How to cite: Emberton M. Lesional management in early prostate cancer. October 2025. Accessed February 2026. https://grandroundsinurology.com/lesional-management-in-early-prostate-cancer/
Summary
Mark Emberton, MD, FRCS, Dean, Faculty of Medical Sciences, Professor of Interventional Oncology, Division of Surgery and Interventional Science, University College London, London, United Kingdom, traces the evolution of prostate cancer care from an era in which the gland is removed without imaging guidance to a present day environment in which magnetic resonance imaging (MRI) and other modalities routinely visualize individual tumor masses. He notes that multiparametric MRI and newer functional sequences now depict lesions with high conspicuity, even when prostate-specific antigen levels are low and clinical examination is unremarkable. These visible lesions often exhibit biological features that differ from those of incidental small-volume disease.
He reviews data from active surveillance cohorts, indicating that men with MRI visible lesions experience higher rates of upgrading and conversion to radical treatment than men without visible lesions. He highlights analyses in which lesion-directed biopsy significantly reduces the proportion of men classified with Gleason 3+3 disease. When biopsy focuses on imaging targets, low-grade labels almost disappear, and many tumors that appear to be low-risk are reclassified as clinically significant. This suggests that traditional biopsy pathways underestimate risk in men with visible lesions.
Dr. Emberton discusses translational work comparing gene expression profiles of visible and invisible cancers. MRI-invisible tumors often resemble benign tissue at a molecular level, whereas MRI-visible tumors express pathways associated with aggression, proliferation, and immune escape. This supports the concept that visibility on imaging reflects distinct biology rather than only size.
He illustrates an image-based pathway in which early diagnosis imaging, targeted biopsy, and lesion-focused treatment occur within a short time frame. He argues that management in early prostate cancer should increasingly concentrate on the visible lesion and its biological characteristics while acknowledging that much of the gland harbors indolent or incidental disease. He emphasizes that imaging-led lesional management offers the potential for more precise risk stratification and tailored therapy than has been possible with systematic needle sampling alone.
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ABOUT THE AUTHOR
Mark Emberton, MD, FRCS, is Dean for the Faculty of Medical Sciences, and Professor of Interventional Oncology for the Division of Surgery and Interventional Science at University College London in London, England. He is also an Honorary Clinical Director of the Clinical Effectiveness Unit at the Royal College of Surgeons of England, and UCL Partners' Pathway Director for urological oncology for London Cancer. Professor Emberton’s clinical research is aimed at improving the diagnostic and risk stratification tools and treatment strategies for prostate cancer. He specializes in the implementation of new imaging techniques, nanotechnologies, bio-engineering materials, and non-invasive treatment approaches, such as high intensity focused ultrasound and photo-dynamic therapy.
