Update of the Standard Operating Procedure on the Use of Multiparametric Magnetic Resonance Imaging for the Diagnosis, Staging and Management of Prostate Cancer

Prediction of extracapsular extension in prostate cancer using the Likert scale combined with clinical and pathological parameters

Abstract

This study aimed to investigate the independent clinical, pathological, and radiological factors associated with extracapsular extension in radical prostatectomy specimens and to improve the accuracy of predicting extracapsular extension of prostate cancer before surgery.

Methods

From August 2018 to June 2023, the clinical and pathological data of 229 patients with confirmed prostate cancer underwent radical prostatectomy from The Second Hospital of Yinzhou. The patients' multiparametric magnetic resonance imaging data were graded using the Likert scale. The chi-square or independent-sample T-test was used to analyze the related factors for an extracapsular extension. Multivariate analysis was used to identify independent factors associated with extracapsular extension in prostate cancer. Additionally, receiver operating characteristic curve analysis was used to calculate the area under the curve and assess the diagnostic performance of our model. The clinical decision curve was used to analyze the clinical net income of Likert scale, biopsy positive rate, biopsy GG, and combined mode.

Results

Of the 229 patients, 52 had an extracapsular extension, and 177 did not. Multivariate analysis showed that the Likert scale score, biopsy grade group and biopsy positive rate were independent risk factors for extracapsular extension in prostate cancer. The area under the curves for the Likert scale score, biopsy grade group, and biopsy positive rate were 0.802, 0.762, and 0.796, respectively. Furthermore, there was no significant difference in the diagnostic efficiency for extracapsular extension (P>0.05). However, when these three factors were combined, the diagnostic efficiency was significantly improved, and the area under the curve increased to 0.905 (P<0.05). In the analysis of the decision curve, The clinical net income of the combined model is obviously higher than that of Likert scale, biopsy positive rate, and biopsy GG.

Conclusion

The Likert scale, biopsy grade group and biopsy positive rate are independent risk factors for extracapsular extension in prostate cancer, and their combination can significantly improve the diagnostic efficiency for an extracapsular extension.

Low cancer yield in PI-RADS 3 upgraded to 4 by dynamic contrast-enhanced MRI: is it time to reconsider scoring categorization?

OBJECTIVES

To evaluate MRI diagnostic performance in detecting clinically significant prostate cancer (csPCa) in peripheral-zone PI-RADS 4 lesions, comparing those with clearly restricted diffusion (DWI-score 4), and those with equivocal diffusion pattern (DWI-score 3) and positive dynamic contrast-enhanced (DCE) MRI.

METHODS

This observational prospective study enrolled 389 men referred to MRI and, if positive (PI-RADS 3 with PSA-density [PSAD] ≥ 0.15 ng/mL/mL, 4 and 5), to MRI-directed biopsy. Lesions with DWI-score 3 and positive DCE were classified as "PI-RADS 3up," instead of PI-RADS 4. Univariable and multivariable analyses were implemented to determine features correlated to csPCa detection.

RESULTS

Prevalence of csPCa was 14.5% and 53.3% in PI-RADS categories 3up and 4, respectively (p < 0.001). MRI showed a sensitivity of 100.0%, specificity 40.9%, PPV 46.5%, NPV 100.0%, and accuracy 60.9% for csPCa detection. Modifying the threshold to consider MRI positive and to indicate biopsy (same as previously described, but PI-RADS 3up only when associated with elevated PSAD), the sensitivity changed to 93.9%, specificity 57.2%, PPV 53.0%, NPV 94.8%, and accuracy 69.7%. Age (p < 0.001), PSAD (p < 0.001), positive DWI (p < 0.001), and PI-RADS score (p = 0.04) resulted in independent predictors of csPCa.

CONCLUSIONS

Most cases of PI-RADS 3up were false-positives, suggesting that upgrading peripheral lesions with DWI-score 3 to PI-RADS 4 because of positive DCE has a detrimental effect on MRI accuracy, decreasing the true prevalence of csPCa in the PI-RADS 4 category. PI-RADS 3up should not be upgraded and directed to biopsy only if associated with increased PSAD.

KEY POINTS

• As per PI-RADS v2.1 recommendations, in case of a peripheral zone lesion with equivocal diffusion-weighted imaging (DWI score 3), but positive dynamic contrast-enhanced (DCE) MRI, the overall PI-RADS score should be upgraded to 4. • The current PI-RADS recommendation of upgrading PI-RADS 3 lesions of the peripheral zone to PI-RADS 4 because of positive DCE decreased clinically significant prostate cancer detection rate in our series. • According to our results, the most accurate threshold for setting indication to prostate biopsy is PI-RADS 3 or PI-RADS 3 with positive DCE both associated with increased PSA density.

American College of Radiology initiatives on prostate magnetic resonance imaging quality

Magnetic resonance imaging (MRI) has become integral to diagnosing and managing patients with suspected or confirmed prostate cancer. However, the benefits of utilizing MRI can be hindered by quality issues during imaging acquisition, interpretation, and reporting. As the utilization of prostate MRI continues to increase in clinical practice, the variability in MRI quality and how it can negatively impact patient care have become apparent. The American College of Radiology (ACR) has recognized this challenge and developed several initiatives to address the issue of inconsistent MRI quality and ensure that imaging centers deliver high-quality patient care. These initiatives include the Prostate Imaging Reporting and Data System (PI-RADS), developed in collaboration with an international panel of experts and members of the European Society of Urogenital Radiology (ESUR), the Prostate MR Image Quality Improvement Collaborative, which is part of the ACR Learning Network, the ACR Prostate Cancer MRI Center Designation, and the ACR Appropriateness Criteria. In this article, we will discuss the importance of these initiatives in establishing quality assurance and quality control programs for prostate MRI and how they can improve patient outcomes.

Inter-reader agreement of the prostate imaging quality (PI-QUAL) score for basic readers in prostate MRI: A multi-center study

BACKGROUND

The Prostate Imaging Quality (PI-QUAL) score is the first step toward image quality assessment in multi-parametric prostate MRI (mpMRI). Previous studies have demonstrated moderate to excellent inter-rater agreement among expert readers; however, there is a need for studies to assess the inter-reader agreement of PI-QUAL scoring in basic prostate readers.

OBJECTIVES

To assess the inter-reader agreement of the PI-QUAL score amongst basic prostate readers on multi-center prostate mpMRI.

METHODS

Five basic prostate readers from different centers assessed the PI-QUAL scores independently using T2-weighted images, diffusion-weighted imaging (DWI) including apparent diffusion coefficient (ADC) maps, and dynamic-contrast-enhanced (DCE) images on mpMRI data obtained from five different centers following Prostate Imaging-Reporting and Data System Version 2.1. The inter-reader agreements amongst radiologists for PI-QUAL were evaluated using weighted Cohen's kappa. Further, the absolute agreements in assessing the diagnostic adequacy of each mpMRI sequence were calculated.

RESULTS

A total of 355 men with a median age of 71 years (IQR, 60-78) were enrolled in the study. The pair-wise kappa scores ranged from 0.656 to 0.786 for the PI-QUAL scores, indicating good inter-reader agreements between the readers. The pair-wise absolute agreements ranged from 0.75 to 0.88 for T2W imaging, from 0.74 to 0.83 for the ADC maps, and from 0.77 to 0.86 for DCE images.

CONCLUSIONS

Basic prostate radiologists from different institutions provided good inter-reader agreements on multi-center data for the PI-QUAL scores.

Literature review: Imaging in prostate cancer

Imaging plays an increasingly important role in the detection and characterization of prostate cancer (PC). This review summarizes the key conventional and advanced imaging modalities including multiparametric magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging and tries to instruct clinicians in finding the best image modality depending on the patient`s PC-stage. We aim to give an overview of the different image modalities and their benefits and weaknesses in imaging PC. Emphasis is put on primary prostate cancer detection and staging as well as on recurrent and castration resistant prostate cancer. Results from studies using various imaging techniques are discussed and compared. For the different stages of PC, advantages and disadvantages of the different imaging modalities are discussed. Moreover, this review aims to give an outlook about upcoming, new imaging modalities and how they might be implemented in the future into clinical routine. Imaging patients suffering from PC should aim for exact diagnosis, accurate detection of PC lesions and should mirror the true tumor burden. Imaging should lead to the best patient treatment available in the current PC-stage and should avoid unnecessary therapeutic interventions. New image modalities such as long axial field of view PET/CT with photon-counting CT and radiopharmaceuticals like androgen receptor targeting radiopharmaceuticals open up new possibilities. In conclusion, PC imaging is growing and each image modality is aiming for improvement.

Findings from an international survey of urology trainee experience with prostate biopsy

OBJECTIVE

To assess urology trainees' exposure to transperineal prostate biopsy (TP-Bx) and intent to use TP-Bx in practice.

SUBJECTS AND METHODS

A 34-question survey about prostate biopsy was distributed to urology trainees in the United States and Europe. Primary outcomes were exposure to TP-Bx in training and intent to use TP-Bx post training. Exposure to transrectal prostate biopsy (TR-Bx) and magnetic resonance imaging-targeted biopsy (MRI-Bx) was also assessed. Survey answers were compared between groups as categorical variables using Fisher's exact test. Multivariable logistic regression was used to identify factors associated with intent of performing TP-Bx post training.

