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Introduction <p>Men with Grade Group (GG) 1–2 prostate cancer (PCa) are generally candidates for active surveillance, yet the presence of a PI-RADS 5 lesion on mpMRI often prompts definitive treatment. Data on pathological outcomes in this specific subgroup remain scarce. The aim of this study was to assess the prevalence of adverse and aggressive pathology after radical prostatectomy (RP) and to identify predictors of biochemical recurrence (BCR).</p> Methods <p>A retrospective, single-center study was conducted including 72 men with biopsy-proven GG 1–2 PCa and a PI-RADS 5 lesion on prebiopsy mpMRI, confirmed by local review, who underwent RP between 2017 and 2024. The primary endpoint was adverse (i.e., GG 3 and/or pT3a) or aggressive (i.e., GG ≥ 4 and/or pT3b and/or pN1) features at final pathology. Secondary endpoint was BCR-free survival.</p> Results <p>At final pathology, 64% of men (<i>n</i> = 46) showed favorable features, 15% (<i>n</i> = 11) adverse pathology, and 21% (<i>n</i> = 15) aggressive pathology. When stratifying GG2 tumors by pattern-4 burden, both GG2 &lt; 20% (HR 5.75, 95% CI 1.25–26.33; <i>p</i> = 0.024) and GG2 ≥ 20% (HR 8.26, 95% CI 1.84–37.01; <i>p</i> = 0.006) were independently associated with adverse/aggressive pathology compared with GG1. After a median follow-up of 28 months, 13 men developed BCR (3-year BCR-free survival: 89%). In multivariable Cox analysis, only aggressive pathology at RP was independently associated with BCR (HR 5.42, 95% CI 1.3–24; <i>p</i> = 0.025).</p> Conclusions <p>Among men with PI-RADS 5/GG1–2 PCa, one third harbor adverse or aggressive features at RP. The burden of Gleason pattern 4 plays a key role in stratifying risk within GG2 disease. While AS may remain suitable for carefully selected GG1 patients with confirmatory reassurance, GG2 tumors, particularly those with substantial pattern-4 volume, demonstrate less favorable pathological profiles and warrant individualized counseling.</p>

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Radical prostatectomy outcomes in patients with PI-RADS 5 lesions and favorable prostate cancer

  • 期刊论文

  • 发表日期：

    2025年12月27日

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  • Anne-Laure Charvet,
  • Thibaut Long Depaquit,
  • Hector Bened,
  • Harry Toledano,
  • David Chemouni,
  • Laurent Daniel,
  • Cyrille Bastide,
  • Michael Baboudjian

摘要

Introduction

Men with Grade Group (GG) 1–2 prostate cancer (PCa) are generally candidates for active surveillance, yet the presence of a PI-RADS 5 lesion on mpMRI often prompts definitive treatment. Data on pathological outcomes in this specific subgroup remain scarce. The aim of this study was to assess the prevalence of adverse and aggressive pathology after radical prostatectomy (RP) and to identify predictors of biochemical recurrence (BCR).

Methods

A retrospective, single-center study was conducted including 72 men with biopsy-proven GG 1–2 PCa and a PI-RADS 5 lesion on prebiopsy mpMRI, confirmed by local review, who underwent RP between 2017 and 2024. The primary endpoint was adverse (i.e., GG 3 and/or pT3a) or aggressive (i.e., GG ≥ 4 and/or pT3b and/or pN1) features at final pathology. Secondary endpoint was BCR-free survival.

Results

At final pathology, 64% of men (n = 46) showed favorable features, 15% (n = 11) adverse pathology, and 21% (n = 15) aggressive pathology. When stratifying GG2 tumors by pattern-4 burden, both GG2 < 20% (HR 5.75, 95% CI 1.25–26.33; p = 0.024) and GG2 ≥ 20% (HR 8.26, 95% CI 1.84–37.01; p = 0.006) were independently associated with adverse/aggressive pathology compared with GG1. After a median follow-up of 28 months, 13 men developed BCR (3-year BCR-free survival: 89%). In multivariable Cox analysis, only aggressive pathology at RP was independently associated with BCR (HR 5.42, 95% CI 1.3–24; p = 0.025).

Conclusions

Among men with PI-RADS 5/GG1–2 PCa, one third harbor adverse or aggressive features at RP. The burden of Gleason pattern 4 plays a key role in stratifying risk within GG2 disease. While AS may remain suitable for carefully selected GG1 patients with confirmatory reassurance, GG2 tumors, particularly those with substantial pattern-4 volume, demonstrate less favorable pathological profiles and warrant individualized counseling.