Comparison of Magnetic Resonance Imaging-stratified Clinical Pathways and Systematic Transrectal Ultrasound-guided Biopsy Pathway for the Detection of Clinically Significant Prostate Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials

A pictorial essay of PI-RADS pearls and pitfalls: toward less ambiguity and better practice

Prostate Imaging Reporting and Data System (PI-RADS) was designed to standardize the interpretation of multiparametric magnetic resonance imaging (MRI) of the prostate, aiding in assessing the probability of clinically significant prostate cancer. By providing a structured scoring system, it enables better risk stratification, guiding decisions regarding the need for biopsy and subsequent treatment options. In this article, we explore both the strengths and weaknesses of PI-RADS, offering insights into its updated diagnostic performance and clinical applications, while also addressing potential pitfalls using diverse, representative MRI cases.

Bridging Communication Gaps Between Radiologists, Referring Physicians, and Patients Through Standardized Structured Cancer Imaging Reporting: The Experience with Female Pelvic MRI Assessment Using O-RADS and a Simulated Cohort Patient Group

RATIONALE AND OBJECTIVES

This study aimed to evaluate whether implementing structured reporting based on Ovarian-Adnexal Reporting and Data System (O-RADS) magnetic resonance imaging (MRI) in women with sonographically indeterminate adnexal masses improves communication between radiologists, referrers, and patients/caregivers and enhances diagnostic performance for determining adnexal malignancy.

MATERIALS AND METHODS

We retrospectively analyzed prospectively issued MRI reports in 2019-2022 performed for characterizing adnexal masses before and after implementing O-RADS MRI; 56 patients/caregivers and nine gynecologic oncologists ("referrers") were surveyed about report interpretability/clarity/satisfaction; responses for pre- and post-implementation reports were compared using Fisher's exact and Chi-squared tests. Diagnostic performance was assessed using receiver operating characteristic curves.

RESULTS

A total of 123 reports from before and 119 reports from after O-RADS MRI implementation were included. Survey response rates were 35.7% (20/56) for patients/caregivers and 66.7% (6/9) for referrers. For patients/caregivers, O-RADS MRI reports were clearer (p < 0.001) and more satisfactory (p < 0.001) than unstructured reports, but interpretability did not differ significantly (p = 0.14), as 28.0% (28/100) of postimplementation and 38.0% (38/100) of preimplementation reports were considered difficult to interpret. For referrers, O-RADS MRI reports were clearer, more satisfactory, and easier to interpret (p < 0.001); only 1.3% (1/77) were considered difficult to interpret. For differentiating benign from malignant adnexal lesions, O-RADS MRI showed area under the curve of 0.92 (95% confidence interval [CI], 0.85-0.99), sensitivity of 0.81 (95% CI, 0.58-0.95), and specificity of 0.91 (95% CI, 0.83-0.96). Diagnostic performance of reports before implementation could not be calculated due to many different phrases used to describe the likelihood of malignancy.

CONCLUSION

Implementing standardized structured reporting using O-RADS MRI for characterizing adnexal masses improved clarity and satisfaction for patients/caregivers and referrers. Interpretability improved for referrers but remained limited for patients/caregivers.

The PRIMARY Score: Diagnostic Performance and Added Value Compared With MRI in Detecting Clinically Significant Prostate Cancer

PURPOSE

Multiparametric MRI is the current standard for detecting clinically significant prostate cancer (csPCa). However, men with negative or equivocal MRI often undergo unnecessary biopsies due to concerns about false-negative results. The recently proposed 68 Ga-PSMA PET/CT-based PRIMARY score exhibited good diagnostic performance for csPCa. This study aimed to externally validate the performance of the PRIMARY score and evaluate its added diagnostic value to MRI triage in detecting csPCa.

PATIENTS AND METHODS

This retrospective cohort study included 431 men who underwent both 68 Ga-PSMA PET/CT and MRI before biopsy. Performance was assessed using the area under the receiver operating characteristic curve and the decision curve analysis. The PRIMARY score + MRI was considered positive for either PRIMARY score 3-5 or Prostate Imaging Reporting and Data System (PI-RADS) 4/5.

