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Can We Better Evaluate Extraprostatic Extension (EPE) Before Surgery? The Use of Preoperative Prostate MRI EPE Scoring System to Predict Post-Prostatectomy Locally Advanced Prostate Cancer
Utsav Bansal, MD, Joseph Black, MD, Tatum Williamson, MD, Angela Estevez, MD, Sumedh Kaul, MS, Catrina Crociani, MPH, Jeffrey Sun, BS, Leo Tsai, MD, Jodi Mechaber-Di Fiori, NP, Boris Gershman, MD, Peter Chang, MD, Andrew Wagner, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

Distinguishing between organ-confined disease and extraprostatic extension (EPE) is crucial for the treatment of patients with prostate cancer. EPE is associated with increased risk of recurrence, positive surgical margins, and metastatic disease. An enhanced preoperative assessment of presence and location of EPE can help not only guide surgical decision making as to the nerve-sparing approach, but also in counseling patients. An MRI-based EPE grading system was developed by Mehralivand et al in 2019 (Table 1); however, it has not been adopted in the Urology community. The purpose of this study is to examine the use of MRI-based EPE scoring in its ability to accurately detect EPE based on surgical pathology.
We conducted a retrospective chart review on a prospectively collected database of male patients who underwent a prostate MRI with EPE scoring by a trained genitourinary radiologist and subsequent robotic radical prostatectomy at our institution from September 2020 to December 2022. The associations between MRI EPE score (mEPE) and the presence of EPE on surgical pathology (pEPE) were examined using logistic regression.
A total of 194 patients were identified in our analysis with a median age of 63 years and median PSA of 7 ng/mL. The rates of pEPE across mEPE scores are presented in Table 2. Among those with mEPE score 3, 96% had pEPE (Table 2). On univariable regression, those patients who had an mEPE score >= 2 had an increased risk of pEPE compared to those with mEPE score of 0 (OR 10.2; 95% CI 4.7-22.1, p<0.05) Furthermore, those with an mEPE score 3 were significantly more likely to have pEPE compared to those with mEPE score 0,1 and 2 independently (Table 3).
MRI EPE is an easily definable tool that strongly correlates with the presence of pEPE. Moving forward, mEPE status could assist in counseling patients regarding nerve-sparing approach.
Source of Funding: NoneCategory: Prostate cancer- Detection & ScreeningKeywords: Prostate cancer, MRI, surgery
Table 1: Mehralivand Radiologic MRI EPE grading system

EPE GradeCriteria
0No suspicion for pathologic EPE
1Either 1.5cm or greater curvilinear contact length or capsular irregularity and/or bulge
2Both 1.5cm or greater curvilinear contact length and capsular irregularity and/or bulge
3Frank EPE visible at MRI or invasion of adjacent anatomic structures

Table 2: Presence of pathologic EPE across MRI EPE scores
Highest Grade for EPE
Characteristic0 66 (34%)11 52 (27%)12 53 (27%)13 23 (12%)1
EPE on pathology
No51 (77)29 (56)18 (34)1 (4)
Yes15 (23)23 (44)35 (66)22 (96)
1n (%)

Table 3: Univariable Logistic Regression Model - EPE on Pathology
CharacteristicOR (95% CI)1
Prostate volume (g) from MRI report0.99 (0.98, 1.00)
PIRADS score
56.42 (3.37, 12.2)*
Highest grade for mEPE score
12.70 (1.22, 5.97)*
2+10.2 (4.70, 22.1)*
Highest grade for mEPE(3 reference)
00.01 (0.00, 0.11)*
10.04 (0.00, 0.29)*
20.09 (0.01, 0.71)*
D''Amico Risk Classification category
Low Risk
Intermediate Risk0.69 (0.24, 1.98)
High Risk1.62 (0.54, 4.83)
Size of the largest lesion from MRI2.57 (1.66, 3.97)*
PSA value prior to surgery1.06 (1.02, 1.11)*

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