基于磁共振成像和前列腺特异性抗原密度的风险分层，可能会减少接受低风险前列腺癌主动监测的男性不必要的后续活检程序。
Risk-stratification based on magnetic resonance imaging and prostate-specific antigen density may reduce unnecessary follow-up biopsy procedures in men on active surveillance for low-risk prostate cancer.
作者信息
Alberts Arnout R, Roobol Monique J, Drost Frank-Jan H, van Leenders Geert J, Bokhorst Leonard P, Bangma Chris H, Schoots Ivo G
机构信息
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
出版信息
BJU Int. 2017 Oct;120(4):511-519. doi: 10.1111/bju.13836. Epub 2017 Apr 4.
OBJECTIVES
To assess the value of risk-stratification based on magnetic resonance imaging (MRI) and prostate-specific antigen density (PSA-D) in reducing unnecessary biopsies without missing Gleason pattern 4 prostate cancer in men on active surveillance (AS).
PATIENTS AND METHODS
In all, 210 men on AS with Gleason score 3 + 3 prostate cancer received a first MRI and if indicated [Prostate Imaging Reporting and Data System (PI-RADS) score ≥3] targeted biopsy (TBx) using MRI-transrectal ultrasonography (TRUS) fusion. The MRI was performed 3 months after diagnosis (group A: n = 97), at confirmatory biopsy (group B: n = 39) or at surveillance biopsy after one or more repeat TRUS-guided systematic biopsies (TRUS-Bx) (group C: n = 74). The primary outcome was upgrading to Gleason score ≥3 + 4 prostate cancer based on MRI ± TBx in groups A, B and C. Biopsy outcomes were stratified for the overall PI-RADS score and PSA-D to identify a subgroup of men in whom a biopsy could have been avoided as no Gleason score upgrading was detected.
RESULTS
In all, 134/210 (64%) men had a positive MRI and 51/210 (24%) men had Gleason score upgrading based on MRI-TBx. The percentage of Gleason score upgrading based on MRI-TBx was 23% (22/97), 23% (9/39) and 27% (20/74) in respectively groups A, B and C. Additional Gleason score upgrading detected by TRUS-Bx occurred in 8% (3/39) of men in group B and 6% (1/17) of men who received TRUS-Bx in group C. No Gleason score upgrading was detected by MRI-TBx in men with a PI-RADS score of 3 and a PSA-D of <0.15 ng/mL (n = 15), nor by TRUS-Bx in men with a PI-RADS score of 1-3 and a PSA-D of <0.15 ng/mL (n = 15).
CONCLUSION
At least one out of five men on AS with Gleason score 3 + 3 prostate cancer at diagnostic TRUS-Bx show Gleason score upgrading based on first MRI ± TBx at baseline, confirmatory or surveillance biopsy. Men with a PI-RADS score of 1-3 and PSA-D of <0.15 ng/mL did not show Gleason score upgrading at MRI ± TBx or TRUS-Bx at each time point of surveillance. Thus risk-stratification based on PI-RADS and PSA-D may reduce unnecessary follow-up biopsy procedures in men on AS.
目的
评估基于磁共振成像（MRI）和前列腺特异性抗原密度（PSA-D）的风险分层在减少不必要活检方面的价值，同时避免在接受主动监测（AS）的男性中漏诊 Gleason 分级 4 级前列腺癌。
患者与方法
共有 210 例 Gleason 评分 3+3 的前列腺癌患者接受 AS 治疗，均接受了首次 MRI 检查，若有指征[前列腺影像报告和数据系统（PI-RADS）评分≥3]，则采用 MRI-经直肠超声（TRUS）融合引导下的靶向活检（TBx）。MRI 在诊断后 3 个月进行（A 组：n = 97）、确诊活检时进行（B 组：n = 39）或在一次或多次重复 TRUS 引导下的系统活检（TRUS-Bx）后的监测活检时进行（C 组：n = 74）。主要结局是 A、B 和 C 组中基于 MRI±TBx 将 Gleason 评分升级至≥3+4 级前列腺癌。根据总体 PI-RADS 评分和 PSA-D 对活检结果进行分层，以确定一组可避免活检的男性亚组，因为未检测到 Gleason 评分升级。
结果
共有 134/210（64%）的男性 MRI 结果为阳性，51/210（24%）的男性基于 MRI-TBx 出现 Gleason 评分升级。A、B 和 C 组中基于 MRI-TBx 的 Gleason 评分升级百分比分别为 23%（22/97）、23%（9/39）和 27%（20/74）。B 组中 8%（3/39）的男性以及 C 组中接受 TRUS-Bx 的 6%（1/17）的男性通过 TRUS-Bx 检测到额外的 Gleason 评分升级。PI-RADS 评分为 3 且 PSA-D<0.15 ng/mL 的男性（n = 15）未通过 MRI-TBx 检测到 Gleason 评分升级，PI-RADS 评分为 1-3 且 PSA-D<0.15 ng/mL 的男性（n = 15）也未通过 TRUS-Bx 检测到 Gleason 评分升级。
结论
在诊断性 TRUS-Bx 时 Gleason 评分 3+3 的前列腺癌患者中，至少五分之一接受 AS 治疗的男性在基线、确诊或监测活检时基于首次 MRI±TBx 出现 Gleason 评分升级。PI-RADS 评分为 1-3 且 PSA-D<0.15 ng/mL 的男性在监测的每个时间点，MRI±TBx 或 TRUS-Bx 均未出现 Gleason 评分升级。因此，基于 PI-RADS 和 PSA-D 的风险分层可能会减少接受 AS 治疗男性不必要的后续活检程序。
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