前列腺 MRI 阴性的前列腺癌男性患者的诊断后治疗决策。
Therapy decisions after diagnosis of prostate cancer in men with negative prostate MRI.
机构信息
Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
Department of Urology, Spital-Limmattal, Schlieren, Switzerland.
出版信息
Prostate. 2023 Jan;83(1):56-63. doi: 10.1002/pros.24435. Epub 2022 Sep 8.
BACKGROUND
To investigate the clinical implications of magnetic resonance imaging (MRI) negative prostate cancer (PCa) in a cohort of men undergoing transperineal prostate biopsy.
METHODS
We included all men without prior diagnosis of PCa undergoing transperineal template saturation ± fusion-guided targeted biopsy of the prostate between November 2014 and March 2018. Before biopsy, all patients underwent MRI and biopsies were performed irrespective of imaging results. Baseline characteristics, imaging, biopsy results, and follow-up information were retrieved from the patient charts. Patients were classified as either MRI negative (Prostate Imaging Reporting and Data System [PIRADS] ≤ 2) or positive (PIRADS ≥ 3). ISUP grade group 1 was defined as clinically nonsignificant (nsPCa) and ≥2 as clinically significant PCa (csPCa). Primary outcome was the individual therapeutic decision after diagnosis of PCa stratified according to MRI visibility. Secondary outcomes were the sensitivity and specificity of MRI, and the urooncological outcomes after radical prostatectomy (RP).
RESULTS
From 515 patients undergoing prostate biopsy, 171 (33.2%) patients had a negative and 344 (66.8%) a positive MRI. Pathology review stratified for MRI negative and positive cases revealed nsPCa in 27 (15.8%) and 32 (9.3%) and csPCa in 26 (15.2%) and 194 (56.4%) of the patients, respectively. The rate of active treatment in the MRI negative was lower compared with the MRI positive cohort (12.3% vs. 53.2%; odd ratio [OR] = 0.12; p < 0.001). While men with negative MRI were more likely to undergo active surveillance (AS) than MRI positive patients (18.1% vs. 10.8%; OR = 1.84; p = 0.027), they rarely underwent RP (6.4% vs. 40.7%, OR = 0.10; p < 0.001). Logistic regression revealed that a negative MRI was independently protective for active treatment (OR = 0.32, p = 0.014). The specificity, sensitivity, negative, and positive predictive value of MRI for detection of csPCa were 49.2%, 88.2%, 56.4%, and 84.8%, respectively. The rate of adverse clinicopathological outcome features (pT3/4, ISUP ≥4, or prostate-specific antigen [PSA]-persistence) following RP was 4.7% for men with MRI negative compared to 17.4% for men with MRI positive PCa (OR = 3.1, p = 0.19).
CONCLUSION
Only few men with MRI negative PCa need active cancer treatment at the time of diagnosis, while the majority opts for AS. Omitting prostate biopsies and performing a follow-up MRI may be a safe alternative to reduce the number of unnecessary interventions.
背景
研究经会阴前列腺穿刺活检的患者中 MRI 阴性前列腺癌（PCa）的临床意义。
方法
我们纳入了所有在 2014 年 11 月至 2018 年 3 月期间未被诊断为 PCa 而行经会阴模板饱和+靶向前列腺活检的男性患者。在活检前，所有患者均接受 MRI 检查，无论影像学结果如何，均进行活检。从患者病历中提取基线特征、影像学、活检结果和随访信息。患者被分为 MRI 阴性（前列腺影像报告和数据系统[PIRADS]≤2）或阳性（PIRADS≥3）。ISUP 分级组 1 定义为临床非显著（nsPCa），≥2 为临床显著（csPCa）。主要结局是根据 MRI 可见性分层后诊断为 PCa 后的个体化治疗决策。次要结局是 MRI 的灵敏度和特异性，以及根治性前列腺切除术后（RP）的尿路上皮肿瘤学结局。
结果
在 515 例行前列腺活检的患者中，171 例（33.2%）患者的 MRI 为阴性，344 例（66.8%）为阳性。对 MRI 阴性和阳性病例进行病理复查，结果显示 nsPCa 分别为 27 例（15.8%）和 32 例（9.3%），csPCa 分别为 26 例（15.2%）和 194 例（56.4%）。与 MRI 阳性患者相比，MRI 阴性患者的积极治疗率较低（12.3% vs. 53.2%；比值比[OR] 0.12；p<0.001）。尽管 MRI 阴性的患者更倾向于接受主动监测（AS），而不是 MRI 阳性患者（18.1% vs. 10.8%；OR 1.84；p=0.027），但他们很少接受 RP（6.4% vs. 40.7%，OR 0.10；p<0.001）。Logistic 回归显示，MRI 阴性是积极治疗的独立保护因素（OR 0.32，p=0.014）。MRI 对 csPCa 的检测特异性、灵敏度、阴性预测值和阳性预测值分别为 49.2%、88.2%、56.4%和 84.8%。与 MRI 阳性 PCa 患者相比，MRI 阴性患者 RP 后出现不良临床病理特征（pT3/4、ISUP≥4 或前列腺特异性抗原[PSA]-持续性）的比例为 4.7%（OR 3.1，p=0.19）。
结论
只有少数 MRI 阴性 PCa 患者在诊断时需要积极的癌症治疗，而大多数患者选择 AS。省略前列腺活检并进行随访 MRI 可能是减少不必要干预的安全替代方法。
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