RESULTS

The prevalence of csPCa was 51.7% (223/431). The area under the receiver operating characteristic curve of the 5-level PRIMARY score for csPCa was significantly higher than that of MRI (0.873 vs 0.786, P < 0.001). For the entire group, sensitivity, specificity, positive predictive value, and negative predictive value of the PRIMARY score were 90.6%, 61.1%, 71.4%, and 85.8%, respectively, which outperformed 87.9%, 49.0%, 64.9%, and 79.1% of PI-RADS on MRI. The PRIAMRY score + MRI improved sensitivity (96.0% vs 87.9%, P < 0.001) and negative predictive value (91.5% vs 79.1%, P < 0.001) without compromising specificity and positive predictive value compared with MRI alone. This combined approach avoided 24.6% (106/431) of unnecessary biopsies, while missing 4.0% (9/223) of csPCa cases. The addition of the PRIMARY score in men with PI-RADS 1-3 showed a net benefit, but not in men with PI-RADS 4/5.

CONCLUSIONS

The PRIMARY score was superior to MRI in detecting csPCa, and its added diagnostic value was in men with negative or equivocal MRI results. The PRIMARY score + MRI improved negative predictive value and sensitivity for csPCa compared with MRI alone. Further prospective trials will validate whether men with clinical suspicion of csPCa but negative PRIMARY score + MRI can safely avoid unnecessary biopsies.

2022 Update on Prostate Cancer Epidemiology and Risk Factors-A Systematic Review

CONTEXT

Prostate cancer (PCa) is one of the most common cancers worldwide. Understanding the epidemiology and risk factors of the disease is paramount to improve primary and secondary prevention strategies.

OBJECTIVE

To systematically review and summarize the current evidence on the descriptive epidemiology, large screening studies, diagnostic techniques, and risk factors of PCa.

EVIDENCE ACQUISITION

PCa incidence and mortality rates for 2020 were obtained from the GLOBOCAN database of the International Agency for Research on Cancer. A systematic search was performed in July 2022 using PubMed/MEDLINE and EMBASE biomedical databases. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and was registered in PROSPERO (CRD42022359728).

EVIDENCE SYNTHESIS

Globally, PCa is the second most common cancer, with the highest incidence in North and South America, Europe, Australia, and the Caribbean. Risk factors include age, family history, and genetic predisposition. Additional factors may include smoking, diet, physical activity, specific medications, and occupational factors. As PCa screening has become more accepted, newer approaches such as magnetic resonance imaging (MRI) and biomarkers have been implemented to identify patients who are likely to harbor significant tumors. Limitations of this review include the evidence being derived from meta-analyses of mostly retrospective studies.

CONCLUSIONS

PCa remains the second most common cancer among men worldwide. PCa screening is gaining acceptance and will likely reduce PCa mortality at the cost of overdiagnosis and overtreatment. Increasing use of MRI and biomarkers for the detection of PCa may mitigate some of the negative consequences of screening.

PATIENT SUMMARY

Prostate cancer (PCa) remains the second most common cancer among men, and screening for PCa is likely to increase in the future. Improved diagnostic techniques can help reduce the number of men who need to be diagnosed and treated to save one life. Avoidable risk factors for PCa may include factors such as smoking, diet, physical activity, specific medications, and certain occupations.

ACR Appropriateness Criteria® Pretreatment Detection, Surveillance, and Staging of Prostate Cancer: 2022 Update

Prostate cancer is second leading cause of death from malignancy after lung cancer in American men. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, establishing disease extent (both local and distant), and evaluating aggressiveness, which are the driving factors of patient outcomes such as recurrence and survival. Prostate cancer is typically diagnosed after the recognizing elevated serum prostate-specific antigen level or abnormal digital rectal examination. Tissue diagnosis is obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy, commonly with multiparametric MRI without or with intravenous contrast, which has recently been established as standard of care for detecting, localizing, and assessing local extent of prostate cancer. Although bone scintigraphy and CT are still typically used to detect bone and nodal metastases in patients with intermediate- or high-risk prostate cancer, novel advanced imaging modalities including prostatespecific membrane antigen PET/CT and whole-body MRI are being more frequently utilized for this purpose with improved detection rates. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The role of MRI in prostate cancer: current and future directions

