Deleuze, Claire

Dickinson, Louise

Orczyk, Clement

English

UCL Discovery

E U R O P E A N U R O L O G Y O P E N S C I E N C E 5 2 ( 2 0 2 3 ) 1 3 5 – 1 3 6avai lable at www.sciencedirect .comjournal homepage: www.eu-openscience.europeanurology.comLetter to the EditorRe: Thomas Bommelaere, Arnauld Villers, Philippe Puech,et al. Risk Estimation of Metastatic Recurrence AfterProstatectomy: A Model Using Preoperative MagneticResonance Imaging and Targeted Biopsy. Eur Urol OpenSci 2022;41:24–34Bommelaere et al. [1] report on their refined risk model forassessing the likelihood of metastatic recurrence of prostatecancer after radical surgery based on volume estimation ofoverall and high-grade disease at baseline, using combinedmultiparametric magnetic resonance imaging (mpMRI) andtargeted biopsy outcomes. They should be congratulated forthis innovative single-centre report and for their pioneeringand systematic approach to the detection of prostate cancer.This is a mature cohort from a centre that has used mpMRIbefore targeted biopsy for more than a decade [2]. One lim-itation of the study could be in the validation of their modelin other centres in the near future. This historic cohort pre-sents another limitation linked to the temporality of itsacquisition. More than one-third of the metastatic recur-rences occurred within the first year, suggesting potentialunderstaging at baseline. If prostate-specific membraneantigen positron emission tomography imaging had beenintroduced earlier, would the curves (Fig. 1 [1]) have takena different shape, identifying rather than predicting spreadof disease? The use of Harrell’s C index is time-sensitiveby definition [3], pairing each early event to another oneand then comparing the predicted risk. It is therefore diffi-cult to establish if the model reflects the possibility ofdetection of metastasis by a more performative clinical testat baseline or truly predicts its risk of occurrence. Nonethe-less, the authors used the best approximation of volume andhigher grade derived from mpMRI and targeted biopsy.Using the threshold of 3.2 cm3 of Gleason pattern 4 or 5reported previously by McNeal, the population is nearlysplit in two, with 40% classified as metastatic and 60%remaining under the detection capability of staging imag-ing. Such a divide probably indicates the limits of our cur-rent model of risk of prostate cancer based predominantlyon volume and grade of disease. Beyond the proxy of marginstatus, some other biological mechanisms are probably inplay. The histological taxonomy of prostate cancer basedon morphology is probably limited in value, especially withthe knowledge that 90% of men with prostate-specific anti-gen of <15 ng/ml harbour Gleason 7 disease on high-densitytransperineal mapping biopsies [4]. As an illustration, thishttps://doi.org/10.1016/j.euros.2023.04.0160302-2838/ 2023 The Author(s). Published by Elsevier B.V. on behalf of Eurunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nstudy detected a metastatic event after radical surgery innearly 15% of patients harbouring only small-volumehigh-grade disease (0.5–1 cm3).The attempt to risk-stratify prostate cancer via molecu-lar taxonomy has also failed to demonstrate a single driver,with vast heterogeneity of the disease at this level of anal-ysis [5]. In addition, while mpMRI-visible disease has beensuggested as the dominant phenotype, the visibility phe-nomenon seems to be linked to molecular features ofaggressiveness rather than an identifiable single molecularsubstrate [6]. Nevertheless, the authors of this study havedemonstrated the importance of mpMRI and targetedbiopsy, which should now be considered integral to con-temporary risk models. In the future, a modified risk modelmight integrate molecular analyses from targeted biopsytissue with a more refined quantitative assessment of mul-tiparametric MRI parameters, each one detecting a set ofdifferent features of this heterogeneous disease [4].Conflicts of interest: Claire Deleuze receives research sup-port from EUSP. Louise Dickinson has nothing to disclose.Clement Orczyk is a proctor for Sonablate and a consultantfor Varian and Imaging Medical.References[1] Bommelaere T, Villers A, Puech P, et al. Risk estimation of metastaticrecurrence after prostatectomy: a model using preoperativemagnetic resonance imaging and targeted biopsy. Eur Urol OpenSci 2022;41:24–34. https://doi.org/10.1016/j.euros.2022.04.011.[2] Haffner J, Lemaitre L, Puech P, et al. Role of magnetic resonanceimaging before initial biopsy: comparison of magnetic resonanceimaging-targeted and systematic biopsy for significant prostatecancer detection: role of MRI before initial biopsy. BJU Int2011;108:E171–8. https://doi.org/10.1111/j.1464-410X.2011.10112.x.[3] Longato E, Vettoretti M, Di Camillo B. A practical perspective on theconcordance index for the evaluation and selection of prognostictime-to-event models. J Biomed Inform 2020;108:103496. https://doi.org/10.1016/j.jbi.2020.103496.[4] Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracyof multi-parametric MRI and TRUS biopsy in prostate cancer(PROMIS): a paired validating confirmatory study. Lancet2017;389:815–22. https://doi.org/10.1016/S0140-6736(16)32401-1.[5] Abeshouse A, Ahn J, Akbani R, et al. The molecular taxonomy ofprimary prostate cancer. Cell 2015;163:1011–25. https://doi.org/10.1016/j.cell.2015.10.025.[6] Norris JM, Simpson BS, Parry MA, et al. Genetic landscape of prostatecancer conspicuity on multiparametric magnetic resonance imaging:a systematic review and bioinformatic analysis. Eur Urol Open Sci2020;20:37–47. https://doi.org/10.1016/j.euros.2020.06.006.opean Association of Urology. This is an open access articled/4.0/).E U R O P E A N U R O L O G Y O P E N S C I E N C E 5 2 ( 2 0 2 3 ) 1 3 5 – 1 3 6136Claire Deleuze aLouise Dickinson bClement Orczyk a,c,*aDivision of Surgery and Interventional Sciences, University College London,London, UKbDepartment of Radiology, University College London Hospitals, London, UKcDepartment of Urology, University College London Hospitals, London, UK*Corresponding author. Division of Surgery and Interventional Sciences,University College London, Charles Bell House, 43–45 Foley Street,London W1W 7TS, UK. Tel. +44 7 958550727; Fax: +44 207 6799511.E-mail address: c.orczyk@ucl.ac.uk (C. Orczyk).April 1, 2023

Re: Thomas Bommelaere, Arnauld Villers, Philippe Puech, et al. Risk Estimation of Metastatic Recurrence After Prostatectomy: A Model Using Preoperative Magnetic Resonance Imaging and Targeted Biopsy. Eur Urol Open Sci 2022;41:24–34

https://discovery.ucl.ac.uk/10177196/1/Olczyk_Letter%20to%20the%20Editor_VoR.pdf

Re: Thomas Bommelaere, Arnauld Villers, Philippe Puech, et al. Risk Estimation of Metastatic Recurrence After Prostatectomy: A Model Using Preoperative Magnetic Resonance Imaging and Targeted Biopsy. Eur Urol Open Sci 2022;41:24–34

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