“We got it all and you’ll never have to worry about prostate cancer again.” Those are the sweetest words for patients with prostate cancer (PCa) who decide to have a radical prostatectomy (RP), meaning surgical removal of the entire gland. “Never again” is the hope and the expectation, and most of the time that prediction proves true.

However, not all patients are so fortunate. Some will experience recurrence (return of PCa after surgery). The more aggressive the disease at the time of surgery, the greater the risk of recurrence. Estimates show that 27-53% of treated cases will recur.^[i] The earliest suspicion of recurrence is a raised PSA, known as biochemical recurrence (BCR). For prostatectomy patients, BCR is usually identified as two consecutive PSA blood test readings of 0.4 ng/mL at least four weeks apart.

BCR is scary because it means there’s a high probability that the patient’s cancer will become more aggressive, spreading to other parts of the body and increasing the risk of dying from PCa. As a recent article emphasizes, “…it is essential to identify patients at high risk of biochemical recurrence for closer follow-up and early treatment, if necessary.”^[ii] Currently, there are scales that assign a numerical value to a patient’s risk level:

• The Grade Group (GG) system is a 1-5 risk score that uses the biopsy-based Gleason score. In the GG system, 1 is the least aggressive and 5 is the most aggressive.
• The Partin tables use standard clinical factors in combination: Gleason score, PSA, and PCa stage to predict likelihood that the cancer is still confined to the gland. The tables were developed based on post-surgery prostate specimens from patients whose clinical factors were known in advance.

Higher risk levels correlate with more chance for BCR, but sometimes the true level is not known until after surgery.

There is a need for better and more accurate pre-treatment prediction. A European multidisciplinary team of 22 researchers and clinicians point to a missing element in existing systems: “Current predictive tools to estimate the risk of biochemical recurrence (BCR) after treatment of prostate cancer do not consider multiparametric MRI (mpMRI) information.”^[iii] Today’s MRI advances provide key visual information that rounds out knowledge gained from biopsy, bloodwork, genomic analysis, etc. It gives a 3D portrait of the location, shape and size of a suspicious lesion, including involvement beyond the prostate capsule. This allows treatment strategizing with the most hope for success.

Therefore, the same team created the PIPEN model, whose initials stand for

• PSA density
• International Society of Urological Pathology grade group (GG)
• PI-RADS (Prostate Imaging Reporting and Data System category)
• European Society of Urogenital Radiology extraprostatic extension score (cancer outside the prostate capsule)
• Nodes (cancer spread to lymph nodes)

By integrating these sources of information, the team created 5 risk levels correlated with the likelihood of no BCR at 5 years after surgery:

Risk level	Likely BCR-free at 5 years
Very low risk	92%
Low risk	84%
Intermediate risk	71%
High risk	56%
Very high risk	26%

As you can see, there is considerable need to closely monitor post-surgery patients whose higher risk disease is known prior to surgery. Not only does the addition of mpMRI into the diagnostic pathway help predict the odds for BCR, it also enables treatment planning. For example, if pre surgery MRI reveals that the tumor has penetrated the capsule and is bulging into the prostate bed, a course of radiation after healing from surgery could be planned for, and MRI aids targeting.

Finally, MRI offers a beneficial post-surgery follow-up protocol, particularly for those most in danger of BCR. There is no doubt that multiparametric MRI is a revolutionary game-changer for PCa patients at any stage of the disease, and who are deciding on a treatment.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Aguirre DA, Cardona Ortegón JD. Unlocking the Benefits of Multiparametric MRI for Predicting Prostate Cancer Recurrence. Radiology. 2023 Nov;309(2):e232819.
[ii] Ibid.
[iii] Luzzago S, Colombo A, Mistretta FA, Alessi S et al. Multiparametric MRI-based 5-year Risk Prediction Model for Biochemical Recurrence of Prostate Cancer after Radical Prostatectomy. Radiology. 2023 Nov;309(2):e223349.