RESULTS

A total of 658 trainees from 19 countries completed the survey. Of these, 313 trainees (48%) reported exposure to TP-Bx, 370 (56%) reported exposure to MRI-Bx, and 572 (87%) reported exposure to TR-Bx. There was significant heterogeneity in TP-Bx exposure among countries (P < 0.001), with the highest prevalence in Italy (72%) and the lowest prevalence in Greece (4%). Intent to perform TP-Bx post training was higher in those exposed to TP-Bx during training (89% vs 58%; P < 0.001) and did not differ between trainees in postgraduate year (PGY) 1-3 vs those in PGY ≥4 (73% vs 72%; P = 0.7). On multivariable regression, exposure to TP-Bx in training was independently associated with increased intent to perform TP-Bx post training (odds ratio 5.09, 95% confidence interval 3.29-8.03; P < 0.001).

CONCLUSIONS

Fewer than half of 658 surveyed urology trainees reported exposure to TP-Bx, with significant heterogeneity among countries. Greater experience with TP-Bx in training was associated with greater intent to perform TP-Bx post training. A minimum requirement of TP-Bx cases during urological training may increase resident familiarity and adoption of this guideline-endorsed prostate biopsy approach.

Contemporary Review of Multimodality Imaging of the Prostate Gland

Tissue changes and the enlargement of the prostate, whether benign or malignant, are among the most common groups of diseases that affect men and can have significant impacts on length and quality of life. The prevalence of benign prostatic hyperplasia (BPH) increases significantly with age and affects nearly all men as they grow older. Other than skin cancers, prostate cancer is the most common cancer among men in the United States. Imaging is an essential component in the diagnosis and management of these conditions. Multiple modalities are available for prostate imaging, including several novel imaging modalities that have changed the landscape of prostate imaging in recent years. This review will cover the data relating to commonly used standard-of-care prostate imaging modalities, advances in newer technologies, and newer standards that impact prostate gland imaging.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

Magnetic resonance fingerprinting based comprehensive quantification of T1 and T2 values of the background prostatic peripheral zone: Correlation with clinical and demographic features

PURPOSE

To quantify and assess the distribution of MR fingerprinting (MRF)-derived T1 and T2 values of the whole prostatic peripheral zone (PZ), and perform subgroup analyses according to clinical and demographic features.

METHOD

One hundred and twenty-four patients with prostate MR exams and MRF-based T1 and T2 maps of the prostatic apex, mid gland, and base were identified from our database and included. Regions of interest encompassing the right and left lobes of the PZ were drawn for each axial slice on the T2 map and copied to the T1 map. Clinical data were obtained from medical records. Kruskal-Wallis test was used for assessing differences between subgroups and the Spearman coefficient was used for assessing any correlations.

RESULTS

Mean T1 and T2 values were 1941 and 88 ms, respectively, for the whole-gland, 1884 and 83 ms for the apex, 1974 and 92 ms for the mid-gland, 1966 and 88 ms for the base. T1 values were weakly negatively correlated with PSA values, while T1 and T2 values were weakly positively correlated with prostate weight and moderately positively correlated with PZ width. Finally, patients with PI-RADS 1 scores had higher T1 and T2 values of the whole PZ, compared with those with scores 2-5.

CONCLUSION

Mean T1 and T2 values of the background PZ of the whole gland were 1941 ± 313 and 88 ± 39 ms, respectively. Among clinical and demographic factors, there was a significant positive correlation between T1 and T2 values and PZ width.

Effect of a dedicated PI-QUAL curriculum on the assessment of prostate MRI quality

PURPOSE

The Prostate Imaging Quality (PI-QUAL) score is a metric to evaluate the diagnostic quality of multiparametric magnetic resonance imaging (MRI) of the prostate. This study evaluated the impact of a prostate MRI quality training lecture on the participant's ability to assess prostate MRI image quality.

METHODS

Eighteen in-training-radiologists of varying experience in reviewing diagnostic prostate MRI assessed the image quality of ten examinations. Then, they attended a dedicated lecture on MRI quality assessment using the PI-QUAL score. After the lecture, the same participants evaluated the image quality of a new set of ten scans applying the PI-QUAL score. Results were assessed using receiver operating characteristic (ROC) analysis. The reference standard was the PI-QUAL score assessed by a fellowship trained abdominal radiologist with experience in reading prostate MRI.

RESULTS

There was a significant improvement in the average area under the curve (AUC) for assessment of prostate MRI image quality from baseline (0.82; [0.576 - 0.888]) to post teaching (1.0; [0.954-1]), with an improvement of 0.18 (p < 0.03). When ROC curves were computed for different cohorts stratified based on year of training, difference ranged from 0.48 for second year residents to 0.32 for fourth year residents (p < 0.001-0.01). For abdominal imaging fellows, the pre-teaching AUC was 0.9 [0.557-1] and post teaching AUC was 1 [0.957-1], a difference of 0.1 (p = 0.20).

CONCLUSIONS

A dedicated lecture on PI-QUAL improved the ability of radiologists-in-training to assess prostate MRI image quality, with variable impact depending on year of training.

5-alpha reductase inhibitors and MRI prostates: actively reducing prostate sizes and ambiguity

BACKGROUND

Magnetic resonance imaging (MRI) scans are increasingly first-line investigations for suspected prostate cancer, and essential in the decision for biopsy. 5-alpha reductase inhibitor (5-ARI) use has been shown to reduce prostate size and prostate cancer risk. However, insufficient data exists on how 5-ARI use affects MRI findings and yield of biopsy. This study explores the differences in imaging and prostate cancer diagnoses between patients receiving and not receiving 5-ARI therapy.

METHODS

From 2015 to 2020, we collected retrospective data of consecutive patients undergoing prostate biopsy at one centre. We included patients who were biopsy-naïve, had prior negative biopsies, or on active surveillance for low-grade prostate cancer. Clinical and pathological data was collected, including 5-ARI use, Prostate Imaging Reporting and Data System (PIRADS) classification and biopsy results.

RESULTS

351 men underwent saturation biopsy with or without targeted biopsies. 54 (15.3%) had a history of 5-ARI use. On mpMRI, there was no significant difference between the 5ARI and non-5-ARI groups in PIRADS distribution, number of lesions, and lesion location. Significantly fewer cancers were detected in the 5-ARI group (46.3% vs. 68.0%; p < 0.01). There were no significant differences in PIRADS distribution in 5-ARI patients with positive and negative biopsy.

CONCLUSION

Our study found significant differences in biochemical, imaging and biopsy characteristics between 5-ARI and non-5-ARI groups. While both groups had similar PIRADS distribution, 5-ARI patients had a lower rate of positive biopsies across all PIRADS categories, which may suggest that the use of 5ARI may confound MRI findings. Further studies on how 5-ARI therapy affects the imaging characteristics of prostate cancer should be performed.

A systematic review on the outcomes of local anaesthetic transperineal prostate biopsy

OBJECTIVE

To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy.

METHODS

Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost.

RESULTS

A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45-0.60; I² = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24-0.52; I² = 99%). The rate of infection-related complications in the included studies was 0.15% (95% CI 0.0000-0.0043; I² = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias.

CONCLUSION

Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique.

The use of 68 Ga-PSMA PET/CT to stratify patients with PI-RADS 3 lesions according to clinically significant prostate cancer risk

BACKGROUND

Prostate imaging reporting and data system (PI-RADS) category 3 lesions represent a "gray zone," having an equivocal risk of presenting as clinically significant prostate cancer (csPCa). ⁶⁸ Ga-labelled prostate-specific membrane antigen (⁶⁸ Ga-PSMA) positron emission tomography/computed tomography (PET/CT) has been identified as a diagnostic tool that can help to predict cases of primary PCa. We aimed to explore diagnostic value of ⁶⁸ Ga-PSMA PET/CT for csPCa in PI-RADS 3 lesions to aid in decision-making and avoid unnecessary biopsies.

METHODS

A total of 78 men with PI-RADS 3 lesions who underwent both ⁶⁸ Ga-PSMA PET/CT and transrectal ultrasound/magnetic resonance imaging (MRI) fusion-guided biopsy were enrolled. Images were analyzed by respective physicians who were blinded to the pathological results. Receiver operating characteristic (ROC) curve analysis and decision curve analysis were used to evaluate the diagnostic performance of univariate and multivariate analyses.

RESULTS

A total of 26/78 men had pathologically confirmed csPCa. A lower ADCT/ADCCLP (0.65 vs. 0.71, p = 0.018), smaller prostate volume (25.27 vs. 42.79 ml, p < 0.001), lower free prostate-specific antigen/total prostate-specific antigen (0.11 vs. 0.16, p < 0.001), higher PSA level (13.45 vs. 7.90 ng/ml, p = 0.001), higher PSA density (0.40 vs. 0.16 ng/ml² , p < 0.001), higher SUVmax (9.80 vs. 4.40, p < 0.001) and SUVT/BGp (2.41 vs. 1.00, p < 0.001) were associated with csPCa. ROC analysis illustrated the improvement in SUVmax and SUVT/BGp compared with all independent and combined clinical features as well as multiparametric magnetic resonance imaging (mpMRI) features for csPCa detection. The net benefits of SUVmax and SUVT/BGp were superior to those of other features, respectively. With cutoff values of 5.0 for SUVmax and 1.4 for SUVT/BGp, the diagnostic sensitivity and specificity for csPCa were 96.2%, 100% and 80.8%, 84.6%, respectively.

