Serial hyperpolarized 13C+mpMRI and paired metabolic image-guided biopsy were employed in a new integrative active surveillance (AS) paradigm, exemplified by a patient who initially enrolled in AS for 5 years, but later underwent radical prostatectomy upon progression. Metabolic biomarker kPL images detected early progression preceding radiologic and clinical parameters. Final whole-gland histopathology also linked kPL and PI-RADS targets to multifocal tumors, where kPL spatially reflected intratumoral heterogeneity, and high kPL regions correlated with adverse pathologic features such as G4 cribriform pattern, extracapsular extension, and lymphovascular invasion. Results indicated HP 13C may help optimize AS by improving clinical risk calculation.
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