Elsevier

European Urology

Volume 67, Issue 4, April 2015, Pages 627-636
European Urology

Platinum Priority – Review – Prostate Cancer
Editorial by Chris H. Bangma, Riccardo Valdagni, Peter R. Carroll, Hein van Poppel, Laurence Klotz and Jonas Hugosson on pp. 646–648 of this issue
Magnetic Resonance Imaging in Active Surveillance of Prostate Cancer: A Systematic Review

https://doi.org/10.1016/j.eururo.2014.10.050Get rights and content

Abstract

Context

There is great interest in using magnetic resonance imaging (MRI) for men on active surveillance for prostate cancer.

Objective

To systematically review evidence regarding the use of MRI in men with low- or intermediate-risk prostate cancer suitable for active surveillance.

Evidence acquisition

Ovid Medline and Embase databases were searched for active surveillance, prostate cancer, and MRI from inception until April 25, 2014 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process. Identified reports were critically appraised according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria.

Evidence synthesis

A lesion on MRI suspicious for prostate cancer (positive MRI) is seen in two-thirds of men otherwise suitable for active surveillance. A positive MRI makes the identification of clinically significant disease at repeat biopsy more likely, especially when biopsies are targeted to suspicious MRI lesions. Radical prostatectomy data show that positive MRI is more likely to be associated with upgrading (Gleason score >3 + 3) than a negative MRI (43% vs 27%). A positive MRI is not significantly more likely to be associated with upstaging at radical prostatectomy (>T2) than a negative MRI (10% vs 8%). Although MRI is of interest in the monitoring of men on active surveillance, robust data on the use of repeat MRI in active surveillance are lacking. Prospective studies with clear definitions of radiological significance and progression are needed before this approach can be adopted.

Conclusions

MRI is useful for detection of clinically significant disease at initial assessment of men considering active surveillance. To use MRI as a monitoring tool in surveillance, it will be necessary to define both radiological significance and radiological progression.

Patient summary

This review assesses evidence for the use of magnetic resonance imaging (MRI) in men on active surveillance for prostate cancer. MRI at the start of surveillance can detect clinically significant disease in one-third to half of men. There are few data to assess the use of MRI as a monitoring tool during surveillance, so there is a need to define significant disease on MRI and significant changes over time.

Introduction

There is growing interest in the use of magnetic resonance imaging (MRI) in active surveillance for prostate cancer for both determining initial eligibility and assessing changes over time. The most recent UK National Institute for Health and Care Excellence (NICE) recommendations [1] stipulate that MRI should be performed after an initial decision for active surveillance to detect more aggressive disease not detected at routine biopsy. A second biopsy is recommended at 12 mo, and then further assessment in response to changes in digital rectal examination or adverse prostate-specific antigen (PSA) kinetics can be made via MRI or biopsy.

In this review we systematically assessed evidence for the use of MRI in men with low- or intermediate risk prostate cancer on transrectal ultrasound-guided biopsy and suitable for active surveillance. We sought to address two clinical questions in this population. (1) Can MRI detect clinically significant disease in men on active surveillance? (2) Can MRI be used in place of repeat standard biopsy to detect progression over time?

Section snippets

Evidence acquisition

The Ovid Medline and Embase databases were searched from inception (1946 for Ovid Medline, 1974 for Embase) until April 25, 2014. The search terms used were (active surveillance OR surveillance OR active monitoring) AND (prostate cancer OR prostate adenocarcinoma OR prostate carcinoma OR prostatic carcinoma OR prostatic adenocarcinoma) AND (MRI OR NMR OR magnetic resonance imaging OR mpMRI OR multiparametric MRI).

Abstracts were reviewed independently by four of the authors (IS, LPB, FG, NP) to

Evidence synthesis

We used evidence synthesis across the full papers to answer our two clinically relevant questions. We address each question in turn.

Conclusions

We analysed the first published studies on MRI and active surveillance in men with low or intermediate risk of prostate cancer. The evidence and strength are limited by the relatively small number of studies, as well as the lack of standardisation within those studies. However, it is evident that MRI is positive in roughly two-thirds of men suitable for active surveillance, and that MRI-targeted biopsies or radical prostatectomy histopathology results in reclassification in 1:2–3 men. It should

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