The "Is mpMRI Enough" or IMRIE Study: A Multicentre Evaluation of Prebiopsy Multiparametric Magnetic Resonance Imaging Compared with Biopsy

The evolving role of positron emission tomography in precision prostate cancer biopsy

Prostate cancer is one of the most common cancers among men, and accurate detection and diagnosis are crucial for effective treatment planning. Diagnostic prostate biopsy plays a pivotal role in the detection and characterization of prostate cancer. Recent advancements in molecular imaging, particularly with Positron Emission Tomography (PET) using radiolabelled Prostate-Specific Membrane Antigen (PSMA) tracers, have shown significant improvements in enhancing prostate cancer detection. PSMA PET, when combined with magnetic resonance imaging (MRI) in hybrid PET/MRI systems, provides improved sensitivity and specificity, enabling more precise localization of clinically significant prostate cancer (csPCa) lesions. This narrative review explores the evolving role of PET/CT and PET/MRI-guided prostate biopsy. We examine the integration of PET with MRI for the detection of prostate cancer, highlighting key studies that have demonstrated improved diagnostic outcomes. Additionally, we discuss the current limitations, including the high costs and longer scan times associated with PET/MRI, as well as the challenges in data interpretation. The review also considers emerging technologies, such as promising molecular probes for prostate PET imaging, such as gastrin-releasing peptide receptor (GRPR) and fibroblast activation protein inhibitor (FAPI). Finally, the present work provides the clinician with a comprehensive yet concise up-to-date review of the literature to easily evaluate the possibilities currently offered by hybrid imaging technologies of personalized imaging-guided biopsy for prostate cancer patients.

A Scaled Proteomic Discovery Study for Prostate Cancer Diagnostic Markers Using ProteographTM and Trapped Ion Mobility Mass Spectrometry

There is a significant unmet need for clinical reflex tests that increase the specificity of prostate-specific antigen blood testing, the longstanding but imperfect tool for prostate cancer diagnosis. Towards this endpoint, we present the results from a discovery study that identifies new prostate-specific antigen reflex markers in a large-scale patient serum cohort using differentiating technologies for deep proteomic interrogation. We detect known prostate cancer blood markers as well as novel candidates. Through bioinformatic pathway enrichment and network analysis, we reveal associations of differentially abundant proteins with cytoskeletal, metabolic, and ribosomal activities, all of which have been previously associated with prostate cancer progression. Additionally, optimized machine learning classifier analysis reveals proteomic signatures capable of detecting the disease prior to biopsy, performing on par with an accepted clinical risk calculator benchmark.

Interpreting Prostate MRI Reports in the Era of Increasing Prostate MRI Utilization: A Urologist's Perspective

Multi-parametric prostate MRI (mpMRI) is crucial for diagnosing, staging, and assessing treatment response in individuals with prostate cancer. Radiologists, through an accurate and standardized interpretation of mpMRI, stratify patients who may benefit from more invasive treatment or exclude patients who may be harmed by overtreatment. The integration of prostate MRI into the diagnostic pathway is anticipated to generate a substantial surge in the demand for high-quality mpMRI, estimated at approximately two million additional prostate MRI scans annually in Europe. In this review we examine the immediate impact on healthcare, particularly focusing on the workload and evolving roles of radiologists and urologists tasked with the interpretation of these reports and consequential decisions regarding prostate biopsies. We investigate important questions that influence how prostate MRI reports are handled. The discussion aims to provide insights into the collaboration needed for effective reporting.

Risk of Clinically Significant Prostate Cancer after a Nonsuspicious Prostate MRI-A Comparison with the General Population

BACKGROUND

We compare the risk of clinically significant (csPCa; ISUP Grade Group ≥ 2) and insignificant prostate cancer (isPCa; ISUP Grade Group 1) in men with a nonsuspicious prostate MRI (nMRI; PI-RADS ≤ 2) with the general population, and assess the value of PSA density (PSAD) in stratification.