There has been an increasing role of magnetic resonance imaging (MRI) in the management of prostate cancer. MRI already plays an essential role in the detection and staging, with the introduction of functional MRI sequences. Recent advancements in radiomics and artificial intelligence are being tested to potentially improve detection, assessment of aggressiveness, and provide usefulness as a prognostic marker. MRI can improve pretreatment risk stratification and therefore selection of and follow-up of patients for active surveillance. MRI can also assist in guiding targeted biopsy, treatment planning and follow-up after treatment to assess local recurrence. MRI has gained importance in the evaluation of metastatic disease with emerging technology including whole-body MRI and integrated positron emission tomography/MRI, allowing for not only better detection but also quantification. The main goal of this article is to review the most recent advances on MRI in prostate cancer and provide insights into its potential clinical roles from the radiologist's perspective. In each of the sections, specific roles of MRI tailored to each clinical setting are discussed along with its strengths and weakness including already established material related to MRI and the introduction of recent advancements on MRI.

miRNAs as molecular biomarkers for prostate cancer

MicroRNAs (miRNAs) are short noncoding RNA able to regulate specific mRNA stability, thus influencing target gene expression. Disrupted levels of several miRNA have been associated with prostate cancer, the leading cause of cancer death among men and the fifth leading cause of death worldwide. Here, we investigated whether miR-145, miR-148, and miR-185 circulating levels in plasma could be used as molecular biomarkers, to allow distinguishing between individuals with benign prostatic hyperplasia, precancerous lesion, and prostate cancer. In this study, we recruited 170 urological clinic patients with suspected prostate cancer who underwent prostate biopsy. Total RNA was isolated from plasma, and TaqMan MicroRNA assays were used to analyze miR-145, miR-185, and miR-148 expression. First, differential miRNA expression among patient groups was evaluated. Then, miRNA levels were combined with clinical assessment outcomes, including results from invasive tests, using multivariate analysis to examine their ability in discriminating among the three patient groups. Our results suggest that miRNA is a promising molecular tool for clinical management of at-risk patients.

MRI-detectability of clinically significant prostate cancer relates to oncologic outcomes after prostatectomy

INTRODUCTION/BACKGROUND

Magnetic resonance imaging (MRI) misses a proportion of "clinically significant" prostate cancers (csPC) as defined by histopathology criteria. The aim of this study was to analyze whether long-term oncologic outcomes differ between MRI-detectable and MRI-occult csPC.

PATIENTS AND METHODS

Retrospective analysis of 1449 patients with pre-prostatectomy MRI and csPC on prostatectomy specimens (ie, Grade group ≥2 or extraprostatic spread) between 2001-2006. T2-weighted MRIs were classified according to the Prostate Imaging Reporting and Data System into MRI-occult (categories 1, 2), MRI-equivocal (category 3), and MRI-detectable (categories 4, 5). Cumulative incidence of biochemical recurrence (BCR), metastatic disease, and cancer-specific mortality, estimated with competing risk models. The median follow-up in survivors was 11.0 years (IQR: 8.9-13.1).

RESULTS

In 188 (13%) cases, csPC was MRI-occult, 435 (30%) MRIs were equivocal, and 826 (57%) csPC were MRI-detectable. The 15-year cumulative incidence [95% CI] of BCR was 8.3% [2.2, 19.5] for MRI-occult cases, 17.4% [11.1, 24.8] for MRI-equivocal cases, and 43.3% [38.7, 47.8] for MRI-detectable cases (P < .001). The cumulative incidences of metastases were 0.61% [0.06, 3.1], 3.5% [1.5, 6.9], and 19.6% [15.4, 24.2] for MRI-occult, MRI-equivocal, and MRI-detectable cases, respectively (P < .001). There were no deaths from prostate cancer observed in patients with MRI-occult csPC, compared to an estimated 1.9% [0.54, 4.9], and 7.1 % [4.5, 10.6] for patients with MRI-equivocal and MRI-detectable cancer, respectively (P < .001).

CONCLUSION

Oncologic outcomes after prostatectomy for csPC differ between MRI-occult and MRI-detectable lesions. Judging the clinical significance of a negative prostate MRI based on histopathologic surrogates alone might be misleading.

MICROABSTRACT

Among 1449 patients with pre-prostatectomy MRI and clinically significant prostate cancer on prostatectomy histopathology, MRI-occult cancers (n = 188, 13%) were less likely to recur biochemically (8% vs. 43%, P < .001), metastasize (0.6% vs. 20%, P < .001), or lead to prostate cancer mortality (0% vs. 7%, P < .001) than MRI-detectable cancers (n = 826, 57%). MRI-occult cancers constitute a prognostically distinct subgroup among higher-grade prostate cancers.

