MRI after focal therapy for prostate cancer: what radiologists must know?

Focal therapy (FT) is a rapidly growing field aiming to minimize the side effects of whole gland treatments in patients with localized prostate cancer and multiparametric MRI plays an important role in patient selection, treatment planning, and post-treatment monitoring. This article reviews the currently available prostate cancer FT techniques, discusses the key imaging findings that affect patient selection and treatment planning, and illustrates the spectrum of expected and abnormal post-treatment MRI findings.

Interpreting Prostate Multiparametric MRI: Beyond Adenocarcinoma - Anatomical Variations, Mimickers, and Post-Intervention Changes

Prostate magnetic resonance imaging (MRI) is an essential tool in the diagnostic pathway for prostate cancer. However, its accuracy can be confounded by a spectrum of noncancerous entities with similar radiological features, posing a challenge for definitive diagnosis. This review synthesizes current knowledge on the MRI phenotypes of both common and rare benign prostate conditions that may be mistaken for malignancy. The narrative encompasses anatomical variants, other neoplastic processes, inflammatory conditions, and alterations secondary to medical interventions. Furthermore, this review underscores the critical role of MRI quality in diagnostic accuracy and explores the emerging contributions of artificial intelligence in enhancing image interpretation.

Prostate Imaging for Recurrence Reporting System Made Easy: A Case-Based Review of Prostate Cancer Local Recurrence on Magnetic Resonance Imaging

Prostate cancer (PCa) is one of the most prevalent cancers worldwide. Even following appropriate initial treatments, a subset of the patients develops tumor recurrence. Magnetic resonance imaging (MRI) is pivotal in investigating local recurrence, but its performance is limited in detecting recurrence at other sites (especially in subcentimeter lymph nodes). Recently, an expert consensus proposed a scoring system for MRI-based assessment of local recurrence, called prostate imaging for recurrence reporting system (PI-RR). This case-based review describes the expected post-treatment changes and MRI findings of local PCa recurrence after RP and RT.

Posttreatment Lower Urinary Tract and Prostate Imaging

The treatment of benign and malignant diseases of the lower urinary tract and prostate gland can alter the anatomy and physiology of these regions. The radiologist should be familiar with the commonly performed procedures for conditions affecting the lower urinary tract as well as the expected and unexpected posttreatment appearance on imaging.

Natural language processing pipeline to extract prostate cancer-related information from clinical notes

OBJECTIVES

To develop an automated pipeline for extracting prostate cancer-related information from clinical notes.

MATERIALS AND METHODS

This retrospective study included 23,225 patients who underwent prostate MRI between 2017 and 2022. Cancer risk factors (family history of cancer and digital rectal exam findings), pre-MRI prostate pathology, and treatment history of prostate cancer were extracted from free-text clinical notes in English as binary or multi-class classification tasks. Any sentence containing pre-defined keywords was extracted from clinical notes within one year before the MRI. After manually creating sentence-level datasets with ground truth, Bidirectional Encoder Representations from Transformers (BERT)-based sentence-level models were fine-tuned using the extracted sentence as input and the category as output. The patient-level output was determined by compilation of multiple sentence-level outputs using tree-based models. Sentence-level classification performance was evaluated using the area under the receiver operating characteristic curve (AUC) on 15% of the sentence-level dataset (sentence-level test set). The patient-level classification performance was evaluated on the patient-level test set created by radiologists by reviewing the clinical notes of 603 patients. Accuracy and sensitivity were compared between the pipeline and radiologists.

RESULTS

Sentence-level AUCs were ≥ 0.94. The pipeline showed higher patient-level sensitivity for extracting cancer risk factors (e.g., family history of prostate cancer, 96.5% vs. 77.9%, p < 0.001), but lower accuracy in classifying pre-MRI prostate pathology (92.5% vs. 95.9%, p = 0.002) and treatment history of prostate cancer (95.5% vs. 97.7%, p = 0.03) than radiologists, respectively.

CONCLUSION

The proposed pipeline showed promising performance, especially for extracting cancer risk factors from patient's clinical notes.

CLINICAL RELEVANCE STATEMENT

The natural language processing pipeline showed a higher sensitivity for extracting prostate cancer risk factors than radiologists and may help efficiently gather relevant text information when interpreting prostate MRI.

KEY POINTS

When interpreting prostate MRI, it is necessary to extract prostate cancer-related information from clinical notes. This pipeline extracted the presence of prostate cancer risk factors with higher sensitivity than radiologists. Natural language processing may help radiologists efficiently gather relevant prostate cancer-related text information.

