Decreased accuracy of the prostate cancer EAU risk group classification in the era of imaging-guided diagnostic pathway: proposal for a new classification based on MRI-targeted biopsies and early oncologic outcomes after surgery

World J Urol. 2020 Oct;38(10):2493-2500. doi: 10.1007/s00345-019-03053-6. Epub 2019 Dec 14.

Abstract

Purpose: To assess the performance of EAU risk classification in PCa patients according to the biopsy pathway (standard versus MRI guided) and to develop a new, more accurate, targeted biopsy (TB)-based classification.

Materials and methods: We included 1345 patients consecutively operated by radical prostatectomy (RP) since 2014, when MRI and TB were introduced in the diagnostic pathway. Patients underwent systematic biopsy (SB) only (n = 819) or SB and TB (n = 526) prior to RP during the same time period. Pathological and biochemical outcomes were compared between PCa men undergoing SB (SB cohort) and a combination of TB and SB (TB cohort). Kaplan-Meier and Cox regression models were used to assess biochemical recurrence-free survival (RFS).

Results: Both cohorts were comparable regarding final pathology and RFS (p = 0.538). The EAU risk classification accurately predicted outcomes in SB cohort, but did not significantly separate low from intermediate risk in TB cohort (p = 0.791). In TB cohort, the new proposed three-group risk classification significantly improved the recurrence risk prediction compared with the EAU risk classification: HR 4 (versus HR 1.2, p = 0.009) for intermediate, and HR 15 (versus HR 6.5, p < 0.001) in high-risk groups, respectively. A fourth group defining very high-risk cases (≥ T2c clinical stage or grade group 5) was also proposed.

Conclusions: The new classification integrating TB findings we propose meaningfully improves the recurrence prediction after surgery in patients undergoing a TB-based diagnostic pathway, compared with standard EAU risk classification which is still relevant for patients undergoing only SB. External validation is needed.

Keywords: Biopsy; Fusion biopsies; MRI; Prostate cancer; Radical prostatectomy; Risk; Systematic biopsies; Targeted biopsies.

MeSH terms

  • Aged
  • Biopsy / methods
  • Cohort Studies
  • Humans
  • Image-Guided Biopsy
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Prostate / pathology*
  • Prostatectomy
  • Prostatic Neoplasms / classification*
  • Prostatic Neoplasms / epidemiology
  • Prostatic Neoplasms / pathology*
  • Prostatic Neoplasms / surgery
  • Reproducibility of Results
  • Risk Assessment
  • Treatment Outcome