Local Extent of Prostate Cancer at MRI versus Prostatectomy Histopathology: Associations with Long-term Oncologic Outcomes

Background It is unknown how the imperfect accuracy of MRI for local staging of prostate cancer relates to oncologic outcomes. Purpose To analyze how staging discordances between MRI and histopathologic evaluation relate to recurrence and survival after radical prostatectomy. Materials and Methods Health Insurance Portability and Accountability Act-compliant retrospective analysis of preprostatectomy T2-weighted prostate MRI (January 2001 to December 2006). Extraprostatic extension and seminal vesicle invasion were assessed by using five-point Likert scales; scores of 4 or higher were classified as positive. Biochemical recurrence (BCR), metastases, and prostate cancer-specific mortality rates were estimated with Kaplan-Meier and Cox models. Results A total of 2160 patients (median age, 60 years; interquartile range, 55-64 years) were evaluated. Among patients with histopathologic extraprostatic (pT3) disease (683 of 2160; 32%), those with organ-confined disease at MRI (384 of 683; 56%) experienced better outcomes than those with concordant extraprostatic disease at MRI and pathologic analysis: 15-year risk for BCR, 30% (95% CI: 22, 40) versus 68% (95% CI: 60, 75); risk for metastases, 14% (95% CI: 8.4, 24) versus 32% (95% CI: 26, 39); risk for prostate cancer-specific mortality, 3% (95% CI: 1, 6) versus 15% (95% CI: 9.5, 23) (P < .001 for all comparisons). Among patients with histopathologic organ-confined disease (pT2) (1477 of 2160; 68%), those with extraprostatic disease at MRI (102 of 1477; 7%) were at higher risk for BCR (27% [95% CI: 19, 37] vs 10% [95% CI: 8, 14]; P < .001), metastases (19% [95% CI: 6, 48] vs 3% [95% CI: 1, 6]; P < .001), and prostate cancer-specific mortality (2% [95% CI: 1, 9] vs 1% [95% CI: 0, 5]; P = .009) than those with concordant organ-confined disease at MRI and pathologic analysis. At multivariable analyses, tumor extent at MRI (hazard ratio range, 4.1-5.2) and histopathologic evaluation (hazard ratio range, 3.6-6.7) was associated with the risk for BCR, metastases, and prostate cancer-specific mortality (P < .001 for all analyses). Conclusion The local extent of prostate cancer at MRI is associated with oncologic outcomes after prostatectomy, independent of pathologic tumor stage. This might inform a strategy on how to integrate MRI into a clinical staging algorithm. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gottlieb in this issue.

Emerging role of multiparametric magnetic resonance imaging in identifying clinically relevant localized prostate cancer

PURPOSE OF REVIEW

To explore the recent advances and utility of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis and risk-stratification of prostate cancer.

RECENT FINDINGS

Low-risk, clinically insignificant prostate cancer has a decreased risk of morbidity or mortality. Meanwhile, patients with intermediate and high-risk prostate cancer may significantly benefit from interventions like radiation or surgery. To appropriately risk stratify these patients, MRI has emerged as the imaging modality in the last decade to assist in defining prostate cancer significance, location, and biologic aggressiveness. Traditional 12-core transrectal ultrasound-guided biopsy is associated with over-detection, and ultimately over-treatment of clinically insignificant disease, and the under-detection of clinically significant disease. Biopsy accuracy is improved with MRI-guided targeted biopsy and with the use of standardized risk stratification imaging score systems. Cancer detection accuracy is further improved with combined biopsy techniques that include both systematic and MRI-targeted biopsy that aid in detection of MRI-invisible lesions.

SUMMARY

mpMRI is an area of expanding innovation that continues to refine the diagnostic accuracy of prostate biopsies. As mpMRI-targeted biopsy in prostate cancer becomes more commonplace, advances like artificial intelligence and less invasive dynamic metabolic imaging will continue to improve the utility of MRI.

