The significance of anterior prostate lesions on multiparametric magnetic resonance imaging in African-American men

Likelihood of sampling prostate cancer at systematic biopsy as a function of gland volume and number of cores

BACKGROUND

Pre-biopsy multiparametric magnetic resonance imaging (mpMRI) of the prostate is used to conduct targeted prostate biopsy (TB), guided by ultrasound and registered (fused) to the MRI. Systematic biopsy (SB) continues to be used together with TB or in mpMRI-negative patients. There is insufficient evidence on how to use SB to inform clinical decision-making in the mpMRI era. The purpose of this study was to estimate the effect of prostate volume and number of SB cores on sampling clinically significant prostate cancer (csPCa) using a simulation method based on clinical data.

METHODS

SBs were simulated using data from 42 patients enrolled in a transrectal ultrasound robot-assisted biopsy trial. Linear mixed models were used to examine the relationship between the number of SB cores and prostate volume on 1) clinically significant cancer detection probability (csCDP) and 2) percent of mpMRI depicted regions of interest (ROIs) sampled with the SB.

RESULTS

Median values and interquartile range (IQR) were 47.16 cm3 (35.61-65.57) for prostate volume, 0.57 cm3 (0.39-0.83) for ROI volume, and 4.0 (2-4) for PI-RADS v2.1 scores on MRI. csCDP increased with the increasing number of simulated SB cores and decreased substantially with larger prostate volume. Similarly, the percent of ROIs sampled increased with the increasing number of simulated SB cores and was lower for prostate volumes ≥60 cm3 compared to glands <60 cm3.

CONCLUSIONS

The effect of the number of SBs performed on detecting csPCa varies largely with gland volume. The common 12-core SB can achieve adequate cancer detection and sampling of ROIs in smaller glands, but not in larger glands. In addition to TB or in mpMRI-negative patients, the number of SB cores can be adjusted to prostate volume. Performing 12-core SB alone in ≥60 cm3 glands results in inadequate sampling and potential PCa underdiagnosis.

Racial differences in patient-reported outcomes among men treated with radical prostatectomy for prostate cancer

BACKGROUND

Real-world data on racial differences in the side effects of radical prostatectomy on quality of life (QoL) are lacking. We aimed to evaluate differences in patient-reported outcome measure (PROM) among non-Hispanic Black (NHB) and non-Hispanic White (NHW) men using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) questionnaire to measure health-related QoL after radical prostatectomy.

METHODS

We retrospectively assessed prospectively collected PROMs using EPIC-CP scores at a tertiary care center between 2015 and 2021 for men with prostate cancer undergoing radical prostatectomy. The primary endpoint was the overall QoL score for NHB and NHW men, with a total score of 60 and higher scores indicating worse QoL. An imputed mixed linear regression model was used to examine the effect of covariates on the change in overall QoL score following surgery. A pairwise comparison was used to estimate the mean QoL scores before surgery as well as up to 24 months after surgery.

RESULTS

Our cohort consisted of 2229 men who answered at least one EPIC-CP questionnaire before or after surgery, of which 110 (4.94%) were NHB and 2119 (95.07%) were NHW men. The QoL scores differed for NHB and NHW at baseline (2.34, 95% confidence interval [CI] 0.36-4.31, p = 0.02), 3 months (4.36, 95% CI 2.29-6.42, p < 0.01), 6 months (3.26, 95% CI 1.10-5.43, p < 0.01), and 12 months after surgery (2.48, 95% CI 0.19-4.77, p = 0.03) with NHB having worse scores. There was no difference in QoL between NHB and NHW men 24 months after surgery.

CONCLUSIONS

A significant difference in QoL between NHB and NHW men was reported before surgery, 3, 6, and 12 months after surgery, with NHB having worse QoL scores. However, there was no long-term difference in reported QoL. Our findings inform strategies that can be implemented to mitigate racial differences in short-term outcomes.

