Changes in Magnetic Resonance Imaging Using the Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation Criteria to Detect Prostate Cancer Progression for Men on Active Surveillance

Abstract

Background: The ability of serial magnetic resonance imaging (MRI) to capture pathologic progression during active surveillance (AS) remains in question.

Objective: To determine whether changes in MRI are associated with pathologic progression for patients on AS.

Design, setting, and participants: From July 2007 through January 2020, we identified all patients evaluated for AS at our institution. Following confirmatory biopsy, a total of 391 patients who underwent surveillance MRI and biopsy at least once were identified (median follow-up of 35.6 mo, interquartile range 19.7-60.6).

Outcome measurements and statistical analysis: All MRI intervals were scored using the "Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation" (PRECISE) criteria, with PRECISE scores =4 considered a positive change in MRI. A generalized estimating equation-based logistic regression analysis was conducted for all intervals with a PRECISE score of <4 to determine the predictors of Gleason grade group (GG) progression despite stable MRI.

Results and limitations: A total of 621 MRI intervals were scored by PRECISE and validated by biopsy. The negative predictive value of stable MRI (PRECISE score <4) was greatest for detecting GG1 to?=?GG3 disease (0.94 [0.91-0.97]). If 2-yr surveillance biopsy were performed exclusively for a positive change in MRI, 3.7% (4/109) of avoided biopsies would have resulted in missed progression from GG1 to?=?GG3 disease. Prostate-specific antigen (PSA) density (odds ratio 1.95 [1.17-3.25], p?=? 0.01) was a risk factor for progression from GG1 to =GG3 disease despite stable MRI.

Conclusions: In patients with GG1 disease and stable MRI (PRECISE score <4) on surveillance, grade progression to?=?GG3 disease is not common. In patients with grade progression detected on biopsy despite stable MRI, elevated PSA density appeared to be a risk factor for progression to?=?GG3 disease.

Patient summary: For patients with low-risk prostate cancer on active surveillance, the risk of progressing to grade group 3 disease is low with a stable magnetic resonance image (MRI) after 2?yr. Having higher prostate-specific antigen density increases the risk of progression, despite having a stable MRI.

Keywords: Active surveillance; Fusion biopsy; Multiparametric magnetic resonance imaging; Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation; Prostate cancer.

Fig. 1 -

Three sets of intervals demonstrating how the PRECISE criteria are applied based on changing MRI features. Top row of each set (A–D) is at the beginning of the interval, bottom row (E–H) is corresponding to same pulse sequences at the end of the interval. (1) PI-RADS 3 lesion in right apical peripheral zone which was subsequently downgraded to PI-RADS 2 on follow-up MRI, as lesion is no longer visible on ADC map (PRECISE score = 2). PSA change (ng/mL): 5.23 → 9.00; PSAD change (ng/mL²): 0.11 → 0.15; MRI-targeted biopsy result: benign → benign. (2) PI-RADS 4 lesion in the left midbase peripheral zone remained stable on follow-up imaging (PRECISE score = 3). PSA change (ng/mL): 8.46 → 8.42; PSAD change (ng/mL²): 0.08 → 0.07; MRI-targeted biopsy result: benign → benign. (3) PI-RADS 4 lesion increased in size on T2W and became more prominent on DWI on follow-up MRI (PRECISE score = 4). PSA change (ng/mL): 5.16 → 5.81; PSAD change (ng/mL²): 0.15 → 0.14; MRI-targeted biopsy result: not targeted → GG1. ADC = apparent diffusion coefficient; DCE = dynamic contrast enhanced; DWI = diffusion-weighted imaging; GG = Gleason grade group; MRI = magnetic resonance imaging; PI-RADS = Prostate Imaging Reporting and Data System; PRECISE = Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation; PSA = prostate-specific antigen; PSAD = prostate-specific antigen density; T2W = T2 weighted. ^a b = 1500s/mm².