Natural history of small index lesions suspicious for prostate cancer on multiparametric MRI: recommendations for interval imaging follow-up

Abstract

Purpose: We aimed to determine the natural history of small index lesions identified on multiparametric-magnetic resonance imaging (MP-MRI) of the prostate by evaluating lesion-specific pathology and growth on serial MP-MRI.

Materials and methods: We performed a retrospective review of 153 patients who underwent a minimum of two MP-MRI sessions, on an institutional review board-approved protocol. Index lesion is defined as the lesion(s) with the highest cancer suspicion score based on initial MP-MRI of a patient, irrespective of size. Two study cohorts were identified: (1) patients with no index lesion or index lesion(s) ≤7 mm and (2) a subset with no index lesion or index lesion(s) ≤5 mm. Pathological analysis of the index lesions was performed following magnetic resonance/ultrasound fusion-guided biopsy. Growth rate of the lesions was calculated based on MP-MRI follow-up.

Results: Patients with small index lesions measuring ≤7 mm (n=42) or a subset with lesions ≤5 mm (n=20) demonstrated either benign findings (86.2% and 87.5%, respectively) or low grade Gleason 6 prostate cancer (13.8% and 12.5%, respectively) on lesion-specific targeted biopsies. These lesions demonstrated no significant change in size (P = 0.93 and P = 0.36) over a mean imaging period of 2.31±1.56 years and 2.40±1.77 years for ≤7 mm and ≤5 mm index lesion thresholds, respectively. These findings held true on subset analyses of patients who had a minimum of two-year interval follow-up with MP-MRI.

Conclusion: Small index lesions of the prostate are pathologically benign lesions or occasionally low-grade cancers. Slow growth rate of these small index lesions on serial MP-MRI suggests a surveillance interval of at least two years without significant change.

Figure 1.

Patient selection for analysis cohorts of small index lesions found on initial multiparametric MRI (MP-MRI).

Figure 2.

Lesion-based multiparametric MRI cancer suspicion scoring system. T2W MRI, T2-weighted MRI; ADC, apparent diffusion coefficient; DCE MRI, dynamic contrast enhanced MRI; DW-MRI, diffusion-weighted MRI; MP-MRI, multiparametric MRI.

Figure 3. a–d.

Patient MRI depicting baseline T2-weighted (a) and diffusion-weighted imaging (DWI) (b) sequences which identified a right midanterior peripheral zone lesion measuring 5 mm (arrows). Subsequent T2-weighted (c) and DWI (d) sequences show no change in size or characteristics (arrows). At both time points, dynamic contrast-enhanced MRI and MR spectroscopy were negative in this area, maintaining a moderate level of suspicion. Gleason 3+3=6 was diagnosed in <5% of targeted biopsy cores.