CONCLUSION

⁶⁸ Ga-PSMA PET/CT is potentially capable of stratifying men with PI-RADS 3 lesions according to the presence of csPCa and has better performance than the model established based on clinical and mpMRI features.

Learning Curve of Transperineal MRI/US Fusion Prostate Biopsy: 4-Year Experience

This study aimed to evaluate the learning curve of transperineal magnetic resonance imaging (MRI)/ultrasound (US) fusion biopsy in a team composed of a single surgeon, a single radiologist, and a single pathologist. We prospectively enrolled 206 patients undergoing MRI/US fusion prostate biopsy and divided them into four cohorts by the year of biopsy. We analyzed temporal changes in clinically significant prostate cancer (csPC) detection rate, percentage of positive cores on biopsy, and Gleason upgrading rate after radical prostatectomy. The csPC detection rate by MRI/US fusion targeted biopsy (TB) increased significantly (from 35.3% to 60.0%, p = 0.01). With increased experience, the csPC detection rates for small (≤1 cm) and anterior target lesions gradually increased (from 41.2% to 51.6%, p = 0.5; from 54.5% to 88.2%, p = 0.8, respectively). The percentage of positive cores on TB increased significantly (from 18.4% to 44.2%, p = 0.001). The Gleason upgrading rate gradually decreased (from 22.2% to 11.1%, p = 0.4). In conclusion, with accumulated experience and teamwork, the csPC detection rate by TB significantly increased. Multidisciplinary team meetings and a free-hand biopsy technique were the key factors for overcoming the learning curve.

Should men undergo MRI before prostate biopsy - CON

Prostate magnetic resonance imaging (MRI) is increasingly used prior to biopsy in response to the overdiagnosis and overtreatment of prostate cancer (CaP) associated with prostate-specific antigen (PSA) based screening. However, technical limitations in the conventional diffusion-weighted imaging (DWI) sequences as well as the high degree of radiologist-to-radiologist variability in interpreting prostate MRI result in inadequate accuracy. Specifically, the insufficient negative predictive value (NPV) of prostate MRI (76%-87%) does not allow biopsy to be omitted in the negative MRI setting. Additionally, the variable, and relatively low positive predictive value (PPV) of MRI (27%-44%) provides only an incremental improvement in risk prediction compared to readily available clinical tools such as the Prostate Cancer Prevention Trial risk calculator. This small benefit is likely confined to the minority of patients with positive MRI findings in a typically under-sampled region of the prostate (e.g., anterior lesions), which may be obviated by newer biopsy approaches and tools such as transperineal prostate biopsy and micro-ultrasound technology. With these considerations in mind, pre-biopsy prostate MRI in its current form is unlikely to provide a clinically significant benefit, and should not be considered as routine practice until its accuracy is sufficiently improved.

Biopsy-Integrated 3D Magnetic Resonance Imaging Modeling of Prostate Cancer and Its Application for Gleason Grade and Tumor Laterality Assessment

CONTEXT.—

Grade Group assessed using Gleason combined score and tumor extent is a main determinant for risk stratification and therapeutic planning of prostate cancer.

OBJECTIVE.—

To develop a 3-dimensional magnetic resonance imaging (MRI) model regarding Grade Group and tumor extent in collaboration with uroradiologists and uropathologists for optimal treatment planning for prostate cancer.

DESIGN.—

We studied the data from 83 patients with prostate cancer who underwent multiparametric MRI and subsequent MRI-transrectal ultrasound fusion biopsy and radical prostatectomy. A 3-dimensional MRI model was constructed by integrating topographic information of MRI-based segmented lesions, biopsy paths, and histopathologic information of biopsy specimens. The multiparametric MRI-integrated Grade Group and laterality were assessed by using the 3-dimensional MRI model and compared with the radical prostatectomy specimen.

RESULTS.—

The MRI-defined index tumor was concordant with radical prostatectomy in 94.7% (72 of 76) of cases. The multiparametric MRI-integrated Grade Group revealed the highest agreement (weighted κ, 0.545) and a significantly higher concordance rate (57.9%) than the targeted (47.8%, P = .008) and systematic (39.4%, P = .01) biopsies. The multiparametric MRI-integrated Grade Group showed significantly less downgrading rates than the combined biopsy (P = .001), without significant differences in upgrading rate (P = .06). The 3-dimensional multiparametric MRI model estimated tumor laterality in 66.2% (55 of 83) of cases, and contralateral clinically significant cancer was missed in 9.6% (8 of 83) of cases. The tumor length measured by multiparametric MRI best correlated with radical prostatectomy as compared with the biopsy-defined length.

CONCLUSIONS.—

The 3-dimensional model incorporating MRI and MRI-transrectal ultrasound fusion biopsy information easily recognized the spatial distribution of MRI-visible and MRI-nonvisible cancer and provided better Grade Group correlation with radical prostatectomy specimens but still requires validation.

Landmarks in the evolution of prostate biopsy

Approaches and techniques used for diagnostic prostate biopsy have undergone considerable evolution over the past few decades: from the original finger-guided techniques to the latest MRI-directed strategies, from aspiration cytology to tissue core sampling, and from transrectal to transperineal approaches. In particular, increased adoption of transperineal biopsy approaches have led to reduced infectious complications and improved antibiotic stewardship. Furthermore, as image fusion has become integral, these novel techniques could be incorporated into prostate biopsy methods in the future, enabling 3D-ultrasonography fusion reconstruction, molecular targeting based on PET imaging and autonomous robotic-assisted biopsy.

Environmental Impact of Prostate Magnetic Resonance Imaging and Transrectal Ultrasound Guided Prostate Biopsy

BACKGROUND

Reducing low-value clinical care is an important strategy to mitigate environmental pollution caused by health care.

OBJECTIVE

To estimate the environmental impacts associated with prostate magnetic resonance imaging (MRI) and prostate biopsy.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cradle-to-grave life cycle assessment of prostate biopsy. Data included materials and energy inventory, patient and staff travel contributed by prostate MRI, transrectal ultrasound guided prostate biopsy, and pathology analysis. We compared environmental emissions across five clinical scenarios: multiparametric MRI (mpMRI) of the prostate with targeted and systematic biopsies (baseline), mpMRI with targeted biopsy cores only, systematic biopsy without MRI, mpMRI with systematic biopsy, and biparametric MRI (bpMRI) with targeted and systematic biopsies. We estimated the environmental impacts associated with reducing the overall number and varying the approach of a prostate biopsy by using MRI as a triage strategy or by omitting MRI. The study involved academic medical centers in the USA, outpatient urology clinics, health care facilities, medical staff, and patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Greenhouse gas emissions (CO₂ equivalents, CO₂e), and equivalents of coal and gasoline burned were measured.

RESULTS AND LIMITATIONS

In the USA, a single transrectal prostate biopsy procedure including prostate MRI, and targeted and systematic biopsies emits an estimated 80.7 kg CO₂e. An approach of MRI targeted cores alone without a systematic biopsy generated 76.2 kg CO₂e, a systematic 12-core biopsy without mpMRI generated 36.2 kg CO₂e, and bpMRI with targeted and systematic biopsies generated 70.5 kg CO₂e; mpMRI alone contributed 42.7 kg CO₂e (54.3% of baseline scenario). Energy was the largest contributor, with an estimated 38.1 kg CO₂e, followed by staff travel (20.7 kg CO₂e) and supply production (11.4 kg CO₂e). Performing 100 000 fewer unnecessary biopsies would avoid 8.1 million kg CO₂e, the equivalent of 4.1 million liters of gasoline consumed. Per 100 000 patients, the use of prostate MRI to triage prostate biopsy and guide targeted biopsy cores would save the equivalent of 1.4 million kg of CO₂ emissions, the equivalent of 700 000 l of gasoline consumed. This analysis was limited to prostate MRI and biopsy, and does not account for downstream clinical management.

CONCLUSIONS

A prostate biopsy contributes a calculable environmental footprint. Modifying or reducing the number of biopsies performed through existing evidence-based approaches would decrease health care pollution from the procedure.

PATIENT SUMMARY

We estimated that prostate magnetic resonance imaging (MRI) with a prostate biopsy procedure emits the equivalent of 80.7 kg of carbon dioxide. Performing fewer unnecessary prostate biopsies or using prostate MRI as a tool to decide which patients should have a prostate biopsy would reduce procedural greenhouse gas emissions and health care pollution.

[Prostate Imaging Reporting and Data System (PI-RADS) v 2.1: Overview and Critical Points]

The technical parameters and imaging interpretation criteria of the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) using multiparametric MRI (mpMRI) are updated in PI-RADS v2.1. These changes have been an expected improvement for prostate cancer evaluation, although some issues remain unsolved, and new issues have been raised. In this review, a brief overview of PI-RADS v2.1 is and several critical points are discussed as follows: the need for more detailed protocols of mpMRI, lack of validation of the revised transition zone interpretation criteria, the need for clarification for the revised diffusion-weighted imaging and dynamic contrast-enhanced imaging criteria, anterior fibromuscular stroma and central zone assessment, assessment of background signal and tumor aggressiveness, changes in the structured report, the need for the parameters for imaging quality and performance control, and indications for expansion of the system to include other indications.

Therapy decisions after diagnosis of prostate cancer in men with negative prostate MRI

BACKGROUND

To investigate the clinical implications of magnetic resonance imaging (MRI) negative prostate cancer (PCa) in a cohort of men undergoing transperineal prostate biopsy.

