN1 and ISUP ≥4. Ten-year CSM-free rates in upstaged (96.0%), upgraded (95.9%) and combined upstaged and upgraded (91.0%) patients were significantly lower (P < .001) than others (98.9%). Significantly lower 10-year CSM-free rates were recorded in ≥pT3b/pN1-only (91.9%), ISUP ≥4-only (94.6%), and combined ≥pT3b/pN1 and ISUP ≥4 (85.3%) patients (all P < .05). In multivariable CRMs, upstaging (HR: 3.8), upgrading (HR: 3.5) as well as both upstaging and upgrading (HR: 8.3), independently increased CSM. Specific upstaging to ≥pT3b/pN1-only, upgrading to ISUP ≥4-only, and both upgrading and upstaging independently increased CSM by 3.5-, 6.7-, and 26-fold, respectively.

CONCLUSION

Of all FIR RP patients, the vast majority is neither upstaged nor upgraded. Those with ≥pT3b/pN1 upstaging, ISUP ≥4 upgrading, or both are at high, higher, and extremely elevated risk of CSM, respectively, and thus require special considerations.

MRI characteristics and oncological follow-up of patients with ISUP grade group 4 or 5 prostate cancer

OBJECTIVES

To analyze multiparametric MRI (mpMRI) characteristics of patients with International Society of Urological Pathology (ISUP) grade group (GG) 4 or 5 prostate cancer (PC) and to correlate MRI parameters with the occurrence of biochemical recurrence (BCR) after radical prostatectomy (RPE).

METHODS

In this single-center cohort study consecutive patients with mpMRI and ISUP GG 4 or 5 PC were retrospectively analyzed. Clinical, MR-guided biopsy, and diagnostic mpMRI parameter were assessed. A subcohort of patients with RPE and follow-up was analyzed separately. A univariate and multivariate analyses were performed to determine parameters that are associated to patients with BCR after RPE.

RESULTS

145 patients (mean age 70y, median PSA 10.9 ng/ml) were analyzed. 99% had a PI-RADS classification of 4 or 5, 48% revealed MRI T3 stage, and median diameter of the MRI index lesion (IL) was 15 mm. IL showed a median ADC value of 668 ×10-6 mm2/s and exhibited contrast enhancement in 94% of the cases. For patients with follow-up after RPE (n = 82; mean follow-up time 68 ± 27 m), MRI parameters were significantly different for contact length of the IL to the pseudocapsule (LCC), MRI T3 stage, and IL localization (p < 0.05). Higher PSAD and MRI T3 stage were independent parameters for the risk of BCR when incorporating clinical, biopsy, and MRI parameters.

CONCLUSION

ISUP GG 4 or 5 PC has distinctive characteristics on mpMRI and were detected on MRI in all cases. In addition, higher PSAD and MRI T3 stage were significant predictors for BCR after RPE.

Magnetic Resonance Imaging-Targeted Biopsy and Pretherapeutic Prostate Cancer Risk Assessment: a Systematic Review: Biopsie ciblée par Imagerie par résonance magnétique et évaluation pré-thérapeutique du risque de cancer de la prostate : revue systématique

INTRODUCTION

Multiparametric magnetic resonance imaging (MRI) has been included in prostate cancer (PCa) diagnostic pathway and may improve disease characterization. The aim of this systematic review is to assess the added value of MRI-targeted biopsy (TB) in pre-therapeutic risk assessment models over existing tools based on systematic biopsy (SB) for localized PCa.

EVIDENCE ACQUISITION

A systematic search was conducted using Pubmed (Medline), Scopus and ScienceDirect databases according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We included studies through October 2021 reporting on TB in pretherapeutic risk assessment models.

EVIDENCE SYNTHESIS

We identified 24 eligible studies including 24'237 patients for the systematic review. All included studies were retrospective and conducted in patients undergoing radical prostatectomy. Nine studies reported on the risk of extraprostatic extension, seven on the risk of lymph node invasion, three on the risk of biochemical recurrence and nine on the improvement of PCa risk stratification. Overall, the combination of TB with imaging, clinical and biochemical parameters outperformed current pretherapeutic risk assessment models. External validation studies are lacking for certain endpoints and the absence of standardization among TB protocols, including number of TB cores and fusion systems, may limit the generalizability of the results.

CONCLUSION

TB should be incorporated in pretherapeutic risk assessment models to improve clinical decision making. Further high-quality studies are required to determine models' generalizability while there is an urgent need to reach consensus on a standardized TB protocol. Long-term outcomes after treatment are also awaited to confirm the superiority of such models over classical risk classifications only based on SB. © 2022 Elsevier Masson SAS. All rights reserved.