Interactive, Up-to-date Meta-Analysis of MRI in the Management of Men with Suspected Prostate Cancer

The aim of this study was to test an interactive up-to-date meta-analysis (iu-ma) of studies on MRI in the management of men with suspected prostate cancer. Based on the findings of recently published systematic reviews and meta-analyses, two freely accessible dynamic meta-analyses (https://iu-ma.org) were designed using the programming language R in combination with the package "shiny." The first iu-ma compares the performance of the MRI-stratified pathway and the systematic transrectal ultrasound-guided biopsy pathway for the detection of clinically significant prostate cancer, while the second iu-ma focuses on the use of biparametric versus multiparametric MRI for the diagnosis of prostate cancer. Our iu-mas allow for the effortless addition of new studies and data, thereby enabling physicians to keep track of the most recent scientific developments without having to resort to classical static meta-analyses that may become outdated in a short period of time. Furthermore, the iu-mas enable in-depth subgroup analyses by a wide variety of selectable parameters. Such an analysis is not only tailored to the needs of the reader but is also far more comprehensive than a classical meta-analysis. In that respect, following multiple subgroup analyses, we found that even for various subgroups, detection rates of prostate cancer are not different between biparametric and multiparametric MRI. Secondly, we could confirm the favorable influence of MRI biopsy stratification for multiple clinical scenarios. For the future, we envisage the use of this technology in addressing further clinical questions of other organ systems.

Convolutional Neural Networks for Automated Classification of Prostate Multiparametric Magnetic Resonance Imaging Based on Image Quality

Background

Prostate magnetic resonance imaging (MRI) is technically demanding, requiring high image quality to reach its full diagnostic potential. An automated method to identify diagnostically inadequate images could help optimize image quality.

Purpose

To develop a convolutional neural networks (CNNs) based analysis pipeline for the classification of prostate MRI image quality.

Study Type

Retrospective.

Subjects

Three hundred sixteen prostate mpMRI scans and 312 men (median age 67).

Field Strength/Sequence

A 3 T; fast spin echo T2WI, echo planar imaging DWI, ADC, gradient‐echo dynamic contrast enhanced (DCE).

Assessment

MRI scans were reviewed by three genitourinary radiologists (V.P., M.D.M., S.C.) with 21, 12, and 5 years of experience, respectively. Sequences were labeled as high quality (Q1) or low quality (Q0) and used as the reference standard for all analyses.

Statistical Tests

Sequences were split into training, validation, and testing sets (869, 250, and 120 sequences, respectively). Inter‐reader agreement was assessed with the Fleiss kappa. Following preprocessing and data augmentation, 28 CNNs were trained on MRI slices for each sequence. Model performance was assessed on both a per‐slice and a per‐sequence basis. A pairwise t‐test was performed to compare performances of the classifiers.

Results

The number of sequences labeled as Q0 or Q1 was 38 vs. 278 for T2WI, 43 vs. 273 for DWI, 41 vs. 275 for ADC, and 38 vs. 253 for DCE. Inter‐reader agreement was almost perfect for T2WI and DCE and substantial for DWI and ADC. On the per‐slice analysis, accuracy was 89.95% ± 0.02% for T2WI, 79.83% ± 0.04% for DWI, 76.64% ± 0.04% for ADC, 96.62% ± 0.01% for DCE. On the per‐sequence analysis, accuracy was 100% ± 0.00% for T2WI, DWI, and DCE, and 92.31% ± 0.00% for ADC. The three best algorithms performed significantly better than the remaining ones on every sequence (P‐value < 0.05).

Data Conclusion

CNNs achieved high accuracy in classifying prostate MRI image quality on an individual‐slice basis and almost perfect accuracy when classifying the entire sequences.

Evidence Level

4

Technical Efficacy

Stage 1

Effects of Clinical Pathways on Cesarean Sections in China: Length of Stay and Direct Hospitalization Cost Based on Meta-Analysis of Randomized Controlled Trials and Controlled Clinical Trials

The cesarean section (CS) on maternal request increased sharply in China, bringing pressure to medical resources and national insurance. We assessed the use of clinical pathways (CPWs) for CS compared with conventional medical care by outcomes of length of stay (LOS) in hospital and direct hospitalization cost (DHC). Four Chinese electronic databases, including China National Knowledge Infrastructure (CNKI), Wanfang, CQVIP, and SinoMed, were explored to December 2020 for the full-text papers published in Chinese. Literature that quantitatively assessed the effects of CPW on LOS or DHC were eligible for inclusion. The weighted mean differences (WMDs) were pooled. Twenty-five articles were included in our analysis, with a total sample of 7761 women. These studies were performed from 2004 to 2017 and reported from 2005 to 2018. The synthesized results showed a shorter LOS (in days) (WMD = −1.37, 95% CI: −1.48 to −1.26) and a less DHC (CNY¥) (WMD = −520.46, 95% CI: −554.06 to −503.63) in the CPW group, comparing with that of conventional care. With the need for CS on the rise, the introduction of CPW could effectively reduce LOS and DHC, thereby releasing the medical resources and insurance pressure.

