This study evaluated whether preoperative MRI-derived tumor volume and Gleason pattern 4/5 (GP4/5) burden from targeted biopsy could predict long-term metastatic recurrence and biochemical recurrence (BCR) in 646 men undergoing radical prostatectomy (RP) between 2009–2018, with a median follow-up of 8.3 years. It also examined whether tumor zonal origin (peripheral zone [PZ] vs. transition zone/anterior fibromuscular stroma [TZ/AFMS]) independently predicted outcomes.
At 10 years, metastatic recurrence occurred in 11% (95% CI 9–15%) and BCR in 28% (95% CI 24–32%). MRI- and biopsy-derived GP4/5 burden strongly predicted metastatic recurrence (c-index 0.82, 95% CI 0.76–0.88) and BCR (c-index 0.73, 95% CI 0.69–0.78). PZ tumors had significantly higher 10-year BCR rates than TZ tumors (32% vs. 14%, p=0.004), but zonal origin was not an independent predictor after multivariable adjustment.
- Single-center cohort design limits generalizability. - Zonal origin analysis relied on unadjusted comparisons; the mediation pathway through GP4/5 burden was not formally tested. - Overlapping confidence intervals for metastatic recurrence by zonal origin mean that difference between PZ and TZ cannot be confirmed.
Quantifying GP4/5 burden from preoperative MRI and targeted biopsy offers strong long-term prediction of metastatic recurrence after RP (c-index 0.82) and can guide risk stratification. Peripheral zone origin should not be used as an independent risk factor in multivariable models, as its apparent effect is likely mediated by higher GP4/5 burden.
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