METHODS

In this retrospective population-based cohort study we identified 1,682 50-79-year-old men, who underwent nMRI at HUS (2016-2019). We compared their age-standardized incidence rates (IR) of csPCa and the odds of isPCa to a local age- and sex-matched general population (n = 230,458) during a six-year follow-up. Comparisons were performed by calculating incidence rate ratios (IRR) and ORs with 95% confidence intervals (CI). We repeated the comparison for the 920 men with nMRI and PSAD < 0.15 ng/mL/cm3.

RESULTS

Compared with the general population, the IR of csPCa was significantly higher after nMRI [1,852 vs. 552 per 100,000 person-years; IRR 3.4 (95% CI, 2.8-4.1)]. However, the IR was substantially lower if PSAD was low [778 per 100,000 person-years; IRR 1.4 (95% CI, 0.9-2.0)]. ORs for isPCa were 2.4 (95% CI, 1.7-3.5) for all men with nMRI and 5.0 (95% CI, 2.8-9.1) if PSAD was low.

CONCLUSIONS

Compared with the general population, the risk of csPCa is not negligible after nMRI. However, men with nMRI and PSAD <0.15 ng/mL/cm3 have worse harm-benefit balance than men in the general population.

IMPACT

Prostate biopsies for men with nMRI should be reserved for cases indicated by additional risk stratification. See related In the Spotlight, p. 641.

Utilization trend of prebiopsy multiparametric magnetic resonance imaging and its impact on prostate cancer detection: Real-world insights from a high-volume center in southwest China

BACKGROUND

Data on the utilization and effects of prebiopsy prostate multiparametric magnetic resonance imaging (mpMRI) to support its routine use in real-world setting are still scarce.

OBJECTIVE

To evaluate the change of clinical practice of prebiopsy mpMRI over time, and assess its diagnostic accuracy.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed data from 6168 patients who underwent primary prostate biopsy (PBx) between January 2011 and December 2021 and had prostate-specific antigen (PSA) values ranging from 3 to 100 ng/mL.

INTERVENTION

Prebiopsy MRI at the time of PBx.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We performed general linear regression and to elucidate trends in the annual use of prebiopsy mpMRI and conducted multivariable logistic regression to evaluate the potential benefits of incorporating prebiopsy mpMRI for prostate cancer (PCa) detection.

RESULTS AND LIMITATIONS

The utilization of prebiopsy mpMRI significantly increased from 9.2% in 2011 to 75.0% in 2021 (p < 0.001). In addition, prebiopsy mpMRI significantly reduced negative PBx by 8.6% while improving the detection of clinically significant PCa (csPCa) by 7.0%. Regression analysis showed that the utilization of prebiopsy mpMRI was significantly associated with a 48% (95% confidence interval [CI]: 1.19-1.84) and 36% (95% CI: 1.12-1.66) increased PCa detection rate in the PSA 3-10 ng/mL and 10-20 ng/mL groups, respectively; and a 34% increased csPCa detection rate in the PSA 10-20 ng/mL group (95% CI: 1.09-1.64). The retrospective design and the single center cohort constituted the limitations of this study.

CONCLUSIONS

Our study demonstrated a notable rise in the utilization of prebiopsy mpMRI in the past decade. The adoption of this imaging technique was significantly associated with an increased probability of detecting prostate cancer.

PATIENT SUMMARY

From 2011 to 2021, we demonstrated a steady increase in the utilization of prebiopsy mpMRI among biopsy-naïve men. We also confirmed the positive impact of prebiopsy mpMRI utilization on the detection of prostate cancer.

The Lancet Commission on prostate cancer: planning for the surge in cases

Prostate cancer is the most common cancer in men in 112 countries, and accounts for 15% of cancers. In this Commission, we report projections of prostate cancer cases in 2040 on the basis of data for demographic changes worldwide and rising life expectancy. Our findings suggest that the number of new cases annually will rise from 1·4 million in 2020 to 2·9 million by 2040. This surge in cases cannot be prevented by lifestyle changes or public health interventions alone, and governments need to prepare strategies to deal with it. We have projected trends in the incidence of prostate cancer and related mortality (assuming no changes in treatment) in the next 10–15 years, and make recommendations on how to deal with these issues.

