在主动监测的男性中，通过连续前列腺磁共振成像和重复活检进行前列腺癌升级：是否仍需要确认性活检？
Prostate cancer upgrading with serial prostate magnetic resonance imaging and repeat biopsy in men on active surveillance: are confirmatory biopsies still necessary?
机构信息
Departments of, Department of, Radiology & Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
Department of, Urology, Erasmus University Medical Center, Rotterdam, The Netherlands.
出版信息
BJU Int. 2020 Jul;126(1):124-132. doi: 10.1111/bju.15065. Epub 2020 Apr 22.
OBJECTIVES
To investigate whether serial prostate magnetic resonance imaging (MRI) may guide the utility of repeat targeted (TBx) and systematic biopsy (SBx) when monitoring men with low-risk prostate cancer (PCa) at 1-year of active surveillance (AS).
PATIENTS AND METHODS
We retrospectively included 111 consecutive men with low-risk (International Society of Urological Pathology [ISUP] Grade 1) PCa, who received protocolled repeat MRI with or without TBx and repeat SBx at 1-year of AS. TBx was performed in Prostate Imaging-Reporting and Data System (PI-RADS) score ≥3 lesions (MRI-positive men). Upgrading defined as ISUP Grade ≥2 PCa (I), Grade ≥2 with cribriform growth/intraductal carcinoma PCa (II), and Grade ≥3 PCa (III) was investigated. Upgrading detected by TBx only (not by SBx) and SBx only (not by TBx) was investigated in MRI-positive and -negative men, and related to radiological progression on MRI (Prostate Cancer Radiological Estimation of Change in Sequential Evaluation [PRECISE] score).
RESULTS
Overall upgrading (I) was 32% (35/111). Upgrading in MRI-positive and -negative men was 48% (30/63) and 10% (5/48) (P < 0.001), respectively. In MRI-positive men, there was upgrading in 23% (seven of 30) by TBx only and in 33% (10/30) by SBx only. Radiological progression (PRECISE score 4-5) in MRI-positive men was seen in 27% (17/63). Upgrading (I) occurred in 41% (seven of 17) of these MRI-positive men, while this was 50% (23/46) in MRI-positive men without radiological progression (PRECISE score 1-3) (P = 0.534). Overall upgrading (II) was 15% (17/111). Upgrading in MRI-positive and -negative men was 22% (14/63) and 6% (three of 48) (P = 0.021), respectively. In MRI-positive men, there was upgrading in three of 14 by TBx only and in seven of 14 by SBx only. Overall upgrading (III) occurred in 5% (five of 111). Upgrading in MRI-positive and -negative men was 6% (four of 63) and 2% (one of 48) (P = 0.283), respectively. In MRI-positive men, there was upgrading in one of four by TBx only and in two of four by SBx only.
CONCLUSION
Upgrading is significantly lower in MRI-negative compared to MRI-positive men with low-risk PCa at 1-year of AS. In serial MRI-negative men, the added value of repeat SBx at 1-year surveillance is limited and should be balanced individually against the harms. In serial MRI-positive men, the added value of repeat SBx is substantial. Based on this cohort, SBx is recommended to be performed in combination with TBx in all MRI-positive men at 1-year of AS, also when there is no radiological progression.
目的
研究在低危前列腺癌（PCa）患者主动监测（AS） 1 年时，连续前列腺磁共振成像（MRI）是否可以指导重复靶向（TBx）和系统活检（SBx）的应用。
患者和方法
我们回顾性纳入了 111 例连续的低危（国际泌尿病理学会 [ISUP] 分级 1）PCa 患者，他们在 AS 1 年时接受了协议规定的重复 MRI 检查，包括或不包括 TBx 和重复 SBx。TBx 仅在 PI-RADS 评分≥3 病变（MRI 阳性男性）中进行。升级定义为 ISUP 分级≥2 PCa（I）、分级≥2 伴有筛状生长/导管内癌 PCa（II）和分级≥3 PCa（III）。在 MRI 阳性和阴性男性中，研究了仅 TBx 检测到的升级（未通过 SBx 检测到）和仅 SBx 检测到的升级（未通过 TBx 检测到），并与 MRI 上的放射学进展（前列腺癌放射学估计连续评估变化 [PRECISE] 评分）相关。
结果
总体升级（I）为 32%（35/111）。MRI 阳性和阴性男性的升级分别为 48%（30/63）和 10%（5/48）（P<0.001）。在 MRI 阳性男性中，仅通过 TBx 升级的有 23%（7/30），仅通过 SBx 升级的有 33%（10/30）。MRI 阳性男性中观察到放射学进展（PRECISE 评分 4-5）为 27%（17/63）。这些 MRI 阳性男性中升级（I）发生在 41%（7/17），而在没有放射学进展（PRECISE 评分 1-3）的 MRI 阳性男性中为 50%（23/46）（P=0.534）。总体升级（II）为 15%（17/111）。MRI 阳性和阴性男性的升级分别为 22%（14/63）和 6%（3/48）（P=0.021）。在 MRI 阳性男性中，仅通过 TBx 升级的有 3 例，仅通过 SBx 升级的有 7 例。总体升级（III）为 5%（5/111）。MRI 阳性和阴性男性的升级分别为 6%（4/63）和 2%（1/48）（P=0.283）。在 MRI 阳性男性中，仅通过 TBx 升级的有 1 例，仅通过 SBx 升级的有 2 例。
结论
与低危 PCa 患者 AS 1 年时的 MRI 阴性男性相比，MRI 阳性男性的升级明显更高。在连续 MRI 阴性男性中，1 年监测时重复 SBx 的附加价值有限，应根据个体情况权衡与危害的关系。在连续 MRI 阳性男性中，重复 SBx 的附加价值很大。基于该队列，建议在 AS 1 年时，所有 MRI 阳性男性都应结合 TBx 进行 SBx，即使没有放射学进展。
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