Prognostic significance of the PI-RADS score in men with prostate cancer undergoing radical prostatectomy.

Am J Clin Exp Urol 2024;12(4):162-172 www.ajceu.us /ISSN:2330-1910/AJCEU0156745 Original Article Prognostic significance of the PI-RADS score in men with prostate cancer undergoing radical prostatectomy Julum Nwanze1, Yuki Teramoto1, Ying Wang1, Hiroshi Miyamoto1,2,3 Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA; Department of Urology, University of Rochester Medical Center, Rochester, NY, USA; 3James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA 1 2 Received March 22, 2024; Accepted July 24, 2024; Epub August 25, 2024; Published August 30, 2024 Abstract: Objectives: MRI-targeted biopsy (T-Bx) for which Prostate Imaging Reporting and Data System (PI-RADS) assessment categories are useful has been shown to more accurately detect clinically significant prostate cancer. However, the prognostic significance of the PI-RADS in prostate cancer patients needs further investigation. In the present study, we compared radical prostatectomy findings and postoperative oncologic outcomes in men with prostate cancer initially undergoing T-Bx for PI-RADS 3 vs. 4 vs. 5 lesions. Methods: We assessed consecutive patients undergoing T-Bx with concurrent systematic biopsy (S-Bx), followed by radical prostatectomy. Within our Surgical Pathology database, we identified a total of 207 men where prostatic adenocarcinoma was detected on either S-Bx or T-Bx, or both. Results: Prostate cancer was detected on S-Bx only (n = 32; 15%), T-Bx only (n = 39; 19%), or both S-Bx and T-Bx (n = 136; 66%). These patients had PI-RADS 3 (n = 42; 20%), 4 (n = 86; 42%), or 5 (n = 79; 38%) lesions, while T-Bx detected cancer in 31 (74%) of PI-RADS 3 cases, 72 (84%) of PI-RADS 4 cases, and 72 (91%) of PI-RADS 5 cases. There were no significant differences in any of the clinicopathologic features examined, including tumor grade on biopsy or prostatectomy and pT or pN stage, among the PI-RADS 3 vs. 4 vs. 5 groups, except a significantly higher rate of positive margin and significantly larger tumor volume in PI-RADS 5 cases than in PI-RADS 3 cases. Univariate and multivariable analyses revealed significantly higher risks of biochemical recurrence after prostatectomy in patients with PI-RADS 5 lesion than in those with PI-RADS 3 or 4 lesion. Additionally, compared with respective controls, detection of any grade cancer (P = 0.046) or Grade Group 2 or higher cancer (P = 0.005) on T-Bx was associated with a significantly higher risk of recurrence in patients with PI-RADS 5 lesion, but not in those with PI-RADS 3 or 4 lesion. Conclusion: PI-RADS 5 lesions were thus found to independently predict a significantly poorer postoperative prognosis. Moreover, the failure of detection of any grade cancer or clinically significant cancer on T-Bx of PI-RADS 5 lesion may particularly indicate favorable outcomes in radical prostatectomy cases. Keywords: PI-RADS, prognosis, prostate cancer, radical prostatectomy, systematic biopsy, targeted biopsy Introduction Prostate cancer has represented one of the most common malignancies, and the incidence of worldwide cancer-related deaths is likely increasing considerably (e.g. 307,500 in 2012 [1], 375,304 in 2020 [2]). Definitive therapy, such as radical prostatectomy, often offers a cure in men with localized disease, but these patients have a considerable risk of developing postoperative recurrence [3, 4]. Accurate stratification of such risks not only after definitive therapy but also at the time of initial diagnosis is thus crucial for improving patient care. The most widespread method for the definitive diagnosis of prostate cancer remains the ultrasonography-guided systematic biopsy (S-Bx), which relies primarily on anatomic guidance to achieve evenly spaced biopsies within the gland, without the pre-procedure information of tumor location [5]. However, this technique is known to lead to the underdiagnosis of highrisk cancer, as well as the overdetection and overtreatment of indolent disease [5-7]. Over the last decade, detection of clinically significant prostate cancer [e.g. Gleason score 3 + 4/Grade Group (GG) 2 or higher lesion] has been noticeably improved by the introduction of https://doi.org/10.62347/BODM5001 Prognostic impact of PI-RADS the Prostate Imaging Reporting and Data System (PI-RADS) classification on multiparametric magnetic resonance imaging (mpMRI) and biopsy of the target lesion [8-11]. In the PI-RADS system initially standardized in 2009 [12] and most recently updated in 2019 [13], 5-point scale scores given based on mpMRI findings predict the likelihood of clinically significant prostate cancer [i.e. scores 1 (clinically significant cancer highly unlikely to be present), 2 (unlikely), 3 (equivocal), 4 (likely), and 5 (highly likely)]. A combination of S-Bx and targeted biopsy (T-Bx) is thus expected to yield much higher sensitivity, while a meta-analysis has demonstrated that T-Bx alone does not more effectively detect clinically significant prostate cancer than S-Bx [14]. Accordingly, conducting a mpMRI before initial biopsy is currently recommended [15]. In contrast to the known role of T-Bx in prostate cancer diagnosis, however, the prognostic significance of its detection on S-Bx vs. T-Bx remains controversial. We recently demonstrated a significantly higher risk of biochemical recurrence following radical prostatectomy in patients whose cancer had been detected on T-Bx only or both S-Bx and T-Bx than in those on S-Bx only (i.e. concurrent T-Bx negative) [16]. Nonetheless, the clinical impact of the PI-RADS score, particularly that on postoperative patient prognosis, needs to be further determined. In the present study, we compared radical prostatectomy findings and oncologic outcomes in men with prostate cancer who had initially undergone T-Bx for PI-RADS 3 vs. 4 vs. 5 lesions. Materials and methods Study population Following the approval from the Institutional Review Board at the University of Rochester Medical Center (#00003996), including the request to waive the documentation of patient consent, we retrospectively assessed consecutive 207 patients who had undergone T-Bx with concurrent 6-site S-Bx, followed by robotassisted radical prostatectomy for prostatic adenocarcinoma, both performed at our institution between 2015 and 2018. Excluded cases were those who had undergone: 1) T-Bx/ S-Bx at an outside institution; 2) T-Bx in 2014 (due to the learning curve of the MRI interpreta163 tion and biopsy technique at our institution, as described previously [16, 17]); and 3) neoadjuvant therapy prior to prostatectomy. Data analysis We collected clinical data, including preoperative prostate-specific antigen (PSA) value, PI-RADS assessment category, and postoperative follow-up information (e.g. PSA value), via the hospital’s integrated electronic health record system (last accessed in May 2024), as well as biopsy and radical prostatectomy findings, in (...truncated)