For the Commission, we established four working groups, each of which examined a different aspect of prostate cancer: epidemiology and future projected trends in cases, the diagnostic pathway, treatment, and management of advanced disease, the main problem for most men diagnosed with prostate cancer worldwide. Throughout we have separated problems in high-income countries (HICs) from those in low-income and middle-income countries (LMICs), although we acknowledge that this distinction can be an oversimplification (some rich patients in LMICs can access high-quality care, whereas many patients in HICs, especially the USA, cannot because of inadequate insurance coverage). The burden of disease globally is already substantial, but options to improve care are already available at moderate cost. We found that late diagnosis is widespread worldwide, but especially in LMICs, where it is the norm. Early diagnosis improves prognosis and outcomes, and reduces societal and individual costs, and we recommend changes to the diagnostic pathway that can be immediately implemented. For men diagnosed with advanced disease, optimal use of available technologies, adjusted to the resource levels available, could produce improved outcomes. We also found that demographic changes (ie, changing age structures and increasing life expectancy) in LMICs will drive big increases in prostate cancer, and cases are also projected to rise in high-income countries. This projected rise in cases has driven the main thrust of our recommendations throughout. Dealing with this rise in cases will require urgent and radical interventions, particularly in LMICs, including an emphasis on education (both of health professionals and the general population) linked to outreach programmes to increase awareness. If implemented, these interventions would shift the case mix from advanced to earlier-stage disease, which in turn would necessitate different treatment approaches: earlier diagnosis would prompt a shift from palliative to curative therapies based around surgery and radiotherapy. Although age-adjusted mortality from prostate cancer is falling in HICs, it is rising in LMICs. And, despite large, well known differences in disease incidence and mortality by ethnicity (eg, incidence in men of African heritage is roughly double that in men of European heritage), most prostate cancer research has disproportionally focused on men of European heritage. Without urgent action, these trends will cause global deaths from prostate cancer to rise rapidly.

Diagnostic Performance of Prostate-specific Antigen Density for Detecting Clinically Significant Prostate Cancer in the Era of Magnetic Resonance Imaging: A Systematic Review and Meta-analysis

CONTEXT

There has been a dramatic increase in the use of prostate magnetic resonance imaging (MRI) in the diagnostic workup. With prostate volume calculated from MRI, prostate-specific antigen density (PSAD) now is a ready-to-use parameter for prostate cancer (PCa) risk stratification before prostate biopsy, especially among patients with negative MRI or equivocal lesions.

OBJECTIVE

In this review, we aimed to evaluate the diagnostic performance of PSAD for clinically significant prostate cancer (CSPCa) among patients who received MRI before prostate biopsy.

EVIDENCE ACQUISITION

Two investigators performed a systematic review according of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies (published between January 1, 2012, and December 31, 2021) reporting the diagnostic performance (outcomes) of PSAD (intervention) for CSPCa among men who received prebiopsy prostate MRI and subsequent prostate biopsy (patients), using biopsy pathology as the gold standard (comparison), were eligible for inclusion.

EVIDENCE SYNTHESIS

A total of 1536 papers were identified in PubMed, Scopus, and Embase. Of these, 248 studies were reviewed in detail and 39 were qualified. The pooled sensitivity (SENS) and specificity (SPEC) for diagnosing CSPCa among patients with positive MRI were, respectively, 0.87 and 0.35 for PSAD of 0.1 ng/ml/ml, 0.74 and 0.61 for PSAD of 0.15 ng/ml/ml, and 0.51 and 0.81 for PSAD of 0.2 ng/ml/ml. The pooled SENS and SPEC for diagnosing CSPCa among patients with negative MRI were, respectively, 0.85 and 0.36 for PSAD of 0.1 ng/ml/ml, 0.60 and 0.66 for PSAD of 0.15 ng/ml/ml, and 0.33 and 0.84 for PSAD of 0.2 ng/ml/ml. The pooled SENS and SPEC among patients with Prostate Imaging Reporting and Data System (PI-RADS) 3 or Likert 3 lesions were, respectively, 0.87 and 0.39 for PSAD of 0.1 ng/ml/ml, 0.61 and 0.69 for PSAD of 0.15 ng/ml/ml, and 0.42 and 0.82 for PSAD of 0.2 ng/ml/ml. The post-test probability for CSPCa among patients with negative MRI was 6% if PSAD was <0.15 ng/ml/ml and dropped to 4% if PSAD was <0.10 ng/ml/ml.