MR-guided Focused Ultrasound Focal Therapy for Prostate Cancer

Prostate cancer (PCa) is a prevalent malignancy in men, and the management of localized disease has evolved significantly in recent years. Focal therapy, wherein the biopsy confirmed site of tumor with margins is treated leaving the remaining gland intact, has emerged as a promising strategy for treating localized clinically significant PCa, minimizing side effects associated with radical therapies. We present the technical aspects, a summary of the most relevant evidence to date on the performance and safety of this technique, and the characteristic MR imaging findings during treatment, in the early posttreatment period and in the long term.

A Detailed Clinical Case of Localized Prostate Tumors Treated with Nanoparticle-Assisted Sub-Ablative Laser Ablation

AuroLase® Therapy-a nanoparticle-enabled focal therapy-has the potential to safely and effectively treat localized prostate cancer (PCa), preserving baseline functionality. This article presents a detailed case of localized PCa treated with AuroLase, providing insight on expectations from the diagnosis of PCa to one year post-treatment. AuroLase Therapy is a two-day treatment consisting of a systemic infusion of gold nanoshells (~150-nm hydrodynamic diameter) on Day 1, and sub-ablative laser treatment on Day 2. Multiparametric MRI (mpMRI) was used for tumor visualization, treatment planning, and therapy response assessment. The PCa was targeted with a MR/Ultrasound-fusion (MR/US) transperineal approach. Successful treatment was confirmed at 6 and 12 months post-treatment by the absence of disease in MR/US targeted biopsies. On the mpMRI, confined void space was evident, an indication of necrotic tissues encompassing the treated lesion, which was completely resolved at 12 months, forming a band-like scar with no evidence of recurrent tumor. The patient's urinary and sexual functions were unchanged. During the one-year follow-up, changes on the DCE sequence and in the Ktrans and ADC values assist in qualitatively and quantitatively evaluating tissue changes. The results highlight the potential of gold-nanoparticle-enabled sub-ablative laser treatment to target and control localized PCa, maintain quality of life, and preserve baseline functionality.

Automated prostate gland segmentation in challenging clinical cases: comparison of three artificial intelligence methods

OBJECTIVE

Automated methods for prostate segmentation on MRI are typically developed under ideal scanning and anatomical conditions. This study evaluates three different prostate segmentation AI algorithms in a challenging population of patients with prior treatments, variable anatomic characteristics, complex clinical history, or atypical MRI acquisition parameters.

MATERIALS AND METHODS

A single institution retrospective database was queried for the following conditions at prostate MRI: prior prostate-specific oncologic treatment, transurethral resection of the prostate (TURP), abdominal perineal resection (APR), hip prosthesis (HP), diversity of prostate volumes (large ≥ 150 cc, small ≤ 25 cc), whole gland tumor burden, magnet strength, noted poor quality, and various scanners (outside/vendors). Final inclusion criteria required availability of axial T2-weighted (T2W) sequence and corresponding prostate organ segmentation from an expert radiologist. Three previously developed algorithms were evaluated: (1) deep learning (DL)-based model, (2) commercially available shape-based model, and (3) federated DL-based model. Dice Similarity Coefficient (DSC) was calculated compared to expert. DSC by model and scan factors were evaluated with Wilcox signed-rank test and linear mixed effects (LMER) model.

RESULTS

683 scans (651 patients) met inclusion criteria (mean prostate volume 60.1 cc [9.05-329 cc]). Overall DSC scores for models 1, 2, and 3 were 0.916 (0.707-0.971), 0.873 (0-0.997), and 0.894 (0.025-0.961), respectively, with DL-based models demonstrating significantly higher performance (p < 0.01). In sub-group analysis by factors, Model 1 outperformed Model 2 (all p < 0.05) and Model 3 (all p < 0.001). Performance of all models was negatively impacted by prostate volume and poor signal quality (p < 0.01). Shape-based factors influenced DL models (p < 0.001) while signal factors influenced all (p < 0.001).

CONCLUSION

Factors affecting anatomical and signal conditions of the prostate gland can adversely impact both DL and non-deep learning-based segmentation models.

Prostatic Urethral Length on MRI Potentially Predicts Late Genitourinary Toxicity After Prostate Cancer Radiation

RATIONALE AND OBJECTIVES

The purpose of our study was to evaluate pretreatment prostate quantitative magnetic resonance imaging (MRI) measurements and clinical characteristics in predicting genitourinary (GU) toxicity after radiotherapy (RT) for prostate cancer.