African American Men have Increased Risk of Prostate Cancer Detection Despite Similar Rates of Anterior Prostatic Lesions and PI-RADS Grade on Multiparametric Magnetic Resonance Imaging

OBJECTIVE

To determine whether the frequency of anterior prostate lesions (APL) on multiparametric magnetic resonance imaging (mpMRI) prior to biopsy differed between African American (AA) and non-AA men and evaluate implications of race and tumor location for prostate cancer (PCa) detection.

METHODS

Patients from the Prospective Loyola University mpMRI (PLUM) Prostate Biopsy Cohort (January 2015-December 2020) without prior diagnosis of PCa were evaluated for APLs by race. Multivariable logistic regression models evaluated predictors of APLs and associations of APLs and race with detection of any PCa (grade group 1+) and clinically significant PCa (csPCa; grade group 2+). Additional stratified and propensity score matched analyses were conducted.

RESULTS

Of 1,239 men included, 190 (15.3%) were AA and 302 (24.4%) had at least one APL with no differences by race on multivariable analysis. While men with APLs were twice as likely to harbor PCa or csPCa, the unadjusted proportion of targeted biopsy-confirmed APL PCa (12.6% vs 12.0%) or csPCa (8.4% vs 8.9%) were similar for AA and non-AA men. AA men had higher risk of prostate cancer on targeted cores (OR 1.66 (95%CI 1.06 - 2.61), P = 0.026) which was independent of lesion location or PI-RADS.

CONCLUSION

AA men were found to have similar rates of APLs on mpMRI to non-AA men indicating access to mpMRI may mitigate some of the historical racial disparity based on lesion location. AA men have increased risk of PCa detection compared to non-AA men independent of anterior location or lesion grade on mpMRI reinforcing the importance of identifying genetic, biologic, and socioeconomic drivers.

A Systematic Review for Health Disparities and Inequities in Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis

RATIONALE AND OBJECTIVES

Multi-parametric Magnetic Resonance Imaging (mpMRI) is a novel procedure recommended by the American Urological Association for Prostate Cancer (PCa) diagnosis. In radiology, differences in utilization of expensive screening techniques are described but never reviewed for mpMRI. Thus, our article aims at summarizing disparities relating to the expensive yet revolutionary mpMRI in United States men with PCa while highlighting needed research areas.

MATERIAL AND METHODS

Eligible articles were gathered via PubMed query, referred publications known to the authors or from the reference lists of the identified publications. We excluded studies that didn't specifically evaluate mpMRI technique, weren't conducted in the United States, or didn't directly assess the relationship between disparities and mpMRI. No date restrictions were applied, resulting articles were published through 2020.

RESULTS

Out of 80 publications, 17 were selected. Two unique themes were identified: 1) disparities in mpMRI utilization, and 2) performance. While demographic factors such as race, age and socioeconomic status played a significant role in utilization, mpMRI demonstrated equal and sometimes superior performance in AAs.

CONCLUSION

Our findings illustrate the importance of disparity awareness in PCa mpMRI and highlight the need to examine additional mpMRI disparities across other races and social determinants. A new area of inequity in PCa was theoretically illustrated, as lower utilization of mpMRI was detected in a group that could potentially benefit from it the most. Major limitation was the selected search terms. Our review is unique as disparities related to mpMRI were found to be multilayered, affecting utilization and performance. Continued research is needed to discover additional areas in efforts to reduce disparity gaps related to mpMRI and PCa.

TMPRSS2-ERG fusion impacts anterior tumor location in men with prostate cancer

BACKGROUND

In prostate cancer (PCa), lack of androgen receptor (AR) regulated TMPRSS2-ETS-related gene (ERG) gene fusion (ERG^negative ) status has been associated with African American race; however, the implications of ERG status for the location of dominant tumors within the prostate remains understudied.

METHODS

An African American-enriched multiinstitutional cohort of 726 PCa patients consisting of both African American men (AAM; n = 254) and European American men (EAM; n = 472) was used in the analyses. Methods of categorical analysis were used. Messenger RNA (mRNA) expression differences between anterior and posterior tumor lesions were analyzed using Wilcoxon rank-sum tests with multiple comparison corrections.