CONCLUSIONS

In this systematic review, we quantitatively evaluated the diagnosis performance of PSAD for CSPCa in combination with prostate MRI. It demonstrated a complementary performance and predictive value, especially among patients with negative MRI and PI-RADS 3 or Likert 3 lesions. Integration of PSAD into decision-making for prostate biopsy may facilitate improved risk-adjusted care.

PATIENT SUMMARY

Prostate-specific antigen density is a ready-to-use parameter in the era of increased magnetic resonance imaging (MRI) use in clinically significant prostate cancer (CSPCa) diagnosis. Findings suggest that the chance of having CSPCa was very low (4% or 6% for those with negative prebiopsy MRI or Prostate Imaging Reporting and Data System (Likert) score 3 lesion, respectively, if the PSAD was <0.10 ng/ml/ml), which may lower the need for biopsy in these patients.

Prostate cancer screening-stepping forward with MRI

OBJECTIVE

To comprehensively review the literature on the integration of MRI as a diagnostic tool in prostate cancer screening and offer practical recommendations for optimising its use.

METHODS

Existing research studies, clinical guidelines and expert opinions were reviewed to support the optimisation standards for MRI use in screening. Consolidated screening principles were used to make appropriate recommendations regarding the integration of MRI into the diagnostic pathway.

RESULTS

To strike a balance between the potential benefits of early detection on mortality and minimising the harm of over-diagnosing indolent cancers, it is necessary to have a clear understanding of the context of MRI use. The key to optimisation is patient selections and MRI-targeted biopsies. For men at higher-than-average risk, it is essential to use screening-specific MRI protocols and establish accuracy levels and interpretation criteria. Optimisation of readings by the automation of data acquisition, image quality monitoring, post-processing, radiologist certification and deep-learning computer-aided software is needed. The optimal utilisation of MRI involves its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.

CONCLUSION

MRI in the prostate cancer screening pathway can bring substantial diagnostic benefits. By carefully considering its advantages, limitations and safety concerns and integrating it into a multistep diagnostic pathway, clinicians can improve outcomes while minimising harm to screening participants.

CLINICAL RELEVANCE STATEMENT

The manuscript discusses the role of MRI in prostate cancer screening, highlighting its potential to improve accuracy and reduce overdiagnosis. It emphasises the importance of optimising protocols and integrating MRI into a multistep diagnostic pathway for successfully delivering screening benefits.

KEY POINTS

• Population screening for prostate cancer is a new indication for prostate MRI that allows the detection of high-risk cancers while reducing the need for biopsies and associated harm. • To optimise prostate cancer screening using MRI, it is essential to redefine MRI protocols; establish accuracy levels, reliability and interpretation criteria; and optimise reading (including post-processing, image quality, radiologist certification, and deep-learning computer-aided software). • The optimal utilisation of MRI for prostate cancer screening would involve its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.

Up-to-Date Imaging and Diagnostic Techniques for Prostate Cancer: A Literature Review

Prostate cancer (PCa) faces great challenges in early diagnosis, which often leads not only to unnecessary, invasive procedures, but to over-diagnosis and treatment as well, thus highlighting the need for modern PCa diagnostic techniques. The review aims to provide an up-to-date summary of chronologically existing diagnostic approaches for PCa, as well as their potential to improve clinically significant PCa (csPCa) diagnosis and to reduce the proliferation and monitoring of PCa. Our review demonstrates the primary outcomes of the most significant studies and makes comparisons across the diagnostic efficacies of different PCa tests. Since prostate biopsy, the current mainstream PCa diagnosis, is an invasive procedure with a high risk of post-biopsy complications, it is vital we dig out specific, sensitive, and accurate diagnostic approaches in PCa and conduct more studies with milestone findings and comparable sample sizes to validate and corroborate the findings.