International Multi-Site Initiative to Develop an MRI-Inclusive Nomogram for Side-Specific Prediction of Extraprostatic Extension of Prostate Cancer

BACKGROUND

To develop an international, multi-site nomogram for side-specific prediction of extraprostatic extension (EPE) of prostate cancer based on clinical, biopsy, and magnetic resonance imaging- (MRI) derived data.

METHODS

Ten institutions from the USA and Europe contributed clinical and side-specific biopsy and MRI variables of consecutive patients who underwent prostatectomy. A logistic regression model was used to develop a nomogram for predicting side-specific EPE on prostatectomy specimens. The performance of the statistical model was evaluated by bootstrap resampling and cross validation and compared with the performance of benchmark models that do not incorporate MRI findings.

RESULTS

Data from 840 patients were analyzed; pathologic EPE was found in 320/840 (31.8%). The nomogram model included patient age, prostate-specific antigen density, side-specific biopsy data (i.e., Gleason grade group, percent positive cores, tumor extent), and side-specific MRI features (i.e., presence of a PI-RADSv2 4 or 5 lesion, level of suspicion for EPE, length of capsular contact). The area under the receiver operating characteristic curve of the new, MRI-inclusive model (0.828, 95% confidence limits: 0.805, 0.852) was significantly higher than that of any of the benchmark models (p < 0.001 for all).

CONCLUSIONS

In an international, multi-site study, we developed an MRI-inclusive nomogram for the side-specific prediction of EPE of prostate cancer that demonstrated significantly greater accuracy than clinical benchmark models.

ESUR/ESUI position paper: developing artificial intelligence for precision diagnosis of prostate cancer using magnetic resonance imaging

Abstract

Artificial intelligence developments are essential to the successful deployment of community-wide, MRI-driven prostate cancer diagnosis. AI systems should ensure that the main benefits of biopsy avoidance are delivered while maintaining consistent high specificities, at a range of disease prevalences. Since all current artificial intelligence / computer-aided detection systems for prostate cancer detection are experimental, multiple developmental efforts are still needed to bring the vision to fruition. Initial work needs to focus on developing systems as diagnostic supporting aids so their results can be integrated into the radiologists’ workflow including gland and target outlining tasks for fusion biopsies. Developing AI systems as clinical decision-making tools will require greater efforts. The latter encompass larger multicentric, multivendor datasets where the different needs of patients stratified by diagnostic settings, disease prevalence, patient preference, and clinical setting are considered. AI-based, robust, standard operating procedures will increase the confidence of patients and payers, thus enabling the wider adoption of the MRI-directed approach for prostate cancer diagnosis.

Key Points

• AI systems need to ensure that the benefits of biopsy avoidance are delivered with consistent high specificities, at a range of disease prevalence.

• Initial work has focused on developing systems as diagnostic supporting aids for outlining tasks, so they can be integrated into the radiologists’ workflow to support MRI-directed biopsies.

• Decision support tools require a larger body of work including multicentric, multivendor studies where the clinical needs, disease prevalence, patient preferences, and clinical setting are additionally defined.

Is Additional Systematic Biopsy Necessary in All Initial Prostate Biopsy Patients With Abnormal MRI?

Purpose

To determine whether additional systematic biopsy is necessary in all biopsy naïve patients with MRI visible lesions by taking PI-RADS score and prostate volume into consideration.

Materials and Methods

Patients who underwent combined systematic biopsy (SB) and cognitive MRI-targeted biopsy (TB) in our hospital between May 2018 and June 2020 were retrospectively reviewed. The detection rate of clinical significant prostate cancer (csPCa), biopsy grade group (GG) concordance, and disease upgrading rate on radical prostatectomy were compared between SB and TB and further stratified by PI-RADS v2.0 category and prostate volume.