RESULTS

Anti-ERG immunohistochemistry staining showed that the association between ERG status and anterior tumors is independent of race and is consistently robust for both AAM (ERG^negative 81.4% vs. ERG^positive 18.6%; p = .005) and EAM (ERG^negative 60.4% vs. ERG^positive 39.6%; p < .001). In a multivariable model, anterior tumors were more likely to be IHC-ERG^negative (odds ratio [OR]: 3.20; 95% confidence interval [CI]: 2.14-4.78; p < .001). IHC-ERG^negative were also more likely to have high-grade tumors (OR: 1.73; 95% CI: 1.06-2.82; p = .02). In the exploratory genomic analysis, mRNA expression of location-dependent genes is highly influenced by ERG status and African American race. However, tumor location did not impact the expression of AR or the major canonical AR-target genes (KLK3, AMACR, and MYC).

CONCLUSIONS

ERG^negative tumor status is the strongest predictor of anterior prostate tumors, regardless of race. Furthermore, AR expression and canonical AR signaling do not impact tumor location.

Health disparities and inequities in the utilization of diagnostic imaging for prostate cancer

PURPOSE

To review and summarize the reported health disparities and inequities in diagnostic imaging for prostate cancer.

METHODS

We queried the PubMed search engine for original publications studying disparate utilization of diagnostic imaging for prostate cancer. Query terms were as follows: prostate AND cancer AND diagnostic AND imaging AND (magnetic resonance imaging (MRI) OR computed tomography (CT) OR bone scintigraphy OR positron emission tomography (PET)-CT)) AND (inequities OR disparities OR socioeconomic OR race). Studies were included if they involved United States patients, had diagnostic imaging as a part of their care, and addressed health inequities.

RESULTS

A total of 104 studies were captured in the initial query with 17 meeting inclusion criteria, comprising 10 population-based analyses, 5 single institutional analyses, 1 multi-institutional analysis, and 1 review. Socioeconomic status and race were frequently associated with imaging utilization and guideline-concordant care. SEER analyses revealed that African-American men had higher odds of experiencing overuse of pelvic CT/pelvic MRI and bone scans, while older men experienced underuse. Higher income and younger age were more likely to receive imaging that was adherent to NCCN guidelines. African-American and Hispanic men were less likely than white men to receive prostate multiparametric MRI.

CONCLUSION

Race, age, and socioeconomic status play a significant role in the diagnostic management of prostate cancer. Certain demographics are more disparately affected and less likely to receive guideline-concordant care. Continued research and interventions are needed to ensure appropriate and accessible diagnostic imaging for prostate cancer and ultimately the delivery of quality and equitable care.

Clinicopathologic features and outcomes of anterior-dominant prostate cancer: implications for diagnosis and treatment

OBJECTIVE

This study aims to describe the pathological features and clinical outcomes in anterior-dominant prostate cancer (APCA) compared to posterior/posterolateral-dominant prostate cancer (PPCA) among men treated with radical prostatectomy for localized prostate cancer.

METHODS

This is a single-institution, matched case-control analysis of short-term clinical outcomes stratified by pathologic tumor location at radical prostatectomy. Pathologic data extracted by expert genitourinary pathologists on tumor location was linked to clinical and oncologic outcomes data from a prospective institutional database for analysis.

RESULTS

From 2005 to 2013, 1580 patients were identified for analysis with 150 (9.5%) having APCA. One-hundred and thirty two of these APCA men had complete clinical data and were matched to 353 men with PPCA (~1:3 ratio) by GrdGrp at surgery, margin status, and pathologic T stage. There were no racial/ethnic differences between APCA and PPCA (p = 0.13). Men with APCA demonstrated a higher median PSA at diagnosis (6.4 [4.6-9.1] ng/mL vs 5.6 [4.4-8.1] ng/mL; p = 0.04), a higher rate of GrdGrp 1 disease at diagnosis (57.7% vs. 40.0%, p = 0.003), and lower rates of abnormal digital rectal examination (DRE) (10.1% vs. 23.2%, p = 0.003) when compared to PPCA. The rate of surgical upgrading was higher among men with APCA vs. PPCA (55.3% vs 42.0%, p = 0.015). Freedom from biochemical failure (BF) at 5-years was 85.1% (95% CI 73.1-98.9) for APCA and 82.9% (95% CI 69.2-99.5) for men with PPCA (p = 0.70, log-rank test).