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 Cancer Imaging: What We Already Know and What Is on the Horizon

Conventional as well as advanced imaging modalities contribute to accurate detection of prostate cancer and have important roles in screening, staging, active surveillance, and evaluation for biochemical recurrence.

Can multi-parametric magnetic resonance imaging and prostate-specific antigen density accurately stratify patients prior to prostate biopsy?

Objective:

This study examines the diagnostic accuracy of multi-parametric magnetic resonance imaging (mpMRI) in a high-volume centre to potentially stratify patients prior to prostate biopsy.

Methods:

All biopsy naïve patients who had mpMRI prostate and transperineal biopsy of prostate (TPBx) in 2017 and 2018 were included. There were no exclusion criteria. All patients, regardless of the mpMRI result, underwent systematic template biopsy under general anaesthesia with cognitive target biopsy if indicated. Clinicopathological data were extracted from medical records. The primary outcome was the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of mpMRI prostate in the detection of prostate cancer (PCa) compared with template TPBx.

Results:

In total, 140 patients were included. Overall, 57.1% had a positive biopsy. A higher Prostate Imaging-Reporting and Data Systems (PI-RADS) score was associated with a higher risk of diagnosing clinically significant PCa (International Society of Urological Pathology (ISUP) ⩾ 2) ( p < 0.001). The sensitivity, specificity, NPV, and PPV of mpMRI in detecting clinically significant PCa with a PI-RADS ⩾ 3 lesion, was 95% (95% confidence interval (CI) 83.0–99.3%), 41% (95% CI 31.3–51.3%), 95.3% (95% CI 84.2–99.4%) and 39.2% (95% CI 29.4–49.6%), respectively. Combining this with prostate-specific antigen density (PSAD) of <0.15 further improved the NPV to 100% (86.3–100). Binomial logistic regression to understand the effects of PSA, DRE and PI-RADS score on predicting clinically significant PCa (ISUP ⩾ 2) found increasing PSA (odds ratio (OR) 1.06, (95% CI 1.00–1.11, p = 0.022)) and PI-RADS (OR 3.17, (95% CI 1.94–5.18, p < 0.001)) to be significant predictors. Malignant DRE was not a significant predictor ( p = 0.087).

Conclusion:

This study demonstrates that the high sensitivity and NPV of mpMRI combined with PSAD may play a pivotal role in stratifying men for prostate biopsy and help avoid biopsy and its associated morbidity in select patients.

Level of Evidence:

2b (Oxford Centre for Evidence-Based Medicine: Levels of Evidence)

Balancing the benefits and harms of MRI-directed biopsy pathways

KEY POINTS

• Before a prostate biopsy, the likely benefits and the harms emanating from true and false test MRI results need to be balanced. Prioritizing patients' preferences and their tolerance to potential harms are essential to assess.• The decision curve analysis method is an analytical framework where the net clinical benefit is plotted against a range of risk thresholds of having important cancers, helping patients and their physicians to decide between cancer averse (important cancers being detected) and biopsy averse (biopsies avoided) strategies.• The decision curve analysis method showed that the incorporation of clinical risk factors with MRI findings optimizes biopsy outcomes over a range of clinically relevant risk thresholds, compared to other biopsy strategies.

MRI-based nomogram for the prediction of prostate cancer diagnosis: A multi-centre validated patient–physician decision tool

Objective:

To update and externally validate a magnetic resonance imaging (MRI)-based nomogram for predicting prostate biopsy outcomes with a multi-centre cohort.

Materials and methods:

Prospective data from five UK-based centres were analysed. All men were biopsy naïve. Those with missing data, no MRI, or prostate-specific antigen (PSA) > 30 ng/mL were excluded. Logistic regression analysis was used to confirm predictors of prostate cancer outcomes including MRI-PIRADS (Prostate Imaging Reporting and Data System) score, PSA density, and age. Clinically significant disease was defined as International Society of Urological Pathology (ISUP) Grade Group ⩾ 2 (Gleason grade ⩾ 7). Biopsy strategy included transrectal and transperineal approaches. Nomograms were produced using logistic regression analysis results.