METHODS

We included all men without prior diagnosis of PCa undergoing transperineal template saturation ± fusion-guided targeted biopsy of the prostate between November 2014 and March 2018. Before biopsy, all patients underwent MRI and biopsies were performed irrespective of imaging results. Baseline characteristics, imaging, biopsy results, and follow-up information were retrieved from the patient charts. Patients were classified as either MRI negative (Prostate Imaging Reporting and Data System [PIRADS] ≤ 2) or positive (PIRADS ≥ 3). ISUP grade group 1 was defined as clinically nonsignificant (nsPCa) and ≥2 as clinically significant PCa (csPCa). Primary outcome was the individual therapeutic decision after diagnosis of PCa stratified according to MRI visibility. Secondary outcomes were the sensitivity and specificity of MRI, and the urooncological outcomes after radical prostatectomy (RP).

RESULTS

From 515 patients undergoing prostate biopsy, 171 (33.2%) patients had a negative and 344 (66.8%) a positive MRI. Pathology review stratified for MRI negative and positive cases revealed nsPCa in 27 (15.8%) and 32 (9.3%) and csPCa in 26 (15.2%) and 194 (56.4%) of the patients, respectively. The rate of active treatment in the MRI negative was lower compared with the MRI positive cohort (12.3% vs. 53.2%; odd ratio [OR] = 0.12; p < 0.001). While men with negative MRI were more likely to undergo active surveillance (AS) than MRI positive patients (18.1% vs. 10.8%; OR = 1.84; p = 0.027), they rarely underwent RP (6.4% vs. 40.7%, OR = 0.10; p < 0.001). Logistic regression revealed that a negative MRI was independently protective for active treatment (OR = 0.32, p = 0.014). The specificity, sensitivity, negative, and positive predictive value of MRI for detection of csPCa were 49.2%, 88.2%, 56.4%, and 84.8%, respectively. The rate of adverse clinicopathological outcome features (pT3/4, ISUP ≥4, or prostate-specific antigen [PSA]-persistence) following RP was 4.7% for men with MRI negative compared to 17.4% for men with MRI positive PCa (OR = 3.1, p = 0.19).

CONCLUSION

Only few men with MRI negative PCa need active cancer treatment at the time of diagnosis, while the majority opts for AS. Omitting prostate biopsies and performing a follow-up MRI may be a safe alternative to reduce the number of unnecessary interventions.

Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway

Multiparametric MRI of the prostate is now recommended as the initial diagnostic test for men presenting with suspected prostate cancer, with a negative MRI enabling safe avoidance of biopsy and a positive result enabling MRI-directed sampling of lesions. The diagnostic pathway consists of several steps, from initial patient presentation and preparation to performing and interpreting MRI, communicating the imaging findings, outlining the prostate and intra-prostatic target lesions, performing the biopsy and assessing the cores. Each component of this pathway requires experienced clinicians, optimized equipment, good inter-disciplinary communication between specialists, and standardized workflows in order to achieve the expected outcomes. Assessment of quality and mitigation measures are essential for the success of the MRI-directed prostate cancer diagnostic pathway. Quality assurance processes including Prostate Imaging-Reporting and Data System, template biopsy, and pathology guidelines help to minimize variation and ensure optimization of the diagnostic pathway. Quality control systems including the Prostate Imaging Quality scoring system, patient-level outcomes (such as Prostate Imaging-Reporting and Data System MRI score assignment and cancer detection rates), multidisciplinary meeting review and audits might also be used to provide consistency of outcomes and ensure that all the benefits of the MRI-directed pathway are achieved.

Assessing the Role of High-resolution Microultrasound Among Naïve Patients with Negative Multiparametric Magnetic Resonance Imaging and a Persistently High Suspicion of Prostate Cancer

Background

Multiparametric magnetic resonance imaging (mpMRI) is an invaluable diagnostic tool in the decision-making for prostate biopsies (PBx). However, a non-negligible proportion of patients with negative MRI (nMRI) may still harbour prostate cancer (PCa).

Objective

To assess whether microultrasound (micro-US) can help in substratifying the presence of PCa and clinically significant PCa (csPCa; ie, any Gleason score ≥7 PCa) in patients with nMRI despite a persistently high clinical suspicion of PCa.

Design setting and participants

A total of 125 biopsy-naïve patients who underwent micro-US-guided PBx with the ExactVu system for a persistently high suspicion of PCa despite nMRI were prospectively enrolled.

Intervention

The Prostate Risk Identification using micro-US (PRI-MUS) protocol was used to identify suspicious areas; PBx included targeted sampling of PRI-MUS ≥3 areas and systematic sampling.

Outcome measurements and statistical analysis

The primary endpoint was the assessment of micro-US diagnostic accuracy in detecting csPCa. Secondary endpoints included determining the proportion of patients with nMRI who may avoid PBx after micro-US or transrectal US, presence of cribriform and intraductal patterns on biopsy core examination, predictors of csPCa in patients presenting with nMRI, and comparing micro-US-targeted and systematic PBx in identifying csPCa.

Results and limitations

Considering csPCa detection rate, micro-US showed optimal sensitivity and negative predictive value (respectively, 97.1% and 96.4%), while specificity and positive predictive value were 29.7% and 34.0%, respectively. Twenty-eight (22.4%) patients with a negative micro-US examination could have avoided PBx with one (2.9%) missed csPCa. Cribriform and intraductal patterns were found in 14 (41.2%) and four (11.8%) of csPCa patients, respectively. In multivariable logistic regression models, positive micro-US, age, digital rectal examination, and prostate-specific antigen density ≥0.15 emerged as independent predictors of PCa. Targeted and systematic sampling identified 33 (97.1%) and 26 (76.5%) csPCa cases, respectively. The main limitation of the current study is represented by its retrospective single-centre nature on an operator-dependent technology.

Conclusions

Micro-US represents a valuable tool to rule out the presence of csPCa among patients with a persistent clinical suspicion despite nMRI.

Patient summary

According to our results, microultrasound (micro-US) may represent an effective tool for the diagnosis of clinically significant prostate cancer in patients with negative magnetic resonance imaging (nMRI), providing high sensitivity and negative predictive value. Further randomised studies are needed to confirm the potential role of micro-US in the diagnostic pathway of patients with a persistent suspicion of prostate cancer despite nMRI.

A prospective study of cancer detection rates following early repeat imaging and biopsy of PI-RADS 4 and 5 regions of interest exhibiting no clinically significant prostate cancer on prior biopsy

INTRODUCTION

We aimed to determine cancer detection rates following early repeat multiparametric magnetic resonance imaging (mpMRI) and biopsy of Prostate Imaging-Reporting and Data System (PI-RADS), v2.1 4 and 5 regions of interest (ROI) exhibiting no clinically significant prostate cancer (csPCa) on prior biopsy and to identify predictors for these missed csPCa.

METHODS

Between January 2019 and August 2020, 36 men with 38 PI-RADS 4 or 5 ROI with no evidence of csPCa (defined as Gleason grade group [GGG] >1) on prior MRI fusion target biopsy (MRFTB) + systematic biopsy (SB) were invited to participate in the present prospective study. All men underwent repeat mpMRI and persistent PI-RADS >2 ROI were advised to undergo repeat MRFTB + SB. Cancer detection rates of any and csPCa were determined. Relative risk was calculated to analyze association of baseline variables with the finding of csPCa on repeat biopsy.

RESULTS

Of the 38 initial PI-RADS 4 and 5 ROI, on followup mpMRI, 14 were downgraded to PI-RADS 1/2 and, per protocol, did not undergo repeat biopsy and; eight (33%), 12 (50%), and four (17%) were PI-RADS 3, 4, and 5, respectively. Of these 24 persistently suspicious mpMRI ROI, 20 (83%) underwent repeat biopsy and six (30%), six (30%), and eight (40%) were benign, GGG 1, and GGG >1, respectively. Only prostate-specific antigen ≥10 ng/mL was a predictor for missed csPCa.

CONCLUSIONS

Our prospective study supports a recommendation for early repeat mpMRI of all PI-RADS 4 or 5 ROI exhibiting no csPCa, with repeat MRFTB + SB of persistent PI-RADS >2 ROI.

Transperineal Ultrasound Before and After Prostatectomy: Technical Approach and Description

This study assessed the feasibility of dynamic transperineal ultrasound (TPUS) pre/post-radical prostatectomy (RP). Ninety-eight patients were scanned pre-operatively and at four time-points post-operatively. TPUS was performed in 98 patients using an abdominal transducer at rest, during pelvic floor contraction (PFC) and Valsalva (VS) maneuver in supine and standing positions. Urodynamic evaluations included bladder neck angle at rest/PFC/VS, and degree of bladder neck movement. Pre-operative and post-operative measurements were technically feasible in >85% (supine) and >90% (standing) of patients. TPUS offers a reliable non-invasive dynamic assessment of the pelvic floor post-prostatectomy and may prove a useful adjunct for guiding exercises to preserve continence.

Amide Proton Transfer Could Provide More Accurate Lesion Characterization in the Transition Zone of the Prostate

BACKGROUND

There is an overlap comparing transition zone prostate cancer (TZ PCa) and benign prostatic hyperplasia (BPH) on T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI), creating additional challenges for assessment of TZ tumors on MRI.

PURPOSE

To evaluate whether amide proton transfer-weighted (APTw) imaging provides new diagnostic ideas for TZ PCa.

STUDY TYPE

Prospective.

