Association between baseline prostate MRI PI-RADS classification and risk of Gleason upgrade during active surveillance: a systematic review and meta-analysis.

PURPOSE: Although prostate magnetic resonance imaging (MRI) enhances the detection of high-grade prostate cancer (PCa), its predictive role in active surveillance (AS) of favorable risk PCa is unclear. We examined the association between baseline MRI Prostate Imaging-Reporting and Data System (PI-RADS) score and Gleason Grade Group (GG) upgrade risk among patients managed with AS.

METHODS

We systematically searched eight databases to identify studies evaluating the association between baseline PI-RADS score and the risk of GG upgrade in patients managed with AS for PCa (PROSPERO: CRD42024567762). We pooled the hazard ratios (HR)using Hartung-Knapp random-effects meta-analysis models. We assessed the risk of bias using the ROBINS-I tool.

RESULTS

We included eleven studies (n = 6309) in the meta-analysis. The risk of bias was moderate, attributed to the retrospective and unblinded design of seven included studies. Among studies reporting baseline PI-RADS, 2,640 patients (52.1%) had PI-RADS 1-3 lesions, and 2,421 patients (47.9%) had PI-RADS 4-5 lesions. Baseline PI-RADS 4-5 was associated with an increased risk of upgrade compared to those with PI-RADS 1-3 lesions (HR:2.21, 95%CI: 1.66-2.93, p<.001). Compared to PI-RADS 1-2, the presence of PI-RADS 3 (HR:1.88, 95%CI: 1.29-2.74, p=.008), PI-RADS 4 (HR:2.73, 95%CI: 2.08-3.58, p<.001), or PI-RADS 5 (HR:3.69, 95%CI: 2.50-5.45, p<.001) lesions were associated with an increased risk of upgrade.

CONCLUSIONS

Baseline prostate MRI finding as assessed with PI-RADS is highly prognostic for GG upgrading among patients with favorable risk PCa managed with AS. These findings support further study of tailored surveillance strategies based on initial MRI findings.