Results:

A total of 506 men were included in the analysis with median age 66 (interquartile range (IQR) = 60–69). Median PSA was 6.6 ng/mL (IQR = 4.72–9.26). PIRADS ⩾ 3 was reported in 387 (76.4%). Grade Group ⩾ 2 detection was 227 (44.9%) and 318 (62.8%) for any cancer. Performance of the MRI-based nomogram was an area under curve (AUC) of 0.84 (95% confidence interval (CI) = 0.81–0.88) for Grade Group ⩾ 2% and 0.85 (95% CI = 0.82–0.88) for any prostate cancer.

Conclusion:

We present external validation of a novel MRI-based nomogram in a multi-centre UK-based cohort, showing good discrimination in identifying men at high risk of having clinically significant disease. These findings support this risk calculator use in the prostate biopsy decision-making process.

Level of evidence:

2c

Results from a PI-RADS-based MRI-directed diagnostic pathway for biopsy-naive patients in a non-university hospital

Purpose

To assess the safety and performance of a MRI-directed diagnostic pathway for patients with first-time suspicion of prostate cancer in a non-university hospital.

Methods

Between May 2017 and December 2018 all biopsy-naive patients examined in our hospital followed a MRI-directed diagnostic work-up algorithm based on PI-RADS score. In short, PI-RADS 1–2 was generally not biopsied and PI-RADS 3–5 was reviewed by a multidisciplinary team. Patients with PI-RADS 4-5 were all referred to biopsy, either transrectal ultrasound-guided biopsy or MRI in-bore biopsy for small tumors and for sites difficult to access. PI-RADS scores were compared to the histopathology from biopsies and surgical specimens for patients who had prostatectomy. Non-biopsied patients were referred to a safety net monitoring regimen.

Results

Two hundred and ninety-eight men were enrolled. 97 (33%) had PI-RADS 1–2, 44 (15%) had PI-RADS 3, and 157 (53%) had PI-RADS 4–5. 116 (39%) of the patients avoided biopsy. None of these were diagnosed with significant cancer within 2–3.5 years of safety net monitoring. Almost all high ISUP grade groups (≥ 3) were in the PI-RADS 4–5 category (98%). Prostatectomy specimens and systematic biopsies from MRI-negative areas indicated that very few clinically significant cancers were missed by the MRI-directed diagnostic pathway.

Conclusion

Our findings add to evidence that a MRI-directed diagnostic pathway can be safely established in a non-university hospital. The pathway reduced the number of biopsies and reliably detected the site of the most aggressive cancers.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-021-03249-8.

Changes in Prostate-Specific Antigen Testing Relative to the Revised US Preventive Services Task Force Recommendation on Prostate Cancer Screening

Importance

In April 2017, the US Preventive Services Task Force (USPSTF) published a draft guideline that reversed its 2012 guidance advising against prostate-specific antigen (PSA)-based screening for prostate cancer in all men (grade D), instead endorsing individual decision-making for men aged 55 to 69 years (grade C).

Objective

To evaluate changes in rates of PSA testing after revisions in the USPSTF guideline on prostate cancer screening.

Design, Setting, and Participants

This retrospective cohort study used deidentified claims data from Blue Cross Blue Shield beneficiaries aged 40 to 89 years from January 1, 2013, through December 31, 2019.

Exposures

Publication of the USPSTF's draft (April 2017) and final (May 2018) recommendation on prostate cancer screening.

Main Outcomes and Measures

Age-adjusted rates of PSA testing in bimonthly periods were calculated, and PSA testing rates from calendar years before (January 1 to December 31, 2016) and after (January 1 to December 31, 2019) the guideline change were compared. Interrupted time series analyses were used to evaluate the association of the draft (April 2017) and published (May 2018) USPSTF guideline with rates of PSA testing. Changes in rates of PSA testing were further evaluated among beneficiaries within the age categories reflected in the guideline: 40 to 54 years, 55 to 69 years, and 70 to 89 years.