Results

A total of 234 patients were analyzed in this study. TB alone detected more csPCa and less clinically insignificant prostate cancer (cisPCa) than SB alone in the whole cohort (57.3 vs 53%, P = 0.041; 3.8 vs 7.7%, P = 0.049 respectively). The additional SB indicated only a marginal increase of csPCa detection but a remarkable increase of cisPCa detection compared with targeted biopsy (59.4 vs 57.3%, P = 0.064; 3.8 vs 7.7%, P = 0.012). As stratified by PI-RADS category, the difference of csPCa detection rate between TB and SB was not significant either in PI-RADS 5 subgroup (83.8 vs 76.3%, P = 0.07) or in PI-RADS 3–4 subgroup (43.5 vs 40.9%, P = 1.0). Additional SB decreased the rate of disease upgrading on radical prostatectomy (RP) than TB alone in PI-RADS 3–4 subgroup (14.5 vs 25.5%, P = 0.031) other than PI-RADS 5 subgroup (6 vs 6%, P = 1.0). When stratified by prostate volume (PV), TB alone detected more csPCa than SB in small prostate (PV < 30 ml) group (81.0 vs 71.0%, P = 0.021) but not in large prostate (PV ≥ 30 ml) group (44.0 vs 42.7%, P = 0.754). The additional SB did not significantly decrease the rate of disease upgrading on RP than TB alone in either small or large prostate (6.4 vs 8.5%, P = 1.0; 13.8 vs 22.4%, P = 0.063).

Conclusion

The combination biopsy method was no superior than targeted biopsy alone in PI-RADS 5 or in small volume prostate subgroup.

Magnetic resonance imaging-guided prostate biopsy-A review of literature

Objective

Multiparametric magnetic resonance imaging (MP-MRI) helps to identify lesion of prostate with reasonable accuracy. We aim to describe the various uses of MP-MRI for prostate biopsy comparing different techniques of MP-MRI guided biopsy.

Materials and methods

A literature search was performed for "multiparametric MRI", "MRI fusion biopsy", "MRI guided biopsy", "prostate biopsy", "MRI cognitive biopsy", "MRI fusion biopsy systems", "prostate biopsy" and "cost analysis". The search operation was performed using the operator "OR" and "AND" with the above key words. All relevant systematic reviews, original articles, case series, and case reports were selected for this review.

Results

The sensitivity of MRI targeted biopsy (MRI-TB) is between 91%-93%, and the specificity is between 36%-41% in various studies. It also has a high negative predictive value (NPV) of 89%-92% and a positive predictive value (PPV) of 51%-52%. The yield of MRI fusion biopsy (MRI-FB) is similar, if not superior to MR cognitive biopsy. In-bore MRI-TB had better detection rates compared to MR cognitive biopsy, but were similar to MR fusion biopsy.

Conclusions

The use of MRI guidance in prostate biopsy is inevitable, subject to availability, cost, and experience. Any one of the three modalities (i.e. MRI cognitive, MRI fusion and MRI in-bore approach) can be used. MRI-FB has a fine balance with regards to accuracy, practicality and affordability.

Nonsuspicious prebiopsy multiparametric MRI: is prostate biopsy still necessary?

PURPOSE

To evaluate the negative predictive value (NPV) of multiparametric magnetic resonance imaging (mpMRI), alone or combined with Prostate-Specific Antigen density (PSAd) to exclude clinically significant prostate cancer (csPCa).

PATIENTS AND METHODS

We performed a retrospective chart review of all the patients who had transrectal ultrasound-guided biopsy (TRUSGB) in our center between January 2014 and March 2019. We included patients who had nonsuspicious prebiopsy mpMRI defined as Prostate Imaging-Reporting and Data System (PI-RADS) ≤ 2. MRI was performed using a 1.5 or 3-Tesla Magnetic Resonance scanners with external phased-array coil. The primary outcome was the detection of csPCa, defined as a Gleason score 3 + 4 (ISUP 2) or higher on at least one biopsy core.

RESULTS

One hundred and ninety-one consecutive men (median age: 65 years, median PSA level: 9.3 ng/mL) underwent TRUSGB following negative prebiopsy mpMRI corresponding to 126 (66%) biopsy-naïve patients, 36 (18.8%) patients with prior negative biopsy, and 29 (15.2%) patients under active surveillance with confirmatory biopsies. The overall PCa and csPCA detection rates were 26.7% and 5.2%, conferring a NPV of 73.3% and 94.8%, respectively. The NPV of negative mpMRI improved to 95.8% in patients with PSAd < 0.15 ng/mL/cm³ and to 100% in patients with PSAd < 0.10 ng/mL/cm³.