POPULATION

A total of 51 TZ PCa patients (age, 49-89), 44 stromal BPH (age, 57-92), and 45 glandular BPH patients (age, 56-92).

FIELD STRENGTH/SEQUENCE

A 3 T; T2WI turbo spin echo (TSE), quantitative T2*-weighted imaging, DWI echo planar imaging, 3D APTw TSE.

ASSESSMENT

Differences in APTw, apparent diffusion coefficient (ADC), and T2* among three lesions were compared by one-way analysis of variance (ANOVA). Regions of interest were drawn by two radiologists (X.Q.Z. and X.Y.Q., with 21 and 15 years of experience, respectively).

STATISTICAL TESTS

Multivariable logistic regression analyses; ANOVA with post hoc testing; receiver operator characteristic curve analysis; Delong test. Significance level: P < 0.05.

RESULTS

APTw among TZ PCa, stromal BPH, and glandular BPH (3.48% ± 0.83% vs. 2.76% ± 0.49% vs. 2.72% ± 0.45%, respectively) were significantly different except between stromal BPH and glandular BPH (P > 0.99). Significant differences were found in ADC (TZ PCa 0.76 ± 0.16 × 10^-3  mm² /sec vs. stromal BPH 0.91 ± 0.14 × 10^-3  mm² /sec vs. glandular BPH 1.08 ± 0.18 × 10^-3  mm² /sec) among three lesions. APTw (OR = 12.18, 11.80, respectively) and 1/ADC (OR = 703.87, 181.11, respectively) were independent predictors of TZ PCa from BPH and stromal BPH. The combination of APTw and ADC had better diagnostic performance in the identification of TZ PCa from BPH and stromal BPH.

DATA CONCLUSION

APTw imaging has the potential to be of added value to ADC in differentiating TZ PCa from BPH and stromal BPH.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy

OBJECTIVES

We aimed to develop and compare strategies that help optimize current prostate biopsy practice by identifying patients who may forgo concurrent systematic biopsy (SBx) in favor of MRI-targeted (TBx) alone.

METHODS

Retrospective study on 745 patients who underwent combined MRI-TBx plus SBx. Primary outcome was the upgrade to clinically significant prostate cancer (csPCa; grade group ≥ 2) on SBx versus MRI-TBx. Variables (age, previous biopsy status, Prostate Imaging Reporting and Data System (PI-RADS) score, index lesion size/location, number of lesions, PSA, PSA density, prostate volume) associated with the primary outcome were identified by logistic regression and used for biopsy strategies. Clinical utility was assessed by decision curve analysis (DCA).

RESULTS

SBx detected 47 (6%) additional men with csPCa. The risk of detecting csPCa uniquely on SBx was significantly lower in men with PI-RADS 5 (versus PI-RADS 3: OR 0.30, p = 0.03; versus PI-RADS 4: OR 0.33, p = 0.01), and previous negative biopsy (versus previous positive biopsy: OR 0.40, p = 0.007), and increased with age (per 10 years: OR 1.64, p = 0.016). No significant association was observed for other variables. DCA identified the following strategies as most useful: (a) avoid SBx in men with PI-RADS 5 and (b) additionally in those with previous negative biopsy, resulting in avoiding SBx in 201 (27%) and 429 (58%), while missing csPCa in 5 (1%) and 15 (2%) patients, respectively.

CONCLUSION

Not all men benefit equally from the combination of SBx and MRI-TBx. SBx avoidance in men with PI-RADS 5 and/or previous negative biopsy may reduce the risk of excess biopsies with a low risk of missing csPCa.

KEY POINTS

• In men undergoing MRI-targeted biopsy, the risk of detecting clinically significant prostate cancer (csPCa) only on additional systematic biopsy (SBx) decreased in men with PI-RADS 5, previous negative biopsy, and younger age. • Using these variables may help select men who could avoid the risk of excess SBx. • If missing csPCa in 5% was acceptable, forgoing SBx in men with PI-RADS 5 and/or previous negative biopsy enabled the highest net reduction in SBx.

Comparison of Multiparametric and Fast MRI Protocols in Detecting Clinically Significant Prostate Cancer and a Detailed Cost Analysis

BACKGROUND

Due to the long acquisition time and high cost of multiparametric magnetic resonance imaging (mpMRI), biparametric and, more recently, fast prostate magnetic resonance imaging (fpMRI) protocols have been described. However, there is insufficient data about the diagnostic performance and cost of fpMRI.

PURPOSE

To compare the diagnostic performances and cost analysis of fpMRI and mpMRI in clinically significant prostate cancer (csPCA).

STUDY TYPE

Retrospective.

POPULATION

A total of 103 patients (63 had csPCA) with a mean age of 66.83 (± 7.22) years were included.

FIELD STRENGTH/SEQUENCE

A 1.5-T; T1- and T2-weighted turbo spin-echo imaging (T1WI and T2WI), echo-planar diffusion-weighted images, and dynamic contrast-enhanced T1W imaging.

ASSESSMENT

Three readers independently evaluated the fpMRI and mpMRI images in different sessions blinded to all patient information. Diagnostic performances of fpMRI and mpMRI were evaluated. Kappa coefficient (κ) was used to determine the interreader and intrareader agreement. A detailed cost analysis was performed for each protocol.

STATISTICAL TESTS

Receiver operating characteristics analysis, area under the curve (AUC), and κ test were used. Diagnostic performance parameters were also calculated.

RESULTS

Of the 63 malignant index lesions (csPCA), 53/63 of those (84.1%) originated from the peripheral zone and 10/63 lesions (15.9%) originated from the transition zone. The AUC values for fpMRI were 0.878 for reader 1, 0.937 for reader 2, and 0.855 for reader 3. For mpMRI, the AUC values were 0.893 for reader 1, 0.94 for reader 2, and 0.862 for reader 3. Inter and intrareader agreements were moderate to substantial (κ range, 0.5-0.79). The total cost per examination was calculated as €12.39 and €30.10 for fpMRI and mpMRI, respectively.

DATA CONCLUSIONS

Fast MRI protocol has similar diagnostic performance with mpMRI in detecting csPCA, and fpMRI can be considered an alternative protocol that could create a lower financial burden on health-care systems.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 6.

Cross-Modality Image Registration Using a Training-Time Privileged Third Modality

In this work, we consider the task of pairwise cross-modality image registration, which may benefit from exploiting additional images available only at training time from an additional modality that is different to those being registered. As an example, we focus on aligning intra-subject multiparametric Magnetic Resonance (mpMR) images, between T2-weighted (T2w) scans and diffusion-weighted scans with high b-value (DWI [Formula: see text]). For the application of localising tumours in mpMR images, diffusion scans with zero b-value (DWI [Formula: see text]) are considered easier to register to T2w due to the availability of corresponding features. We propose a learning from privileged modality algorithm, using a training-only imaging modality DWI [Formula: see text], to support the challenging multi-modality registration problems. We present experimental results based on 369 sets of 3D multiparametric MRI images from 356 prostate cancer patients and report, with statistical significance, a lowered median target registration error of 4.34 mm, when registering the holdout DWI [Formula: see text] and T2w image pairs, compared with that of 7.96 mm before registration. Results also show that the proposed learning-based registration networks enabled efficient registration with comparable or better accuracy, compared with a classical iterative algorithm and other tested learning-based methods with/without the additional modality. These compared algorithms also failed to produce any significantly improved alignment between DWI [Formula: see text] and T2w in this challenging application.

Prostate MRI Qualification: AJR Expert Panel Narrative Review

Prostate MRI is now established as a first-line investigation for individuals presenting with suspected localized or locally advanced prostate cancer. Successful delivery of the MRI-directed pathway for prostate cancer diagnosis relies on high-quality imaging as well as the interpreting radiologist's experience and expertise. Radiologist certification in prostate MRI may help limit interreader variability, optimize outcomes, and provide individual radiologists with documentation of meeting predefined standards. This AJR Expert Panel Narrative Review summarizes existing certification proposals, recognizing variable progress across regions in establishing prostate MRI certification programs. To our knowledge, Germany is the only country with a prostate MRI certification process that is currently available for radiologists. However, prostate MRI certification programs have also recently been proposed in the United States and United Kingdom and by European professional society consensus panels. Recommended qualification processes entail a multifaceted approach, incorporating components such as minimum case numbers, peer learning, course participation, continuing medical education credits, and feedback from pathology results. Given the diversity in health care systems, including in the provision and availability of MRI services, national organizations will likely need to take independent approaches to certification and accreditation. The relevant professional organizations should begin developing these programs or continue existing plans for implementation.

Combining targeted and systematic prostate biopsy improves prostate cancer detection and correlation with the whole mount histopathology in biopsy naïve and previous negative biopsy patients

Objective

Guidelines for previous negative biopsy (PNB) cohorts with a suspicion of prostate cancer (PCa) after positive multiparametric (mp) magnetic-resonance-imaging (MRI) often favour the fusion-guided targeted prostate-biopsy (TB) only approach for Prostate Imaging-Reporting and Data System (PI-RADS) ≥3 lesions. However, recommendations lack direct biopsy performance comparison within biopsy naïve (BN) vs. PNB patients and its prognostication of the whole mount pathology report (WMPR), respectively. We suppose, that the combination of TB and concomitant TRUS-systematic biopsy (SB) improves the PCa detection rate of PI-RADS 2, 3, 4 or 5 lesions and the International Society of Urological Pathology (ISUP)-grade predictability of the WMPR in BN- and PNB patients.