Results

The median number of eligible beneficiaries for each bimonthly period was 8 087 565 (range, 6 407 602-8 747 308), and the median age of all included eligible beneficiaries was 53 years (IQR, 47-59 years). Between 2016 and 2019, the mean (SD) rate of PSA testing increased from 32.5 (1.1) to 36.5 (1.1) tests per 100 person-years, a relative increase of 12.5% (95% CI, 1.1%-24.4%). During the same period, mean (SD) rates of PSA testing increased from 20.6 (0.8) to 22.7 (0.9) tests per 100 person-years among men aged 40 to 54 years (relative increase, 10.1%; 95% CI, -2.8% to 23.7%), from 49.8 (1.9) to 55.8 (1.8) tests per 100 person-years among men aged 55 to 69 years (relative increase, 12.1%; 95% CI, -0.2% to 25.2%), and from 38.0 (1.4) to 44.2 (1.4) tests per 100 person-years among men aged 70 to 89 years (relative increase, 16.2%; 95% CI, 4.2%-29.0%). Interrupted time series analysis revealed a significantly increasing trend of PSA testing after April 2017 among all beneficiaries (0.30 tests per 100 person-years for each bimonthly period; P < .001).

Conclusions and Relevance

This large national cohort study found that rates of PSA testing increased after the USPSTF's draft statement in 2017, reversing trends seen after earlier guidance against PSA testing for all patients. Increased testing was also observed among older men, who may be less likely to benefit from prostate cancer screening.

Identifying Risk Factors for MRI-Invisible Prostate Cancer in Patients Undergoing Transperineal Saturation Biopsy

Purpose

Prostatic multi-parametric magnetic resonance imaging (mpMRI) has markedly improved the assessment of men with suspected prostate cancer (PCa). Nevertheless, as mpMRI exhibits a high negative predictive value, a negative MRI may represent a diagnostic dilemma. The aim of this study was to evaluate the incidence of positive transperineal saturation biopsy in men who have negative mpMRI and to analyse the factors associated with positive biopsy in this scenario.

Patients and Methods

A retrospective study of men with normal mpMRI and suspicion of PCa who underwent saturation biopsy (≥20 cores) was carried out. A total of 580 patients underwent transperineal MRI/transrectal ultrasound fusion targeted biopsies or saturation prostate biopsies from January 2017 to September 2020. Of them, 73 had a pre-biopsy negative mpMRI (with Prostate Imaging – Reporting and Data System, PI-RADS, ≤2) and were included in this study. Demographics, clinical characteristics, data regarding biopsy results and potential predictive factors of positive saturation biopsy were collected. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for MRI-invisible PCa.

Results

The detection rate of PCa with saturation biopsy in patients with negative MRI was 34/73 (46.58%). Out of 34 MRI-invisible prostate cancers detected, 12 (35.29%) were clinically significant PCa (csPCa) forms. Regarding factors of positive biopsy, in univariate analysis, the use of 5-alpha reductase inhibitors and free:total prostate-specific antigen (PSA) ratio were associated with the result of the saturation biopsy. In multivariate analysis, only an unfavourable free:total PSA ratio remained a risk factor (OR 11.03, CI95% 1.93–63.15, p=0.01). Furthermore, multivariate logistic analysis demonstrated that prostate volume >50mL significantly predicts the absence of csPCa on saturation biopsy (OR 0.11, 95% CI 0.01–0.94, p=0.04).

Conclusion

A free:total PSA ratio <20% is a risk factor for MRI-invisible PCa. Saturation biopsy could be considered in patients with suspected PCa, despite having a negative MRI.

mpMRI of the Prostate (MR-Prostatography): Updated Recommendations of the DRG and BDR on Patient Preparation and Scanning Protocol

