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score and its ability of predicting BCR in a U.S. cohort of RP
patients and mortality in a U.K. cohort of patients
predominantly diagnosed via TURP. Additionally, the CCP
was validated by Freedland et al. in primary external
radiation treated patients. Cooperberg et al. analyzed
413 RP patients and reported a combined CCP and CAPRA-S
score for the overall cohort and the low-risk subset more
accurately predicted BCR compared to either alone.
3.9. MRI
MRI traditionally has been used following prostatic biopsy
for staging. However, there is an emerging data suggesting
its role in patient selection for, and monitoring during, AS.
Multiparametric MRI (mpMRI) is a combination of anatom-
ical imaging using T1-weighted and T2-weighted sequences
with one or more functional imaging methods. The
combination of anatomic and functional MRI has been
shown to improve the detection of PCa
Considering low-risk PCa, several studies analyzed
patients (potentially eligible for AS protocols) treated with
RP and preoperatively investigated with MRI Un-
fortunately, different definitions of unfavorable pathology,
biopsy schemes, and inclusion criteria were used. Ploussard
et al failed to assess any improved prediction of high-
risk and/or nonorgan-confined disease in RP for those
patients selected for AS based on an extended 21-core
biopsy scheme and stringent AS criteria. However, other
findings support the use of mpMRI in the accrual of patients
for AS. In this setting, Turkbey et al analyzed
preoperative data of 133 patients staged with mpMRI.
Lesions were identified in mpMRI for 126 patients with a
sensitivity of 93%. In context, a misclassification occurred in
16 patients and with use of mpMRI could be avoided in 12 of
these. The impact of MRI in low and intermediate risk PCa
candidates for AS has been evaluated recently in a meta-
analysis by Schoots et al , who found that a suspicious
lesion at MRI for PCa was found in two-thirds of men
otherwise suitable for AS. MRI therefore helps in determin-
ing clinically significant disease at repeat biopsy especially
when biopsies are targeted to suspicious MRI lesions.
Finally, a positive MRI is more likeably to be associated with
upgrading at RP (Gleason score > 6) than a negative MRI
(43% vs 27%). Consequently, the PRECISE recommendations
suggested indications of MRI for men on AS . Experts
developed a checklist of items for reporting MRI and key
recommendations include reporting the index lesion size
and the change over time on a 1–5 scale. The PRECISE
recommendations might be helpful for physicians to
facilitate data collection and distinguish measurement
error and natural variability in MRI from true radiologic
progression in PCa patients in AS schemes. Similarly, MRI
fusion biopsy may play a role in low-risk PCa patients. Tran
et al examined the role of MRI fusion biopsy for men
with low risk PCa managed with AS, finding that some
lesions observed with MRI fusion were missed with the
standard systematic sampling. In contrast, upgrading also
occurred in areas outside targeted biopsy, suggesting the
need of systematic sampling even in the context of MRI
fusion biopsy. These results confirm previous findings on
this topic
4. Conclusions
The incidence of low-risk PCa has increased as a conse-
quence of PSA-based screening. High quality prospective
trials have not shown a definitive survival benefit for
whole-gland treatments compared to observation. Long-
term AS has shown encouraging results, while more robust
data are required to understand the potential role of focal
therapy. Tissue biomarkers and MRI may improve risk
stratification of low-risk PCa to identify the proportion of
men who might benefit from early treatment.
Author contributions: Marco Moschini had full access to all the data in
the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Moschini, Carroll, Eggener, Epstein, Graefen,
Montironi, Parker.
Acquisition of data: Moschini, Carroll, Eggener, Epstein, Graefen,
Montironi, Parker.
Analysis and interpretation of data: Moschini, Carroll, Eggener, Epstein,
Graefen, Montironi, Parker.
Drafting of the manuscript: Moschini, Carroll, Eggener, Epstein, Graefen,
Montironi, Parker.
Critical revision of the manuscript for important intellectual content:
Moschini, Carroll, Eggener, Epstein, Graefen, Montironi, Parker.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Carroll, Eggener, Epstein, Graefen, Montironi, Parker.
Other: None.
Financial disclosures: Marco Moschini certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
References
[1]
.
[2]
.
[3]
[4]
[5]
.
[6]
.
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