MATERIALS AND METHODS

In this single-institution retrospective cohort study, we evaluated patients with prostate adenocarcinoma who underwent MRI within 6 months before completing definitive RT and follow-up information in our GU toxicity database from June 2016 to February 2023. MRI measurements included quantitative urethra, prostate, and bladder measurements. GU toxicity was physician-scored using the Common Terminology Criteria for Adverse Events (CTCAE v4.0) with acute toxicity defined as ≤180 days and late defined as >180 days. Multivariable logistic regression model was constructed for grade ≥2 acute toxicity and Cox proportional hazards regression for late toxicity, adjusted for clinical factors and RT method.

RESULTS

A total of 361 men (median age 68 years, interquartile range [IQR] 62-73) were included; 14.4% (50/347) men experienced grade ≥2 acute toxicity. Brachytherapy (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1.5-5.8), P < 0.01) was associated with increased odds of acute GU toxicity, and longer MUL (OR: 0.41 [95%CI: 0.18-0.92], P = 0.03) with decreased odds. Median follow-up for late toxicity was 15.0 months (IQR: 9.0-28.0) with approximately 88.7% and 72.0% patients free of toxicity at 1 and 3 years, respectively. Only longer prostatic urethral length (hazard ratio [HR]: 1.6, 95%CI: 1.2-2.1, P < 0.01) was associated with increased risk of late GU toxicity, notably urinary frequency/urgency symptoms (HR: 1.7 [95%CI: 1.3-2.3], P < 0.01).

CONCLUSION

Longer prostatic urethral length measured on prostate MRI is independently associated with higher risk of developing late grade ≥2 GU toxicity after radiation therapy for prostate cancer. This pretreatment metric may be potentially valuable in risk-stratification models for quality of life following prostate RT.

Prostate MRI for the detection of clinically significant prostate cancer: Update and future directions

PURPOSE OF REVIEW

In recent decades, there has been an increasing role for magnetic resonance imaging (MRI) in the detection of clinically significant prostate cancer (csPC). The purpose of this review is to provide an update and outline future directions for the role of MRI in the detection of csPC.

RECENT FINDINGS

In diagnosing clinically significant prostate cancer pre-biopsy, advances include our understanding of MRI-targeted biopsy, the role of biparametric MRI (non-contrast) and changing indications, for example the role of MRI in screening for prostate cancer. Furthermore, the role of MRI in identifying csPC is maturing, with emphasis on standardization of MRI reporting in active surveillance (PRECISE), clinical staging (EPE grading, MET-RADS-P) and recurrent disease (PI-RR, PI-FAB). Future directions of prostate MRI in detecting csPC include quality improvement, artificial intelligence and radiomics, positron emission tomography (PET)/MRI and MRI-directed therapy.

SUMMARY

The utility of MRI in detecting csPC has been demonstrated in many clinical scenarios, initially from simply diagnosing csPC pre-biopsy, now to screening, active surveillance, clinical staging, and detection of recurrent disease. Continued efforts should be undertaken not only to emphasize the reporting of prostate MRI quality, but to standardize reporting according to the appropriate clinical setting.

Evaluation of Prostate Cancer Recurrence with MR Imaging and Prostate Imaging for Recurrence Reporting Scoring System

Detection of prostate cancer recurrence after whole-gland treatment with curative intent is critical to identify patients who may benefit from local salvage therapy. Among the different imaging modalities used in clinical practice, MR imaging is the most accurate in identifying local prostate cancer recurrence; indeed, it is an excellent technique for local recurrence detection superior to PET/CT, even at low PSA, but provides no information about extra-pelvic lymph nodes or bone metastasis. In 2021, a group of experts developed the Prostate Imaging for local Recurrence Reporting scoring system to standardize acquisition, interpretation, and reporting of prostate cancer recurrence.

Evaluation of a Deep Learning-based Algorithm for Post-Radiotherapy Prostate Cancer Local Recurrence Detection Using Biparametric MRI

OBJECTIVE

To evaluate a biparametric MRI (bpMRI)-based artificial intelligence (AI) model for the detection of local prostate cancer (PCa) recurrence in patients with radiotherapy history.

MATERIALS AND METHODS

This study included post-radiotherapy patients undergoing multiparametric MRI and subsequent MRI/US fusion-guided and/or systematic biopsy. Histopathology results were used as ground truth. The recurrent cancer detection sensitivity of a bpMRI-based AI model, which was developed on a large dataset to primarily identify lesions in treatment-naïve patients, was compared to a prospective radiologist assessment using the Wald test. Subanalysis was conducted on patients stratified by the treatment modality (external beam radiation treatment [EBRT] and brachytherapy) and the prostate volume quartiles.