The Working Group Uroradiology and Urogenital Diagnosis of the German Roentgen Society (DRG) revised and updated the recommendations for preparation and scanning protocol of the multiparametric MRI of the Prostate in a consensus process and harmonized it with the managing board of German Roentgen Society and Professional Association of the German Radiologist (BDR e. V.). These detailed recommendation define the referenced "validated quality standards" of the German S3-Guideline Prostate Cancer and describe in detail the topic 1. anamnestic datas, 2. termination of examinations and preparation of examinations, 3. examination protocol and 4. MRI-(in-bore)-biopsy. KEY POINTS:: · The recommendations for preparation and scanning protocol of the multiparametric MRI of the Prostate were revised and updated in a consensus process and harmonized with the managing board of German Roentgen Society (DRG) and Professional Asssociation of the German Radiologist (BDR).. · Detailed recommendations are given for topic 1. anamnestic datas, 2. termination and preparation of examinations, 3. examination protocoll and 4. MRI-(in-bore)-biopsy.. · These recommendations define the referenced "validated quality standards" of the German S3-Guideline Prostate Cancer.. CITATION FORMAT: · Franiel T, Asbach P, Beyersdorff D et al. mpMRI of the Prostate (MR-Prostatography): Updated Recommendations of the DRG and BDR on Patient Preparation and Examination Protocol. Fortschr Röntgenstr 2021; 193: 763 - 776.

A multifaceted approach to quality in the MRI-directed biopsy pathway for prostate cancer diagnosis

KEY POINTS

• Identify, assure, and measure major sources of variability affecting the MRI-directed biopsy pathway for prostate cancer diagnosis.• Develop strategies to control and minimize variations that impair pathway effectiveness including the performance of main players and team working.• Assure end-to-end quality of the diagnostic chain with robust multidisciplinary team working.

Predictive clinical features for negative histopathology of MRI/Ultrasound-fusion-guided prostate biopsy in patients with high likelihood of cancer at prostate MRI: Analysis from a urologic outpatient clinic1

OBJECTIVE

The aim of this study was to evaluate clinical features associated with benign histopathology of Prostate Imaging Reporting and Data System (PI-RADS) category 4 and 5 lesions.

MATERIALS AND METHODS

Between March 2015 and November 2020, 1161 patients underwent mpMRI/Ultrasound-fusion-guided prostate biopsy (FBx) and concurrent 12-core systematic prostate biopsy (SBx) at the Department of Urology of the Ludwig-Maximilians-University of Munich, Germany. 848/ 1161 (73%) patients presented with either PI-RADS 4 or 5 index lesion and were retrospectively evaluated. Multivariate analysis was performed to evaluate clinical parameters associated with a negative outcome of PI-RADS 4 or 5 category lesions after FBx. Area under the receiver operating characteristics (ROC) curve (AUC) was conducted using ROC-analysis.

RESULTS

676/848 (79.7%) patients with either PI-RADS 4 or 5 index lesion were diagnosed with prostate cancer (PCa) by FBx and 172/848 (20.3%) patients had a negative biopsy (including the concurrent systematic prostate biopsy), respectively. Prostate volume (P-Vol) (OR 0.99, 95% CI = 0.98-1.00, p = 0.038), pre-biopsy-status (OR 0.48, 95% CI = 0.29-0.79, p = 0.004) and localization of the lesion in the transitional zone (OR 0.28, 95% CI = 0.13-0.60, p = 0.001) were independent risk factors for a negative outcome of FBx. Age (OR 1.09, 95% CI = 1.05-1.13, p < 0.001) and PSA density (PSAD) (OR 75.92, 95% CI = 1.03-5584.61, p = 0.048) increased the risk for PCa diagnosis after FBx. The multivariate logistic regression model combining all clinical characteristics achieved an AUC of 0.802 (95% CI = 0.765-0.835; p < 0.001) with a sensitivity and specificity of 66% and 85%.

CONCLUSION

Lesions with high or highly likelihood of PCa on multiparametric magnetic resonance imaging (mpMRI) but subsequent negative prostate biopsy occur in a small amount of patients. Localization of the lesion in the transitional zone, prostate volume and prebiopsy were shown to be predictors for benign histopathology of category 4 or 5 lesions on mpMRI. Integration of these features into daily clinical routine could be used for risk-stratification of these patients after negative biopsy of PI-RADS 4 or 5 index lesions.