Methods

Patients with suspicious mpMRI, elevated prostate-specific-antigen and/or abnormal digital rectal examination were included. All PI-RADS reports were intramurally reviewed for biopsy planning. We compared the PI-RADS score substratified TB, SB or combined approach (TB/SB) associated BN- and PNB-PCa detection rate. Furthermore, we assessed the ISUP-grade variability between biopsy cores and the WMPR.

Results

According to BN (n = 499) vs. PNB (n = 314) patients, clinically significant (cs) PCa was detected more frequently by the TB/SB approach (62 vs. 43%) than with the TB (54 vs. 34%) or SB (57 vs. 34%) (all p < 0.0001) alone. Furthermore, we observed that the TB/SB strategy detects a significantly higher number of csPCa within PI-RADS 3, 4 or 5 reports, both in BN and PNB men. In contrast, applied biopsy techniques were equally effective to detect csPCa within PI-RADS 2 lesions. In case of csPCa diagnosis the TB approach was more often false-negative in PNB patients (BN 11% vs. PNB 19%; p = 0.02). The TB/SB technique showed in general significantly less upgrading, whereas a higher agreement was only observed for the total and BN patient cohort.

Conclusion

Despite csPCa is more frequently found in BN patients, the TB/SB method always detected a significantly higher number of csPCa within PI-RADS 3, 4 or 5 reports of our BN and PNB group. The TB/SB strategy predicts the ISUP-grade best in the total and BN cohort and in general shows the lowest upgrading rates, emphasizing its value not only in BN but also PNB patients.

Diagnostic value of combining PI-RADS v2.1 with PSAD in clinically significant prostate cancer

PURPOSE

To investigate the diagnostic value of the Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1) for clinically significant prostate cancer (CsPCa). We also aimed to combine PI-RADS v2.1 with prostate-specific antigen (PSA) derivatives to improve the predictive value of CsPCa.

METHODS

We retrospectively collected relevant data who underwent standard MRI examinations of the prostate and subjected to a prostate biopsy at Shenzhen People's hospital from November 2014 to November 2019. Included 125 cases of CsPCa and 383 cases of non-CsPCa. All cases were scored using the PI-RADS v2.1. The clinical data collected included age, PSA, free PSA/total PSA, prostate volume and PSA density (PSAD). A univariate analysis was performed to identify statistically significant indicators. Logistic regression was used to analyze the predictive value of the multi-parameter combination on CsPCa.

RESULTS

Except age, the difference in all of indicators between the CsPCa group and non-CsPCa group was statistically significant. The PI-RADS score and PSAD value had the highest diagnostic value. Logistic regression analysis revealed that the PI-RADS score and PSAD value were independent predictors of CsPCa, with a regression model AUC of 0.935. CsPCa detection rates were low when the PI-RADS score ≤ 2 or the PI-RADS score = 3 and the PSAD value ≤ 0.33 ng/ml/ml.

CONCLUSION

Combining the PI-RADS score and PSAD value improved the predictive performance of CsPCa. Patients with a PI-RADS score ≤ 2 or a PI-RADS score = 3 and a PSAD value ≤ 0.33 ng/ml/ml can avoid an unnecessary biopsy.

Magnetic Resonance Imaging-Based Predictive Models for Clinically Significant Prostate Cancer: A Systematic Review

Simple Summary

Magnetic resonance imaging (MRI) has allowed the early detection of PCa to evolve towards clinically significant PCa (csPCa), decreasing unnecessary prostate biopsies and overdetection of insignificant tumours. MRI identifies suspicious lesions of csPCa, predicting the semi-quantitative risk through the prostate imaging report and data system (PI-RADS), and enables guided biopsies, increasing the sensitivity of csPCa. Predictive models that individualise the risk of csPCa have also evolved adding PI-RADS score (MRI-PMs), improving the selection of candidates for prostate biopsy beyond the PI-RADS category. During the last five years, many MRI-PMs have been developed. Our objective is to analyse the current developed MRI-PMs and define their clinical usefulness through a systematic review. We have found high heterogeneity between MRI technique, PI-RADS versions, biopsy schemes and approaches, and csPCa definitions. MRI-PMs outperform the selection of candidates for prostate biopsy beyond MRI alone and PMs based on clinical predictors. However, few developed MRI-PMs are externally validated or have available risk calculators (RCs), which constitute the appropriate requirements used in routine clinical practice.

Abstract

MRI can identify suspicious lesions, providing the semi-quantitative risk of csPCa through the Prostate Imaging-Report and Data System (PI-RADS). Predictive models of clinical variables that individualise the risk of csPCa have been developed by adding PI-RADS score (MRI-PMs). Our objective is to analyse the current developed MRI-PMs and define their clinical usefulness. A systematic review was performed after a literature search performed by two independent investigators in PubMed, Cochrane, and Web of Science databases, with the Medical Subjects Headings (MESH): predictive model, nomogram, risk model, magnetic resonance imaging, PI-RADS, prostate cancer, and prostate biopsy. This review was made following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and studied eligibility based on the Participants, Intervention, Comparator, and Outcomes (PICO) strategy. Among 723 initial identified registers, 18 studies were finally selected. Warp analysis of selected studies was performed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Clinical predictors in addition to the PI-RADS score in developed MRI-PMs were age, PCa family history, digital rectal examination, biopsy status (initial vs. repeat), ethnicity, serum PSA, prostate volume measured by MRI, or calculated PSA density. All MRI-PMs improved the prediction of csPCa made by clinical predictors or imaging alone and achieved most areas under the curve between 0.78 and 0.92. Among 18 developed MRI-PMs, 7 had any external validation, and two RCs were available. The updated PI-RADS version 2 was exclusively used in 11 MRI-PMs. The performance of MRI-PMs according to PI-RADS was only analysed in a single study. We conclude that MRI-PMs improve the selection of candidates for prostate biopsy beyond the PI-RADS category. However, few developed MRI-PMs meet the appropriate requirements in routine clinical practice.

Multi-institutional analysis of clinical and imaging risk factors for detecting clinically significant prostate cancer in men with PI-RADS 3 lesions

BACKGROUND

Most Prostate Imaging-Reporting and Data System (PI-RADS) 3 lesions do not contain clinically significant prostate cancer (CSPCa; grade group ≥2). This study was aimed at identifying clinical and magnetic resonance imaging (MRI)-derived risk fac- tors that predict CSPCa in men with PI-RADS 3 lesions.

METHODS

This study analyzed the detection of CSPCa in men who underwent MRI-targeted biopsy for PI-RADS 3 lesions. Multivariable logistic regression models with goodness-of-fit testing were used to identify variables associated with CSPCa. Receiver operating curves and decision curve analyses were used to estimate the clinical utility of a predictive model.

RESULTS

Of the 1784 men reviewed, 1537 were included in the training cohort, and 247 were included in the validation cohort. The 309 men with CSPCa (17.3%) were older, had a higher prostate-specific antigen (PSA) density, and had a greater likelihood of an anteriorly located lesion than men without CSPCa (p < .01). Multivariable analysis revealed that PSA density (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.05-1.85; p < .01), age (OR, 1.05; 95% CI, 1.02-1.07; p < .01), and a biopsy-naive status (OR, 1.83; 95% CI, 1.38-2.44) were independently associated with CSPCa. A prior negative biopsy was negatively associated (OR, 0.35; 95% CI, 0.24-0.50; p < .01). The application of the model to the validation cohort resulted in an area under the curve of 0.78. A predicted risk threshold of 12% could have prevented 25% of biopsies while detecting almost 95% of CSPCas with a sensitivity of 94% and a specificity of 34%.

CONCLUSIONS

For PI-RADS 3 lesions, an elevated PSA density, older age, and a biopsy-naive status were associated with CSPCa, whereas a prior negative biopsy was negatively associated. A predictive model could prevent PI-RADS 3 biopsies while missing few CSPCas.

LAY SUMMARY

Among men with an equivocal lesion (Prostate Imaging-Reporting and Data System 3) on multiparametric magnetic resonance imaging (mpMRI), those who are older, those who have a higher prostate-specific antigen density, and those who have never had a biopsy before are at higher risk for having clinically significant prostate cancer (CSPCa) on subsequent biopsy. However, men with at least one negative biopsy have a lower risk of CSPCa. A new predictive model can greatly reduce the need to biopsy equivocal lesions noted on mpMRI while missing only a few cases of CSPCa.

Longitudinal Changes and Predictive Value of Multiparametric MRI Features for Prostate Cancer Patients Treated with MRI-Guided Lattice Extreme Ablative Dose (LEAD) Boost Radiotherapy

We investigated the longitudinal changes in multiparametric MRI (mpMRI) (T2-weighted, Apparent Diffusion Coefficient (ADC), and Dynamic Contrast Enhanced (DCE-)MRI) of prostate cancer patients receiving Lattice Extreme Ablative Dose (LEAD) radiotherapy (RT) and the capability of their imaging features to predict RT outcome based on endpoint biopsies. Ninety-five mpMRI exams from 25 patients, acquired pre-RT and at 3-, 9-, and 24-months post-RT were analyzed. MRI/Ultrasound-fused biopsies were acquired pre- and at two-years post-RT (endpoint). Five regions of interest (ROIs) were analyzed: Gross tumor volume (GTV), normally-appearing tissue (NAT) and peritumoral volume in both peripheral (PZ) and transition (TZ) zones. Diffusion and perfusion radiomics features were extracted from mpMRI and compared before and after RT using two-tailed Student t-tests. Selected features at the four scan points and their differences (Δ radiomics) were used in multivariate logistic regression models to predict the endpoint biopsy positivity. Baseline ADC values were significantly different between GTV, NAT-PZ, and NAT-TZ (p-values < 0.005). Pharmaco-kinetic features changed significantly in the GTV at 3-month post-RT compared to baseline. Several radiomics features at baseline and three-months post-RT were significantly associated with endpoint biopsy positivity and were used to build models with high predictive power of this endpoint (AUC = 0.98 and 0.89, respectively). Our study characterized the RT-induced changes in perfusion and diffusion. Quantitative imaging features from mpMRI show promise as being predictive of endpoint biopsy positivity.

