Measuring Gleason pattern 4 in millimetres could double surveillance eligibility

The edition in brief

In 2,499 men with Grade Group 2 to 4 prostate cancer on MRI-targeted and systematic biopsy who went on to prostatectomy, those with less than 2 mm of total Gleason pattern 4 had adverse pathology (5.2%) and five-year biochemical recurrence (20%) similar to favourable intermediate-risk disease, suggesting about twice as many men could be candidates for active surveillance. Extended follow-up of the phase 2 LUNAR trial (92 men with one to five PSMA-detected recurrences) showed two cycles of lutetium-177 PSMA before SBRT improved progression-free survival, median 17.6 against 7.4 months (HR 0.38), and hormone therapy-free survival (HR 0.57). A multimodal AI model combining MRI and ultrasound localised significant cancer with higher specificity than radiologists (0.88 vs 0.78) on prostatectomy validation. A meta-analysis of 630 men treated with TULSA found 70% free of significant cancer at 12 months after primary treatment, with 90% pad-free. In 40 men with symptomatic lymphoceles after node dissection, 98% of leaks arose at Cloquet's node. The pearl covers interpreting PSA on 5-alpha reductase inhibitors.