How often should you repeat a prostate MRI?

Additional stratification metrics such as the number of baseline positive biopsy cores, and PSA density should also be used to further refine patient follow-up [31]. Men with positive baseline MRI should be followed more closely, and we favor performing repeat MRI and biopsy within 12–24 months from baseline.

link.springer.com - The utility of prostate MRI within active surveillance - Springer Link

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Rates of reclassification in MRI selected cohorts vs. systematic biopsy cohorts.

MRI is an effective method for ruling out clinically significant cancer at baseline. Chamie et al. evaluated 115 men with MRI followed by radical prostatectomy and whole-mount pathology [13]. The authors calculated a positive predictive value (PPV) of 68% and negative predictive value (NPV) of 84% for csPCa at radical prostatectomy. Similar findings were demonstrated in the PROMIS Trial which compared MRI and systematic TRUS biopsy to template transperineal biopsy, yielding a NPV of 76% and 63% for MRI and TRUS biopsy, respectively [4]. Because of the increased accuracy of MRI, men enrolled in active surveillance with baseline MRI have been hypothesized to have lower rates of reclassification at follow-up. Jayadevan et al. evaluated 332 men with MRI-ultrasound fusion biopsy for active surveillance enrollment and confirmatory biopsy [14]. Within this cohort, reclassification from GG1 to ≥ GG2 prostate cancer was 13% at 1 year. Furthermore, the authors compared biopsy cores obtained from MRI targeted ROI’s and systematic samples, finding that omitting MRI biopsies missed 43% of ≥ GG2 cancer reclassifications. In the ASIST trial, Klotz et al., provided level 1 evidence for the use of MRI targeted biopsy for enrollment in active surveillance [15]. In this trial 259 men were randomized between active surveillance enrollment with MRI targeted and systematic biopsy vs. systematic biopsy alone. The authors found that reclassification occurred in 9.9% of men in the MRI arm vs. 23% in the non-MRI arm at 2 years [15]. The non-MRI arm within this trial had reclassification rates similar to other large active surveillance cohorts omitting MRI at enrollment [16]. Taken as a whole, it is likely that MRI improves risk stratification for patients entering active surveillance; however, it has yet to be established if this translates into a greater number of years on active surveillance and decreased active surveillance failures. At 10 year follow-up, anywhere from 30 to 70% of patients may discontinue active surveillance [3, 17], and 59–73% seek treatment [17,18,19].

Ability of positive MRI to predict reclassification among men on active surveillance

Prostate biopsy plays an essential role in active surveillance, serving as the main indicator of reclassification and prompting treatment. However, the timing and indicators for biopsy are heterogeneous among active surveillance cohorts [3,16,17,18,19]. Elevations in PSA, PSA density, and digital rectal exam have traditionally guided clinicians in determining the frequency of prostate biopsy between scheduled intervention. Significant variations in PSA, and poor sensitivity of annual digital rectal examinations, make MRI a useful additional tool within active surveillance. High scores on PI-RADS v2 are consistently associated with clinically significant prostate cancer [20]. However, there is less known regarding whether a baseline diagnostic MRI can be used to predict future reclassification. Kornberg et al., retrospectively reviewed the UCSF database, identifying 300 men with baseline MRI followed out to 5 years [21]. They evaluated the positive predictive value of baseline PI-RADS scores for reclassification at 1, 3 and 5 years. PI-RADS 5 lesions were most predictive of reclassification with PPV of 21%, 41% and 67% at 1, 3, and 5 years, respectively. PPV decreased to 13%, 33%, and 46% at the same time points when including PI-RADS 3–5 lesions. Amin et al. evaluated 100 men with MRI and transperineal template biopsy at baseline and 3 year follow-up on surveillance, finding that an initial PI-RADS score ≥ 3 yielded a positive predictive value of 38% at 3 years [22]. Both authors found the positive predictive value of MRI to be around 35–40% at 3 years (Fig. 1). Additional studies demonstrated similar positive predictive values for a baseline PI-RADS 3–5 but with higher risk of bias [23, 24].

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Fig. 1 Proposed active surveillance protocol utilizing MRI for risk stratification with baseline MRI and refinement utilizing likelihood ratio calculation from Table 2. Values calculated from Kornberg et al. [21] and Amin et al. [22] Full size image

Ability of negative MRI to predict a negative surveillance biopsy

The negative predictive value of MRI is perhaps of more interest to patients and clinicians in active surveillance. The ability of MRI to predict a negative biopsy and thus safely avoid the associated discomfort and risks would improve current protocols. A recent meta-analysis calculated a negative predictive value of greater than 90% MRI in the biopsy naïve setting. Amin et al. likely performed one of the most rigorous studies evaluating the negative predictive value of MRI in active surveillance [22]. Within this cohort, 100 men were enrolled in active surveillance using a transperineal template biopsy and followed with serial MRI for 3 years. At the end of 3 years, patients were again evaluated with a template prostate biopsy. Of the 64 men with serially negative MRI, 12.5% (8/64) had clinically significant prostate cancer at 3 years. Gallagher et al., followed 211 patients for a median of 4.2 years with serial MRI but less stringent entrance and exit protocol [24]. These authors found similar results among those with a negative MRI, reporting that only 12.8% (11/86) progressed to radical therapy. Overall, a negative MRI performs much better than a positive MRI in predicting biopsy results. Ability of changes on positive MRI to predict reclassification among men on active surveillance Changes in MRI over time while on active surveillance represent an unsolved clinical problem. Rais-Bahrami et al. retrospectively evaluated 153 patients with a minimum of two MRI’s in men with small index lesions, finding minimal change over 2 years [25]. Osses et al. [26] evaluated radiographic progression among 111 men using the PRECISE [8] criteria. The authors found that among patients enrolled with MRI and with a positive MRI at 1 year, systematic and TRUS biopsy demonstrated reclassification in 48% of men. Among the same cohort, progression of the MRI lesion by PRECISE criteria had a positive predictive value of 41%. Similarly, Chesnut et al. evaluated 207 patients for MRI changes over 3 years with scheduled biopsy at baseline and 3 years [27]. The authors noted that higher PI-RADS scores were significantly associated with likelihood of reclassification; however, an increase in PI-RADS had only a 41% positive predictive value for reclassification at 3 years. Both authors concluded that PI-RADS score is an important predictor of ≥ GG2 prostate cancer but increases in PI-RADS score within a given patient on active surveillance is of uncertain utility. In general, surveillance MRI did not provide strong evidence for presence or absence of disease based on calculated likelihood ratios (Table 2) [28]. These findings are somewhat contrary to those of Felker et. al., who performed a detailed review of 49 men on active surveillance with serial MRI [29]. The authors evaluated changes in ROI volume, Apparent Diffusion Coefficient, and PI-RADS score. Among this cohort the positive predictive value of MRI change was 69%. Overall, all authors concluded that PI-RADS ≥ 3 should be investigated; however, changes between serial MRI’s may be more difficult to interpret. Studies of longer duration may address this problem definitively given the slow growth of low and intermediate risk prostate cancer. In addition, and of great importance, many authors still recommended scheduled biopsy at some frequency given the large number of reclassifications that came from systematic rather than targeted biopsy [26, 27, 29].

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link.springer.com - The utility of prostate MRI within active surveillance - Springer Link

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