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The current role of MRI for guiding active surveillance in prostate cancer

Nature Reviews Urology volume 19, pages 357–365 (2022)Cite this article

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Abstract

Active surveillance (AS) is the recommended treatment option for low-risk and favourable intermediate-risk prostate cancer management, preserving oncological and functional outcomes. However, active monitoring using relevant parameters in addition to the usual clinical, biological and pathological considerations is necessary to compensate for initial undergrading of the tumour or to detect early progression without missing the opportunity to provide curative therapy. Indeed, several studies have raised concerns about inadequate biopsy sampling at diagnosis. However, the implementation of baseline MRI and targeted biopsy have led to improved initial stratification of low-risk disease; baseline MRI correlates well with disease characteristics and AS outcomes. The use of follow-up MRI during the surveillance phase also raises the question of the requirement for serial biopsies in the absence of radiological progression and the possibility of using completely MRI-based surveillance, with triggers for biopsies based solely on MRI findings. This concept of a tailored-risk, imaging-based monitoring strategy is aimed at reducing invasive procedures. However, the abandonment of serial biopsies in the absence of MRI progression can probably not yet be recommended in routine practice, as the data from real-life cohorts are heterogeneous and inconclusive. Thus, the evolution towards a routine, fully MRI-guided AS pathway has to be preceded by ensuring quality programme assessment for MRI reading and by demonstrating its safety in prospective trials.

Key points

  • MRI and MRI-guided biopsy should be considered as mandatory investigations before patients are included in active surveillance programmes.

  • During the monitoring phase, MRI helps to identify clinical progression and can be a trigger of re-biopsies, including targeted biopsies, in patients demonstrating radiological progression.

  • The definition of optimal MRI intervals and triggers during active surveillance remains unclear.

  • Data suggest that serial control biopsies could be avoided if MRI and all other parameters are stable.

  • However, cessation of control biopsies cannot be recommended routinely based on the current evidence, as the safety of MRI-based triggers for a control biopsy need to be demonstrated in randomized controlled trials.

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Fig. 1: T2-weighted images of a prostate tumour from a 62-year-old man on active surveillance.

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Authors and Affiliations

  1. La Croix du Sud Hospital, Quint Fonsegrives, France

    Guillaume Ploussard

  2. Prostate Group of the Cancer Committee of the French Association of Urology (CC-AFU), Paris, France

    Guillaume Ploussard, Morgan Rouprêt & Raphaële Renard-Penna

  3. IUCT-O, Toulouse, France

    Guillaume Ploussard

  4. Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hospital Edouard Herriot, Lyon, France

    Olivier Rouvière

  5. Sorbonne University, GRC 5 Predictive Onco-Uro, AP-HP, Urology, Pitié-Salpétrière Hospital, F-75013, Paris, France

    Morgan Rouprêt

  6. Department of Urology, Antonius Hospital, Utrecht, Netherlands

    Roderick van den Bergh

  7. Department of Radiology, Pitié-Salpétrière Hospital, Paris-Sorbonne University, Paris, France

    Raphaële Renard-Penna

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G.P., O.R., R.v.d.B. and R.R.-P. researched data for the article, wrote the manuscript, and reviewed and edited the manuscript before submission. G.P. and M.R. made substantial contributions to discussion of content.

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Correspondence to Guillaume Ploussard.

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Ploussard, G., Rouvière, O., Rouprêt, M. et al. The current role of MRI for guiding active surveillance in prostate cancer. Nat Rev Urol 19, 357–365 (2022). https://doi.org/10.1038/s41585-022-00587-0

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