Reliability of Serial Prostate Magnetic Resonance Imaging to Detect Prostate Cancer Progression During Active Surveillance: A Systematic Review and Meta-analysis - Beyond the Abstract
In real-world MRI has been increasingly adopted as a surrogate for follow-up prostate biopsy during AS, however, there are comparably sparse and inconclusive data that would allow determining serial (at least two) MRI diagnostic accuracy for PCa progression during AS. Furthermore, the recently developed and validated PRECISE recommendations help to standardize serial MRI reports during AS.
In this study, we aimed to provide pooled diagnostic estimates of serial MRI, assessed using individual expert centers definitions and PRECISE criteria, for PCa progression during AS.
We finally included 15 studies with 2240 patients. Two-thirds of the included studies were very recent and have been published since 2020. Six studies used PRECISE recommendations, and nine institution-specific definitions. There was notable heterogeneity in terms of patients population, AS, and MRI protocols. Our pooled results revealed that pooled sensitivity and specificity of serial MRI were 0.59 (95% confidence interval [CI] 0.44–0.73) and 0.75 (95% CI 0.66–0.84), respectively. Pooled accuracy was 73%. Despite a signal towards improved performance of PRECISE compared to individual expert centers criteria of serial MRI assessment, there were no statistically significant differences in pooled sensitivity (p=0.37) and specificity (p=0.74). We set PCa progression prevalence at previously reported ranges (20-30%) and found that negative predictive value ranged from 0.81 (95% CI 0.73–0.88) to 0.88 (95% CI 0.83–0.93) and positive predictive value ranged from 0.37 (95% CI 0.24–0.54) to 0.50 (95% CI 0.36–0.66).
In a clinical setting, these results suggest that serial MRI-guided AS in 1000 men would result in the omitting follow-up biopsy in up to 683 patients while missing up to 124 cases of PCa progression. Moreover, up to 200 biopsies out of up to 351 performed based on MRI progression would be negative for PCa progression.
There are several implications of this work. Despite MRI with other biomarkers allowing tailoring the intensity of AS we are not ready yet for fully MRI-guided AS, thus still regular follow-up biopsies should be performed. On the other hand, biopsies are associated with pain and possible complications and impair quality of life during AS. In the PROTECT trial, patients were diagnosed using systematic biopsies and followed using PSA, and still the results were similar at 10-year follow-up compared to initial active treatment. Furthermore, there is a question regarding the inaccuracy of biopsy itself and if imaging is indeed more accurate (false positives). On the other hand, there are still aggressive tumors that can be invisible on MRI and these could have metastatic potential. We have also to emphasize that all the studies were performed at experts centers and cannot be directly translated to the general community. In conclusion, we believe the present evidence does not allow to support fully MRI-guided AS. We need more prospective long-term follow-up studies with quality improvements or additional MRI assessment tools such as radiomics with artificial intelligence before the use of MRI in this setting.
Written by: Pawel Rajwa, Benjamin Pradere, Fahad Quhal, Keiichiro Mori, Ekaterina Laukhtina, Nicolai A Huebner, David D'Andrea, Aleksandra Krzywon, Sung Ryul Shim, Pascal A Baltzer, Raphaële Renard-Penna, Michael S Leapman, Shahrokh F Shariat, Guillaume Ploussard
Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland., Department of Urology, Medical University of Vienna, Vienna, Austria., Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia., Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan., Department of Urology, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia., Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland., Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea., Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria., Department of Radiology, Pitié-Salpétrière Hospital, Paris-Sorbonne University, Paris, France., Department of Urology, Yale School of Medicine, New Haven, CT, USA., Department of Urology, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic., Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France.
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