Is Repeat Prostate Biopsy Prior to Treatment Necessary for Active Surveillance Patients with Clinical and Radiographic Findings Suggesting Gleason Grade Progression?
Jeffrey K. Twum-Ampofo, MD, Andrew Gusev, BS, Alberto C. Pieretti, MD, Florian Rumpf, BS, Keyan Salari, MD, PhD, Matthew Wszolek, MD, Adam Feldman, MD, MPH, Douglas Dahl, MD.
Massachusetts General Hospital, Boston, MA.
Introduction Studies have described an increased risk of prostate cancer (PCa) grade group (GG) progression with presence of high-risk lesions or lesion progression on active surveillance (AS) MRI. Given the known risks of prostate biopsy, we investigate whether patients at high risk for GG progression may proceed to treatment without repeat biopsy. Materials and methods We retrospectively reviewed our database of men on AS with localized PCa from 1996-2016. We identified men with Gleason Grade (GG) 1 disease on diagnostic biopsy, at least one prostate MRI, and at least one repeat prostate biopsy during AS. All MRIs were scored according to PIRADS version 2.0 and scores of 2 or less were considered to represent a negative MRI. Clinical and radiologic characteristics analyzed included age, PSA, PSA density (PSAd), index PIRADS score, PIRADS lesion size, and NCCN risk group. Univariate and multivariate logistic regression was used to identify factors associated with grade progression to GG 2 or higher on any subsequent surveillance biopsy. Results Of 1268 men evaluated in our AS database, 363 met criteria for this study. Median follow up time was 4.8 months (IQR 3.4 - 6.8). Median number of MRIs was 1 (Range 1-4). 42% of patients had no suspicious lesions on MRI, 13% had PIRADS 3, 30% had PIRADS 4, 15% had PIRADS 5 as their highest risk lesion. Of those with negative MRIs, 20% had GG progression on subsequent biopsy. For index MRI lesions of PIRADS 3, 4, and 5, the GG progression rates were 26%, 39%, and 62%, respectively (p<0.001). For patients with PSAd > 0.15 and PIRADS lesions 3,4, or 5, GG progression rates were 45%, 32 %, and 71%, respectively (p=0.002). On univariate analysis, age at diagnosis, PSAd, NCCN Risk Group (Low vs. Very Low), and PIRADS 4 and 5 lesions were predictors of biopsy GG progression [Table 1]. On multivariate logistic regression, PSAd as well as PIRADS 4 and PIRADS 5 on MRI remained significant predictors of GG progression. Compared to patients with negative MRIs, those with PIRADS 4 and PIRADS 5 lesion had increased risk of biopsy progression (OR 2.22 [95% CI: 1.17-4.21]) and (OR 4.55 [95% CI: 2.00-10.32]), respectively [Figure 1]. Analysis of PIRADS 4 and PIRADS 5 lesions by size demonstrated no difference in GG progression on follow up biopsy. Conclusion Patients on AS with PIRADS 3 and 4 lesions must have a confirmatory biopsy prior to consideration for surgery since a significant proportion of these patients may still be optimal for AS. GG 1 patients with PSAD >0.15 and PIRADS 5 lesions may proceed to surgical treatment with omission of repeat biopsy; however, repeat biopsy should be performed prior to radiation to inform the need and duration of ADT. 
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