Abstract
ObjectivesThe PRECISE recommendations for magnetic resonance imaging (MRI) in patients on active surveillance (AS) for prostate cancer (PCa) include repeated measurement of each lesion, and attribution of a PRECISE radiological progression score for the likelihood of clinically significant change over time. We aimed to compare the PRECISE score with clinical progression in patients who are managed using an MRI-led AS protocol.MethodsA total of 553 patients on AS for low- and intermediate-risk PCa (up to Gleason score 3 + 4) who had two or more MRI scans performed between December 2005 and January 2020 were included. Overall, 2161 scans were retrospectively re-reported by a dedicated radiologist to give a PI-RADS v2 score for each scan and assess the PRECISE score for each follow-up scan. Clinical progression was defined by histological progression to ≥ Gleason score 4 + 3 (Gleason Grade Group 3) and/or initiation of active treatment. Progression-free survival was assessed using Kaplan-Meier curves and log-rank test was used to assess differences between curves.ResultsOverall, 165/553 (30%) patients experienced the primary outcome of clinical progression (median follow-up, 74.5 months; interquartile ranges, 53–98). Of all patients, 313/553 (57%) did not show radiological progression on MRI (PRECISE 1–3), of which 296/313 (95%) had also no clinical progression. Of the remaining 240/553 patients (43%) with radiological progression on MRI (PRECISE 4–5), 146/240 (61%) experienced clinical progression (p < 0.0001). Patients with radiological progression on MRI (PRECISE 4-5) showed a trend to an increase in PSA density.ConclusionsPatients without radiological progression on MRI (PRECISE 1-3) during AS had a very low likelihood of clinical progression and many could avoid routine re-biopsy.Key Points• Patients without radiological progression on MRI (PRECISE 1–3) during AS had a very low likelihood of clinical progression and many could avoid routine re-biopsy.• Clinical progression was almost always detectable in patients with radiological progression on MRI (PRECISE 4–5) during AS.• Patients with radiological progression on MRI (PRECISE 4–5) during AS showed a trend to an increase in PSA density.
Highlights
Most policy groups around the world recommend active surveillance (AS) as an appropriate option for patients with low-risk prostate cancer (PCa) [1, 2]
306/553 (55%) patients had at least an additional biopsy, 178 (58%) of which were targeted by visual registration
We have demonstrated that a Prostate Imaging Reporting and Data System (PI-RADS) score of 4 or 5 at entry to an increase in PSA density over time is significantly associated with radiological progression (PRECISE 4–5)
Summary
Most policy groups around the world recommend active surveillance (AS) as an appropriate option for patients with low-risk prostate cancer (PCa) [1, 2]. The current position is less than satisfactory as most of the evidence base to support its use is from single centres, no standard AS protocol exists and we lack a method of reliably ascertaining when true progression (by either grade or volume) occurs. The ASIST trial initially showed no difference in the upgrade rate between patients having standard re-biopsy and those having MRI with 2 cores targeted to a lesion (upgrade to Gleason Grade Group 2 (GGG 2) was 21% vs 23% respectively, p = 0.9), there were marked differences between the study centres [5]. After 2 years of follow-up, the authors found that baseline mpMRI before confirmatory biopsy resulted in 50% fewer failures of surveillance and less progression to higher-grade cancer, confirming the value of mpMRI during AS [6]
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