CONCLUSIONS

A negative prebiopsy mpMRI had an overall NPV of 94.8% for csPCa when mpMRI was used alone to 95.8% when combined with PSAd < 0.15 ng/mL/cm³. Future studies are needed to balance the low benefit of a biopsy in this indication with the morbidity of the procedure.

Prostate MRI: practical guidelines for interpreting and reporting according to PI-RADS version 2.1

The increasing precision of multiparametric magnetic resonance imaging of the prostate, together with greater experience and standardization in its interpretation, has given this technique an important role in the management of prostate cancer, the most prevalent non-cutaneous cancer in men. This article reviews the concepts in PI-RADS version 2.1 for estimating the probability and zonal location of significant tumors of the prostate, using a practical approach that includes current considerations about the prerequisites for carrying out the test and recommendations for interpreting the findings. It emphasizes benign findings that can lead to confusion and the criteria for evaluating the probability of local spread, which must be included in the structured report.

Intercenter reproducibility of software-based fusion biopsies for grade group prediction when targeting suspicious MRI lesions

PURPOSE

To assess the intercenter reproducibility of software-based fusion targeted biopsy (TB) for grade-group assessment and pretherapeutic evaluation of highly suspicious MRI lesions.

PATIENTS AND METHODS

In this study, were included 380 consecutive patients who underwent radical prostatectomy (RP) after prostate cancer diagnosis and a prebiopsy MRI showing Prostate Imaging-Reporting and Data System (PIRADS) score 4 or 5 lesions. All patients underwent systematic biopsies (SB) combined with software-based fusion TB in the 2 centers. Biopsies were only performed by expert urologists or radiologists in a contemporary time frame. The primary endpoint was the center difference of concordance/upgrading rates between biopsy and RP specimens.

RESULTS

Pathological features on biopsy and RP specimens were significantly different among centers with more unfavourable disease in center 1. The rate of TB upgrading was 33.6% in center 1 vs. 35.4% (P = 0.860) in center 2. Grading concordance was also comparable among centers (50.0% vs. 47.1%) as well as the SB upgrading rate. Regression analysis did not find any baseline characteristics (Age, prostate-specific antigen, MRI lesions, center) predictive for TB upgrading. These findings were achieved by using fewer TB per lesion in center 1 (2.3 vs. 5.0, P < 0.001), at the expense of more SB cores (14.4 vs. 8.5, P < 0.001). The influence of MRI characteristics (lesion size and number, PIRADS score) on upgrading rates was consistent among centers.

CONCLUSIONS

Software-based fusion TB technique leads to comparable outcomes in terms of grade group prediction accuracy in PIRADS 4 to 5 lesions, insignificant between centers, in spite of different non imaging-based aggressiveness features.

The optimal core number and site for MRI-targeted biopsy of prostate? A systematic review and pooled analysis

INTRODUCTION

Prebiopsy multiparametric magnetic resonance imaging (mpMRI) has been increasingly utilized for patients of suspicious prostate cancer (PCa). However, the optimal core number and site for MRI-targeted biopsy have not been clearly elucidated.

EVIDENCE ACQUISITION

A systematic search in Pubmed, Embase and Ovid up to June 2019 was conducted and we identified studies reporting detection details of every MRI-targeted core. The incremental diagnostic value of performing additional cores was pooled on per-lesion analysis. Our secondary outcome concentrated on detection accuracy for cores of different site within one lesion.

EVIDENCE SYNTHESIS

Five studies comprising 2291 patients were identified to elucidate the association between targeted core number and cancer detection rates. Adding the second core to the first one resulted in 19.8% (range: 13.6-26.7%) increase in the detection rate of clinically significant lesions, and adding the third one to the first two resulted in 11.5% (range: 7.8-14.3%) increase. The incremental value of adding the fourth or the fifth core was 6.0% (4.7%, 6.9%) and 4.1% respectively. Four studies arranging MRI-targeted biopsy of more than two cores in well-determined sequences indicated more positive cores with higher cancer grade through center of the lesions.

CONCLUSIONS

Increasing the number of samples per target from one to two, or two to three resulted in a nonnegligible incremental detection rate of clinically significant lesions, while obtaining more than 3 cores per target provided a diminished incremental value. And performing targeted cores accurately through center of the lesions may help improve diagnostic accuracy.