Evaluation of transabdominal and transperineal ultrasound-derived prostate specific antigen (PSA) density and clinical utility compared to MRI prostate volumes: A feasibility study

Purpose

To investigate the accuracy of surface-based ultrasound-derived PSA-density (US-PSAD) versus gold-standard MRI-PSAD as a risk-stratification tool.

Methods

Single-centre prospective study of patients undergoing MRI for suspected prostate cancer (PCa). Four combinations of US-volumes were calculated using transperineal (TP) and transabdominal (TA) views, with triplanar measurements to calculate volume and US-PSAD. Intra-class correlation coefficient (ICC) was used to compare US and MRI volumes. Categorical comparison of MRI-PSAD and US-PSAD was performed at PSAD cut-offs <0.15, 0.15–0.20, and >0.20 ng/mL² to assess agreement with MRI-PSAD risk-stratification decisions.

Results

64 men were investigated, mean age 69 years and PSA 7.0 ng/mL. 36/64 had biopsy-confirmed prostate cancer (18 Gleason 3+3, 18 Gleason ≥3+4). Mean MRI-derived gland volume was 60 mL, compared to 56 mL for TA-US, and 65 mL TP-US. ICC demonstrated good agreement for all US volumes with MRI, with highest agreement for transabdominal US, followed by combined TA/TP volumes. Risk-stratification decisions to biopsy showed concordant agreement between triplanar MRI-PSAD and ultrasound-PSAD in 86–91% and 92–95% at PSAD thresholds of >0.15 ng/mL² and >0.12 ng/mL², respectively. Decision to biopsy at threshold >0.12 ng/mL², demonstrated sensitivity ranges of 81–100%, specificity 85–100%, PPV 86–100% and NPV 83–100%. Transabdominal US provided optimal sensitivity of 100% for this clinical decision, with specificity 85%, and transperineal US provided optimal specificity of 100%, with sensitivity 87%.

Conclusion

Transperineal-US and combined TA-TP US-derived PSA density values compare well with standard MRI-derived values and could be used to provide accurate PSAD at presentation and inform the need for further investigations.

Diagnostic value of 3.0 T versus 1.5 T MRI in staging prostate cancer: systematic review and meta-analysis

Purpose

To compare the diagnostic performance of 3.0 T and 1.5 T MRI in the staging of prostate cancer.

Material and methods

English-language studies on the diagnostic accuracy of 3.0 T and 1.5 T MRI in prostate cancer staging published through May 2020 were searched for in relevant databases. The focus was on studies in which both 3.0 T and 1.5 T MRI were performed in the study population, to reduce interstudy heterogeneity. Pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve were determined for 3.0 T and for 1.5 T along with 95% confidence intervals (CIs).

Results

Out of 8 studies identified, 4 met the inclusion criteria. 3.0 T (n = 160) had a pooled sensitivity of 69.5% (95% CI: 56.4-80.1%) and a pooled specificity of 48.8% (95% CI: 6.0-93.4%), while 1.5 T (n = 139) had a pooled sensitivity of 70.6% (95% CI: 55.0-82.5%; p = 0.91) and a pooled specificity of 41.7% (95% CI: 6.2-88.6%; p = 0.88). The pooled DOR for 3.0 T was 3 (95% CI: 0-26.0%), while the pooled DOR for 1.5 T was 2 (95% CI: 0-18.0%), which was not a significant difference (p = 0.89).

Conclusions

3.0 T has slightly better diagnostic performance than 1.5 T MRI in prostate cancer staging (3 vs. 2), although without statistical significance. Our findings suggest the need for larger, randomized trials directly comparing 3.0 T and 1.5 T MRI in prostate cancer.

Effect of Bicalutamide Combined with Docetaxel on Serum PSA and VEGF Levels in Patients with Advanced Prostate Carcinoma

Objective. To investigate the effect of bicalutamide combined with docetaxel on the levels of prostate-specific antigen (PSA) in serum and vascular endothelial growth factor (VEGF) in patients with advanced prostate carcinoma (PCa). Methods. The clinical data of 103 patients with advanced PCa at our hospital between Feb. 2020 and Feb. 2021 were retrospectively analyzed, the 90 of whom screened by inclusion and exclusion criteria were finally chosen as research objects. They were divided into a control group and an experimental group according to the order of admission, with 45 cases in each group. The control group was treated with conventional treatment, while the experimental group underwent the combination of bicalutamide and docetaxel, and the clinical indices of the two groups were compared. Results. After treatment, the serum indices in the experimental group were remarkably lower than those in the control group ( $P<0.001$ ), with remarkably lower incidence of toxic and side effects ( $P<0.05$ ) and higher Expanded Prostate Cancer Index Composite (EPIC) scores ( $P<0.001$ ) in the experimental group than in the control group. Conclusion. The implementation of bicalutamide combined with docetaxel in patients with advanced PCa is effective in reducing the inflammatory expression and improving quality of life and has a higher safety profile. Compared with conventional treatment, this method is of high application value, and further studies will help establish a better solution for such patients.

Canadian Association of Radiologists Prostate MRI White Paper

Prostate cancer is the most common malignancy and the third most common cause of death in Canadian men. In light of evolving diagnostic pathways for prostate cancer and the increased use of MRI, which now includes its use in men prior to biopsy, the Canadian Association of Radiologists established a Prostate MRI Working Group to produce a white paper to provide recommendations on establishing and maintaining a Prostate MRI Programme in the context of the Canadian healthcare system. The recommendations, which are based on available scientific evidence and/or expert consensus, are intended to maintain quality in image acquisition, interpretation, reporting and targeted biopsy to ensure optimal patient care. The paper covers technique, reporting, quality assurance and targeted biopsy considerations and includes appendices detailing suggested reporting templates, quality assessment tools and sample image acquisition protocols relevant to the Canadian healthcare context.

Follow-up of men with a PI-RADS 4/5 lesion after negative MRI/Ultrasound fusion biopsy

Magnetic resonance imaging/Ultrasound (MRI/US) fusion targeted biopsy (TB) in combination with a systematic biopsy (SB) improves cancer detection but limited data is available how to manage patients with a Prostate Imaging-Reporting and Data System (PI-RADS) ≥ 4 lesion and a negative biopsy. We evaluate the real-world management and the rate of clinically significant Prostate Cancer (csPCa) during follow-up. 1546 patients with a multi-parametric MRI (mpMRI) and a PI-RADS ≥ 3 who underwent SB and TB between January 2012 and May 2017 were retrospectively analyzed. 222 men with a PI-RADS ≥ 4 and a negative biopsy were included until 2019. For 177/222 (80%) complete follow-up data was obtained. 66/84 (78%) had an initial PI-RADS 4 and 18 (22%) a PI-RADS 5 lesion. 48% (84/177) received a repeat mpMRI; in the follow-up mpMRI, 39/84 (46%) lesions were downgraded to PI-RADS 2 and 11 (13%) to PI-RADS 3; three cases were upgraded and 28 lesions remained consistent. 18% (32/177) men underwent repeated TB and csPCa was detected in 44% (14/32). Our study presents real world data on the management of men with a negative TB biopsy. Men with a positive mpMRI and lesions with high suspicion (PI-RADS4/5) and a negative targeted biopsy should be critically reviewed and considered for repeat biopsy or strict surveillance. The optimal clinical risk assessment remains to be further evaluated.

The role of multiparametric ultrasound in the detection of clinically significant prostate cancer

PURPOSE

Transrectal ultrasound (US) imaging is paramount to the successful completion of prostate biopsies. Certain US features have been associated with prostate cancer (PCa), but their utility remains controversial. We explored the role of multiparametric US (mpUS) in the detection of clinically significant PCa.

METHODS

We performed a retrospective cohort study to contrast the findings of prostate MRI and mpUS. Patients who underwent MRI, US and biopsy between 2015 and 2021 were included. Biopsies were performed using a systematic approach (12 cores), as well as with MRI (4 cores/lesion) and US (1 core/lesion) targeting. The US features analyzed consisted of: calcifications, hypoechoic lesions and power or color Doppler positivity. Gleason 3 + 4 or higher was used as to define true positives. Measures of diagnostic accuracy were calculated for the different imaging modalities.

RESULTS

The final cohort included 74 patients, of which 24 (32.4%) had clinically significant PCa. The concordance between MRI and US was 63.5%. Seven individuals with discordant results had clinically significant PCa. MRI alone was more sensitive (87.5% vs 75%) but less specific (28% vs 32%) than US alone. An all-inclusive approach considering any suspicious US or MRI finding had a sensitivity of 95.8%. A more restrictive approach, targeting lesions noted in both US and MRI, yielded the highest specificity (50.0%) and accuracy (55.4%).