RESULTS

Of the 62 patients included (median age = 70 years; median PSA = 3.51 ng/ml; median prostate volume = 27.55 ml), 56 recurrent PCa foci were identified within 46 patients. The AI model detected 40 lesions in 35 patients. The AI model performance was lower than the prospective radiology interpretation (Rad) on a patient-(AI: 76.1% vs. Rad: 91.3%, p = 0.02) and lesion-level (AI: 71.4% vs. Rad: 87.5%, p = 0.01). The mean number of false positives per patient was 0.35 (range: 0-2). The AI model performance was higher in EBRT group both on patient-level (EBRT: 81.5% [22/27] vs. brachytherapy: 68.4% [13/19]) and lesion-level (EBRT: 79.4% [27/34] vs. brachytherapy: 59.1% [13/22]). In patients with gland volumes >34 ml (n = 25), detection sensitivities were 100% (11/11) and 94.1% (16/17) on patient- and lesion-level, respectively.

CONCLUSION

The reported bpMRI-based AI model detected the majority of locally recurrent prostate cancer after radiotherapy. Further testing including external validation of this model is warranted prior to clinical implementation.

Quantitative longitudinal mapping of radiation-treated prostate cancer using MR fingerprinting with radial acquisition and subspace reconstruction

MR fingerprinting (MRF) enables fast multiparametric quantitative imaging with a single acquisition and has been shown to improve diagnosis of prostate cancer. However, most prostate MRF studies were performed with spiral acquisitions that are sensitive to B0 inhomogeneities and consequent blurring. In this work, a radial MRF acquisition with a novel subspace reconstruction technique was developed to enable fast T1/T2 mapping in the prostate in under 4 min. The subspace reconstruction exploits the extensive temporal correlations in the MRF dictionary to pre-compute a low dimensional space for the solution and thus reduce the number of radial spokes to accelerate the acquisition. Iterative reconstruction with the subspace model and additional regularization of the signal representation in the subspace is performed to minimize the number of spokes and maintain matching quality and SNR. Reconstruction accuracy was assessed using the ISMRM NIST phantom. In-vivo validation was performed on two healthy subjects and two prostate cancer patients undergoing radiation therapy. The longitudinal repeatability was quantified using the concordance correlation coefficient (CCC) in one of the healthy subjects by repeated scans over 1 year. One prostate cancer patient was scanned at three time points, before initiating therapy and following brachytherapy and external beam radiation. Changes in the T1/T2 maps obtained with the proposed method were quantified. The prostate, peripheral and transitional zones, and visible dominant lesion were delineated for each study, and the statistics and distribution of the quantitative mapping values were analyzed. Significant image quality improvements compared with standard reconstruction methods were obtained with the proposed subspace reconstruction method. A notable decrease in the spread of the T1/T2 values without biasing the estimated mean values was observed with the subspace reconstruction and agreed with reported literature values. The subspace reconstruction enabled visualization of small differences in T1/T2 values in the tumor region within the peripheral zone. Longitudinal imaging of a volunteer subject yielded CCC of 0.89 for MRF T1, and 0.81 for MRF T2 in the prostate gland. Longitudinal imaging of the prostate patient confirmed the feasibility of capturing radiation treatment related changes. This work is a proof-of-concept for a high resolution and fast quantitative mapping using golden-angle radial MRF combined with a subspace reconstruction technique for longitudinal treatment response assessment in subjects undergoing radiation treatment.

Contemporary Review of Multimodality Imaging of the Prostate Gland

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

Focal nodular enhancement on DCE MRI of the prostatectomy bed: radiologic-pathologic correlations and prognostic value

OBJECTIVES

To determine the concordance of dynamic contrast-enhanced (DCE) imaging findings with clinico-pathologic characteristics and their prognostic impact for predicting biochemical recurrence (BCR) in patients who underwent radical prostatectomy (RP) for prostate cancer.

METHODS

This retrospective study included patients who underwent MRI within 1 year after RP between November 2019 and October 2020. DCE findings and their concordance with the presence and location of positive surgical margin (PSM) were assessed using RP specimens. Kaplan-Meier and logistic regression analyses were used to evaluate the prognostic impact of DCE findings for BCR.