CONCLUSIONS

The majority of anterior tumors were undetectable by DRE and were associated with higher PSA at diagnosis. Despite presenting mostly as low/intermediate grade cancers, more than half of the men with APCA had upgrading at surgery and slightly more than 40% had positive margins and/or extraprostatic disease. When matched to a cohort of posterior predominant tumors, no differences were seen in the rate of biochemical-failure after prostatectomy.

Targeted biopsy: benefits and limitations

PURPOSE OF REVIEW

To review the current literature regarding the role of multiparametric MRI and fusion-guided biopsies in urologic practice.

RECENT FINDINGS

Fusion biopsies consistently show an increase in the detection of clinically significant cancers and decrease in low-risk disease that may be more suitable for active surveillance. Although, when to incorporate multiparametric MRI into workup is not clearly agreed upon, studies have shown a clear benefit in both biopsy naïve and those with prior negative biopsies in determining the appropriate treatment strategy. More recently, cost-analysis models have been published that show that upfront MRIs are more cost-effective when considering missed cancers and treatment courses.

SUMMARY

With improved accuracy over systematic biopsies, fusion biopsies are a superior method for detection of the true grade of cancer for both biopsy naïve and patients with prior negative biopsies, choosing appropriate candidates for active surveillance, and monitoring progression on active surveillance.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation

Objective:

To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective.

Materials and Methods:

MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor.

Results:

Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy.

Conclusion:

Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Anterior Localization of Prostate Cancer Suspicious Lesions in 1,161 Patients Undergoing Magnetic Resonance Imaging/Ultrasound Fusion Guided Targeted Biopsies

PURPOSE

Based on findings in transrectal ultrasound guided biopsy series standard sampling of the prostate targets the posterior/peripheral zone. However, a substantial proportion of lesions that are prostate cancer suspicious and PI-RADS™ (Prostate Imaging Reporting and Data System) 3 or greater on magnetic resonance imaging is located in the anterior segment of the prostate, requiring deeper placement and targeting of the biopsy needle.

MATERIALS AND METHODS

Overall 1,161 patients underwent magnetic resonance imaging/ultrasound fusion guided targeted biopsy. Prostate cancer suspicious lesions on magnetic resonance imaging were dichotomized into anterior vs posterior prostate segments. Patients were stratified by the number of prior negative systematic biopsy sessions. Descriptive statistics included the frequency and proportion of multiparametric magnetic resonance imaging findings and corresponding histological results.

RESULTS

Targeted biopsy was performed in 513 patients (44%) who were systematic biopsy naïve, 396 (34%) with 1 prior negative systematic biopsy and 252 (22%) with 2 or more prior negative systematic biopsies. When patients were stratified by the number of prior systematic biopsy sessions, the proportion with exclusively anterior, PI-RADS 3 or greater lesions on magnetic resonance imaging increased from 3.5% to 9.1% (p = 0.006). Unfavorable 3 + 4 and 4 + 3 or greater primary Gleason patterns were identified in exclusively anterior vs posterior lesions in 31% vs 21% of the 448 patients, of whom 64 had exclusively anterior and 384 had posterior PI-RADS 3 or greater lesions, respectively, on magnetic resonance imaging. Multivariable logistic regression analyses confirmed these findings.

CONCLUSIONS

After multiple previous negative systematic biopsy sessions the proportion of anterior lesions on magnetic resonance imaging increased. Such lesions harbored a greater amount of unfavorable prostate cancer. Therefore, image guidance for precise targeting should be considered, especially after initially negative transrectal ultrasound guided systematic biopsy.

Changes in prostate cancer detection rate of MRI-TRUS fusion vs systematic biopsy over time: evidence of a learning curve

BACKGROUND

To determine the effect of urologist and radiologist learning curves and changes in MRI-TRUS fusion platform during 9 years of NCI's experience with multiparametric magnetic resonance imaging (mpMRI)/TRUS fusion biopsy.