CONCLUSION

Biopsy targeting based on US findings can provide additional diagnostic information that may increase sensitivity or specificity. Additional research into this topic could open the door to a more personalized approach to prostate biopsy.

Dictionary learning compressed sensing reconstruction: pilot validation of accelerated echo planar J-resolved spectroscopic imaging in prostate cancer

Objectives

This study aimed at developing dictionary learning (DL) based compressed sensing (CS) reconstruction for randomly undersampled five-dimensional (5D) MR Spectroscopic Imaging (3D spatial + 2D spectral) data acquired in prostate cancer patients and healthy controls, and test its feasibility at 8x and 12x undersampling factors.

Materials and methods

Prospectively undersampled 5D echo-planar J-resolved spectroscopic imaging (EP-JRESI) data were acquired in nine prostate cancer (PCa) patients and three healthy males. The 5D EP-JRESI data were reconstructed using DL and compared with gradient sparsity-based Total Variation (TV) and Perona-Malik (PM) methods. A hybrid reconstruction technique, Dictionary Learning-Total Variation (DLTV), was also designed to further improve the quality of reconstructed spectra.

Results

The CS reconstruction of prospectively undersampled (8x and 12x) 5D EP-JRESI data acquired in prostate cancer and healthy subjects were performed using DL, DLTV, TV and PM. It is evident that the hybrid DLTV method can unambiguously resolve 2D J-resolved peaks including myo-inositol, citrate, creatine, spermine and choline.

Conclusion

Improved reconstruction of the accelerated 5D EP-JRESI data was observed using the hybrid DLTV. Accelerated acquisition of in vivo 5D data with as low as 8.33% samples (12x) corresponds to a total scan time of 14 min as opposed to a fully sampled scan that needs a total duration of 2.4 h (TR = 1.2 s, 32 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${k}_{x}$$\end{document}kx×16 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${k}_{y}$$\end{document}ky×8 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${k}_{z}$$\end{document}kz, 512 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${t}_{2}$$\end{document}t2 and 64 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${t}_{1}$$\end{document}t1).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10334-022-01029-z.

Cost-effectiveness analysis of short biparametric magnetic resonance imaging protocol in men at risk of prostate cancer

OBJECTIVES

To compare the cost-effectiveness of a short biparametric MRI (BP-MRI) with that of contrast-enhanced multiparametric MRI (MP-MRI) for the detection of prostate cancer in men with elevated prostatespecific antigen (PSA) levels.

MATERIALS AND METHODS

We compared two diagnostic procedures for detection of prostate cancer (Pca), BP-MRI and MP-MRI, in terms of quality-adjusted life years (QALY), incremental costeffectiveness ratio (ICER) and net monetary benefit (NMB) for a hypothetical cohort of 10,000 patients. We compared two scenarios in which different protocols would be used for the early diagnosis of prostate cancer in relation to PSA values. Scenario 1. BP-MRI/MP-MRI yearly if > 3.0 ng/ml, every 2 years otherwise; Scenario 2. BP-MRI/MP-MRI yearly with age-dependent threshold 3.5 ng/ml (50-59 years), 4.5 ng/ml (60-69 years), 6.5 ng/ml (70-79 years).

RESULTS

BP-MRI was more effective than the comparator in terms of cost (160.10 € vs 249.99€) QALYs (a mean of 9.12 vs 8.46), ICER (a mean of 232.45) and NMB (a mean of 273.439 vs 251.863). BP-MRI was dominant, being more effective and less expensive, with a lower social cost. Scenario 2 was more cost-effective compared to scenario 1.

CONCLUSIONS

Our results confirmed the hypothesis that a short bi-parametric MRI protocol represents a cost-efficient procedure, optimizing resources in a policy perspective.

Prostate MRI quality: clinical impact of the PI-QUAL score in prostate cancer diagnostic work-up

OBJECTIVE

To assess the reproducibility and impact of prostate imaging quality (PI-QUAL) scores in a clinical cohort undergoing prostate multiparametric MRI.

METHODS

PI-QUAL scores were independently recorded by three radiologists (two senior, one junior). Readers also recorded whether MRI was sufficient to rule-in/out cancer and if repeat imaging was required. Inter-reader agreement was assessed using Cohen's κ. PI-QUAL scores were further correlated to PI-RADS score, number of biopsy procedures, and need for repeat imaging.

RESULTS

Image quality was sufficient (≥PI-QUAL-3) in 237/247 (96%) and optimal (≥PI-QUAL-4) in 206/247 (83%) of males undergoing 3T-MRI. Overall PI-QUAL scores showed moderate inter-reader agreement for senior (K = 0.51) and junior-senior readers (K = 0.47), with DCE showing highest agreement (K = 0.47). With PI-QUAL-5 studies, the negative MRI calls increased from 50 to 87% and indeterminate PI-RADS-3 rates decreased from 31.8. to 10.4% compared to lower quality PI-QUAL-3 studies. More patients with PI-QUAL scores 1-3 underwent biopsy for negative (47%) and indeterminate probability (100%) MRIs compared to PI-QUAL score 4-5 (30 and 75%, respectively). Ability to rule-in cancer increased with PI-QUAL score, from 50% at PI-QUAL 1-2 to 90% for PI-QUAL 4-5, with a similarly, but greater effect for ruling-out cancer and at a lower threshold, from 0% for scans of PI-QUAL 1-2 to 67.1% for PI-QUAL 4 and 100% for PI-QUAL-5.

CONCLUSION

Higher PI-QUAL scores for image quality are associated with decreased uncertainty in MRI decision-making and improved efficiency of diagnostic pathway delivery.

ADVANCES IN KNOWLEDGE

This study demonstrates moderate inter-reader agreement for PI-QUAL scoring and validates the score in a clinical setting, showing correlation of image quality to certainty of decision making and clinical outcomes of repeat imaging and biopsy of low-to-intermediate risk cases.

A comparative study of transperineal software-assisted magnetic resonance/ultrasound fusion biopsy and transrectal cognitive fusion biopsy of the prostate

BACKGROUND

The advantages and disadvantages of transperineal and transrectal biopsies remain controversial in the era of prostate targeted biopsy. In this study, we compared the cancer detection and complication rates of transperineal magnetic resonance/ultrasound (MR/US) fusion biopsy and transrectal cognitive fusion biopsy of the prostate.

METHODS

This was a comparative study of two prospectively collected cohorts. Men with clinically suspected prostate cancer and prostate imaging reporting and data system (PI-RADS) score ≥ 3 lesions on multi-parametric magnetic resonance imaging (mpMRI) were enrolled. They underwent either transperineal software fusion biopsy or transrectal cognitive fusion biopsy and systematic biopsy. The detection rates of any prostate cancer and clinically significant prostate cancer (csPC, defined as Gleason score ≥ 3 + 4) and the complication rates between both groups were analysed.

RESULTS

Ninety-two and 85 patients underwent transperineal software fusion and transrectal cognitive fusion biopsies, respectively. The detection rate for any prostate cancer was similar between both groups (60.8% vs. 56.4%, p = 0.659). In terms of csPC detection, transperineal fusion biopsy outperformed transrectal fusion biopsy (52.2% vs. 36.5%, p = 0.036). In multivariate regression analysis, age, PI-RADS score > 3, and transperineal route were significant predictors of csPC. Meanwhile, transperineal biopsy resulted in a higher rate of urinary retention than transrectal biopsy (18.5% vs. 4.7%, p = 0.009). No serious infectious complications were noted, although a patient developed sepsis after transrectal biopsy.

CONCLUSIONS

Transperineal software fusion biopsy provided a higher csPC detection rate than transrectal cognitive fusion biopsy and carried minimal risk for infectious complications in patients with MRI-visible prostate lesions.

Quantitative magnetic resonance imaging to aid clinical decision making in autoimmune hepatitis

BACKGROUND

In autoimmune hepatitis (AIH), clinical practice and treatment guidelines frequently diverge as a reflection of disease heterogeneity and challenges in achieving standardised care. We sought to explore the utility of multiparametric (mp) MR in patients with AIH, and the impact of this technology on physicians' decision making and intended patient management.

METHODS

82 AIH patients, recruited from two sites between June and November 2019 as part of an observational cohort study, underwent non-contrast MRI alongside their standard clinical investigations. Correlations between iron-corrected T1 (cT1) and other markers of disease were investigated alongside the utility of imaging markers to risk stratify patients in biochemical remission. The impact of mpMR on clinical decision making was evaluated using pairwise t-tests. The discriminatory ability of the imaging markers was assessed using area under the receiver operating characteristic curves (AUCs).

FINDINGS

cT1 had a significant impact on clinician intended patient management (p<0.0001). cT1 correlated with ALT (p = 0.0005), AST (p<0.001), IgG (p = 0.0005), and liver stiffness (p<0.0001). Patients in deep biochemical remission (N = 11; AST/ALT <50% upper limit of normal [ULN] and IgG <12 g/L) had low cT1, while 7/34 in normal biochemical remission (AST/ALT between 50 and 100% of ULN) had high cT1 and were at risk of disease flare. cT1 measures of disease heterogeneity, ALP and bilirubin made the best predictor of those not in biochemical remission (AUC:0.85).

INTERPRETATION

This study investigates the impact of mpMR results on intended clinical management in a real world setting. Findings showed that mpMR demonstrated a significant impact on clinical management of AIH and has the potential to inform patient risk stratification.

FUNDING

This paper presents independent research supported by the Innovate UK grant (104,915).