During the last decade, a stage migration towards more aggressive and locally advanced prostate cancer (PC) has been observed. At the same time, active surveillance (AS) of low-risk prostate cancer is increasing. The mpMRI-fusion-guided biopsy of the prostate (FBx) is considered to be the gold standard in preoperative risk stratification. However, the role of FBx in terms of risk stratification of low-risk prostate cancer outside of high-volume centers remains unclear. The aim of this study was to evaluate adverse pathology after radical prostatectomy of patients in a real-world setting, with a focus on Gleason Score (GS) 6 in the FBx.
Between March 2015 and March 2022, 1483 patients underwent a FBx in our department. mpMRI for FBx was performed by 111 different radiology offices. FBx was performed by 14 urologists with different levels of experience. 997 patients were diagnosed with prostate cancer. 492 of these patients decided to receive a radical prostatectomy (RP) in our clinic and were retrospectively included in the analysis. The results were then compared to equivalent results of randomized biopsies (SBx) from a pre-FBx era in our clinic.
55.3% of patients diagnosed with GS 6 by FBx were upgraded after RP, compared to 54.5% of patients after SBx and RP (p=0.864). We further analyzed a subgroup of patients of the GS 6 cohort, who would have been eligible for AS based on the EAU inclusion criteria. In total, 29/492 (6%) patients would have been eligible for AS, but underwent RP at our department. In the histopathological report after RP, 5/29 patients (17.2%) showed concordant GS 6 and local stage pT2a and thus would still have met the inclusion criteria for AS. The time between FBx and RP was the only identified potential correlate leading to upgrading. 18.7% of patients diagnosed with PC by FBx were downgraded after RP.
In this study, we present a realistic everyday life approach as our data represent a mix of heterogeneously experienced radiology offices and urologists. The introduction of FBx did not lead to a significant change in the ratio of adverse pathology of GS 6 PC compared to the pre-Fbx era. 82.8% of patients stratified eligible for active surveillance by FBx were upgraded towards clinically significant PC after RP.