METHODS

A prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007 to 2016 was reviewed. The patients were stratified based on the timing of first biopsy. Cohort 1 (7/2007-12/2010) accounted for learning curve. Cohort 2 (1/2011-5/2013) and cohort 3 (5/2013-4/2016) included patients biopsied prior to and after debut of a new software platform, respectively. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. McNemar's test compared cancer detection rates (CDRs) of Sbx and Fbx between time periods.

RESULTS

1528 patients were included in the study with 230, 537 and 761 patients included in three respective cohorts. Median age (interquartile range) was 61.0 (±9.0), 62.0 (±7.3), and 64.0 (±11.0) years in three cohorts, respectively (P<0.001). Fbx and Sbx had comparable CS CDR in cohort 1 (24.8 vs 22.2%, P=0.377). Fbx detected significantly more CS disease compared to Sbx in the following two periods (cohort 2: 31.5 vs 25.0%, P=0.001; cohort 3: 36.4 vs 30.3%, P<0.001) and detected significantly less low risk disease in the same period (cohort 2: 14.5 vs 19.6%, P<0.001; cohort 3: 12.6 vs 16.7%, P<0.001). Even after multivariate adjustment with age, PSA, race, clinical stage and MRI suspicion score, Fbx CS cancer detection increased in successive cohorts (cohort 2: OR 2.23, P=0.043; cohort 3: OR 2.92, P=0.007).

CONCLUSIONS

In the past 9 years, there has been significant improvement in the accuracy of Fbx. Our results show that after an early learning period, Fbx detected higher rates of CS cancer and lower rates of clinically insignificant cancer than Sbx. Software advances allowed for even greater detection of CS disease.

Magnetic resonance imaging detection of prostate cancer in men with previous negative prostate biopsy

Use of transrectal ultrasound guided systematic prostate biopsy has poor diagnostic accuracy for prostate cancer (PCa) detection. Recently multiparametric MRI (mpMRI) of the prostate and MR/US fusion biopsy has been gaining popularity for men who have previously undergone a negative biopsy. We performed PubMed® and Web of Science® searches to identify studies on this subject, particularly focusing on studies consisting of patients who have had at least one previously negative biopsy. Across the literature, when a suspicious lesion is found on mpMRI, MR/US fusion biopsy has consistently demonstrated higher detection rate for any PCa and clinically significant PCa (csPCa) compared to the traditional repeat systematic biopsy (SB) approach. Furthermore, anteriorly located tumors are frequently identified using MR targeted biopsy (TB), suggesting that an MR guided approach allows for increased accuracy for detecting tumors commonly missed by systematic biopsies. We conclude that men with a prior negative biopsy and continued suspicion of PCa should strongly be encouraged to get a prostate mpMRI prior to a repeat biopsy.

Multiparametric MRI/ultrasound fusion-guided biopsy decreases detection of indolent cancer in African-American men

BACKGROUND

Analysis of systematic 12-core biopsies (SBx) has shown that African-American (AA) men tend to harbor higher risk prostate cancer (PCa) at presentation relative to other races. Multiparametric magnetic resonance imaging (mpMRI) and MRI-ultrasound fusion-guided biopsy (FBx) have been shown to diagnose more intermediate- and high-risk PCa in the general population; however, the efficacy in AA remains largely uncharacterized. We aim to evaluate the utility of FBx in an AA patient cohort.

METHODS

Men suspected of PCa underwent an mpMRI and FBx with concurrent SBx from 2007 to 2015 in this institutional review board-approved prospective cohort study. Patient demographics, imaging and fusion biopsy variables were collected. χ², Mann-Whitney U-test and McNemar's tests were performed to compare proportions, means and paired variables, respectively. Clinically significant PCa (CSPCa) was defined as Gleason score ⩾3+4.

