Performing radical prostatectomy (RP) based solely on radiographic findings and skipping conventional biopsies that are the standard of care for diagnosing prostate cancer may be a possible option for well-selected patients, according to a recent report.
In a study of 25 men with a high suspicion for significant prostate cancer based on imaging with multiparametric magnetic resonance imaging (mpMRI) of the prostate and prostate-specific membrane antigen positron emission tomography (PSMA-PET), all patients had Grade Group 2 or higher prostate cancer on postoperative pathology.
“Results of the current retrospective case series were promising and showed that, in patients with a high suspicion of [prostate cancer] in mpMRI and PSMA-PET, avoidance of prostate biopsy prior to RP might represent a valid option in well-counseled, selected patients,” Valentin H. Meissner, MD, of the Technical University of Munich School of Medicine, and colleagues reported in European Urology.
They also observed that this approach “should not be regarded as a standard procedure at the moment, and results illustrate the need for a prospective evaluation within an ethically approved clinical trial to confirm these results.”
The investigators acknowledged that their study is limited by the retrospective design and small sample size.
Dr Meissner’s team defined significant prostate cancer as an mpMRI Prostate Imaging Reporting and Data System (PI-RADS) score of 4 or higher and PET score of 4 or higher on a 5-point Likert scale and maximum standardized uptake value of 4 or higher. On a per-patient basis, sensitivity and positive predictive value for identifying significant prostate cancer were 100% for both mpMRI and PSMA-PET, the investigators reported.
“In this small and very carefully selected group of patients, prostate MRI and PSMA-PET imaging were successful in identifying prostate cancer in all patients,” commented Michael Leapman, MD, assistant professor of urology at the Yale School of Medicine in New Haven, Connecticut, who was not involved with the study. “This work is intriguing because it may suggest the possibility of a diagnostic pathway that avoids prostate biopsy, an invasive procedure that is uncomfortable, costly, and does exposure patients to potential risks.”
Dr Leapman, who is clinical program leader of the Prostate & Urologic Cancers Program at the Yale Cancer Center, said he interprets the findings with caution “as the consequences of exposing even 1 patient without cancer to prostatectomy is substantial, regardless of how they are counseled. Moreover, widespread use of PSMA-PET and prostate MRI raises questions about long-term cost effectiveness and sustainability.”
“While this is an interesting study, and all men were ultimately found to have treatable cancer, the results should be taken with caution given the variability of MRI reading and the concern for false positives,” observed Sanoj Punnen, MD, MAS, associate professor and vice chair of research in the department of urology at the Miller School of Medicine, University of Miami in Florida. “Furthermore, the biopsy provides more information about the true grade and extent of tumor within the prostate, and without this we could underestimate or overestimate the burden of cancer, which could lead to misguided management.”
Dr Punnen, who is co-chair of the Genitourinary Site Disease Group at the University of Miami’s Sylvester Comprehensive Cancer Center, added that while this study is hypothesis generating, “it requires much further validation before considering this as an option in men with suspicious findings on imaging.”
Meissner VH, Rauscher I, Schwamborn K, et al. Radical prostatectomy without prior biopsy following multiparametric magnetic resonance imaging and prostate-specific membrane antigen positron emission tomography. Eur Urol. Published online December 6, 2021. doi:10.1016/j.eururo.2021.11.019