RESULTS

Fusion biopsy demonstrated exact agreement with SBx risk categories in 64% of AA men. There was no statistically significant difference in the detection of CSPCa between FBx vs SBx (68 vs 62 cases, P=0.36). However, FBx detected 41% fewer cases of clinically insignificant PCa (CIPCa) compared with SBx (FBx 30 vs SBx 51 cases, P=0.0004). The combined FBx/SBx biopsy approach detected significantly more cases of CSPCa (FBx/SBx 80 vs SBx 62 cases, P=0.004) while detecting comparable number of cases of CIPCa (FBx/SBx 45 vs SBx 51 cases, P=0.37) compared with SBx alone. FBx/SBx also detected more CSPCa in patients with a history of prior negative SBx (FBx/SBx 28 vs 19 cases, P=0.003).

CONCLUSIONS

FBx when used in combination with SBx detected more cases of CSPCa while not significantly increasing the diagnosis of CIPCa in AA men. Future multicenter studies will be needed to validate ultimately the clinical implications of FBx in AA patients.

Risk stratification of prostate cancer: integrating multiparametric MRI, nomograms and biomarkers

Accurate risk stratification of prostate cancer is achieved with a number of existing tools to ensure the identification of at-risk patients, characterization of disease aggressiveness, prediction of cancer burden and extrapolation of treatment outcomes for appropriate management of the disease. Statistical tables and nomograms using classic clinicopathological variables have long been the standard of care. However, the introduction of multiparametric MRI, along with fusion-guided targeted prostate biopsy and novel biomarkers, are being assimilated into clinical practice. The majority of studies to date present the outcomes of each in isolation. The current review offers a critical and objective assessment regarding the integration of multiparametric MRI and fusion-guided prostate biopsy with novel biomarkers and predictive nomograms in contemporary clinical practice.

Midline lesions of the prostate: role of MRI/TRUS fusion biopsy and implications in Gleason risk stratification

PURPOSE

MRI-TRUS fusion biopsy (FBx) has proven efficacy in targeting suspicious areas that are traditionally missed by systematic 12-core biopsy (SBx). Midline prostate lesions are undersampled during SBx, as traditional approaches aim laterally during TRUS biopsy. The aim of our study was to determine the utility of FBx for targeting midline lesions identified on multiparametric MRI (mpMRI).

METHODS

A review was performed of a prospectively maintained database of patients undergoing mpMRI followed by FBx and SBx from 2007 to 2015. Midline location was defined as any lesion crossing the midline on axial imaging and involving both prostatic lobes. Index lesion was defined as lesion with highest Gleason score on biopsy. Patient demographic, imaging, and histopathologic data were collected. Multivariate logistic regression was conducted to determine independent predictors of having clinically significant (CS) cancer (Gleason ≥ 7) in midline lesions.

RESULTS

Out of 1266 patients, we identified 202 suspicious midline lesions in 190 patients [median (IQR) age 63 (10) years; PSA 7.6 (6.6)]. Eighty-eight (46.3 %) patients had cancer detection on FBx of midline lesion. A midline target represented the index lesion of the prostate in 63/190 (33.2 %) patients. Risk category upgrading based on FBx of a midline lesion compared to SBx occurred in 45/190 patients (23.7 %). On multivariate analysis, higher PSA (p = .001), lower MRI-derived prostate volume (p < .001), and moderate-high or high suspicion on mpMRI (p = .014) predicted CS cancer in midline lesions.

CONCLUSIONS

MRI-TRUS FBx facilitates sampling of midline lesions. Integration of mpMRI and FBx for targeting of midline lesions improves detection of CS prostate cancer.

A urologist's perspective on prostate cancer imaging: past, present, and future

Prostate cancer is unique in that unlike other solid organ malignancies, only recently has imaging been employed to routinely detect and localize disease. The introduction of transrectal ultrasound was a significant development, transitioning digitally guided prostate biopsies to ultrasound guidance. The arrival of multiparametric MRI has become the next major step, transforming the way Urologist's diagnose, stage, and treat prostate cancer. Recent recommendations against PSA screening have changed the landscape of urologic oncology with the changing needs being reflected in the initiation of additional robust imaging techniques at different time points in prostate cancer care. The current review aims to provide a clinical perspective in the history, current standard of care, and novel imaging modalities in the evaluation of prostate cancer.