RESULTS

Among the 272 men (mean age ± standard deviation, 66.6 ± 7.4 years), focal nodular enhancement was more frequently observed in those with PSM compared to those with negative margin (85.4% versus 14.6%; p < 0.001). The sites of focal nodular enhancement were 72.9% (35/48) concordant with the PSM locations. Focal nodular enhancement was associated with a higher Gleason score, higher preoperative PSA (≥ 10 ng/mL), higher Gleason grade at the surgical margin, and non-limited margin involvement (p = 0.002, 0.006, 0.032, and 0.001, respectively). In patients without BCR at the time of MRI, focal nodular enhancement was associated with a shorter time to BCR (p < 0.001) and a significant factor predicting 1-year BCR in both univariate (odds ratio = 8.4 [95% CI: 2.5-28.3]; p = 0.001) and multivariate (odds ratio = 5.49 [1.56-19.3]; p = 0.008) analyses.

CONCLUSIONS

Focal nodular enhancement on post-prostatectomy MRI was associated with adverse clinico-pathologic characteristics of high risk for recurrence and can be a predictor for 1-year BCR in patients undergoing RP.

KEY POINTS

• Focal nodular enhancement (PI-RR DCE score ≥ 4) was 72.9% (35/48) concordant with the site of positive resection margin by radiologic-histologic correlation. • Focal nodular enhancement (PI-RR DCE score ≥ 4) was associated with higher Gleason score ( ≥ 8), preoperative PSA ( > 10 ng/mL), and Gleason grade 4 or 5 at the surgical margin and non-limited margin involvement (p ≤ 0.032). • In patients without BCR at the time of MRI, focal nodular enhancement was a significant factor predicting 1-year BCR (odds ratio = 5.49; 95% CI: 1.56-19.3; p = 0.008).

Development and clinical utility analysis of a prostate zonal segmentation model on T2-weighted imaging: a multicenter study

OBJECTIVES

To automatically segment prostate central gland (CG) and peripheral zone (PZ) on T2-weighted imaging using deep learning and assess the model's clinical utility by comparing it with a radiologist annotation and analyzing relevant influencing factors, especially the prostate zonal volume.

METHODS

A 3D U-Net-based model was trained with 223 patients from one institution and tested using one internal testing group (n = 93) and two external testing datasets, including one public dataset (ETD_pub, n = 141) and one private dataset from two centers (ETD_pri, n = 59). The Dice similarity coefficients (DSCs), 95th Hausdorff distance (95HD), and average boundary distance (ABD) were calculated to evaluate the model's performance and further compared with a junior radiologist's performance in ETD_pub. To investigate factors influencing the model performance, patients' clinical characteristics, prostate morphology, and image parameters in ETD_pri were collected and analyzed using beta regression.

RESULTS

The DSCs in the internal testing group, ETD_pub, and ETD_pri were 0.909, 0.889, and 0.869 for CG, and 0.844, 0.755, and 0.764 for PZ, respectively. The mean 95HD and ABD were less than 7.0 and 1.3 for both zones. The U-Net model outperformed the junior radiologist, having a higher DSC (0.769 vs. 0.706) and higher intraclass correlation coefficient for volume estimation in PZ (0.836 vs. 0.668). CG volume and Magnetic Resonance (MR) vendor were significant influencing factors for CG and PZ segmentation.

CONCLUSIONS

The 3D U-Net model showed good performance for CG and PZ auto-segmentation in all the testing groups and outperformed the junior radiologist for PZ segmentation. The model performance was susceptible to prostate morphology and MR scanner parameters.

Clinical Application of the New Prostate Imaging for Recurrence Reporting (PI-RR) Score Proposed to Evaluate the Local Recurrence of Prostate Cancer after Radical Prostatectomy

Background: We investigated the diagnostic accuracy of the new Prostate Imaging for Recurrence Reporting (PI-RR) score and its inter-observer variability. Secondly, we compared the detection rate of PI-RR and PET and analyzed the correlation between Prostate Specific Antigen (PSA) levels and the PI-RR score. Methods: We included in the analysis 134 patients submitted to multiparametric magnetic resonance imaging for suspected local recurrence. The images were independently reviewed by two radiologists, assigning a value from 1 to 5 to the PI-RR score. Inter-observer agreement and diagnostic accuracy of the PI-RR score (compared to histopathological data, available for 19 patients) were calculated. The detection rate was compared to those of choline PET/CT (46 patients) and PSMA PET/CT (22 patients). The distribution of the PSA values in relation to the PI-RR scores was also analyzed. Results: The accuracy of the PI-RR score was 68.4%. The reporting agreement was excellent (K = 0.884, p < 0.001). The PI-RR showed a higher detection rate than choline PET/CT (69.6% versus 19.6%) and PSMA PET-CT (59.1% versus 22.7%). The analysis of the PSA distribution documented an increase in the PI-RR score as the PSA value increased. Conclusion: The excellent reproducibility of the PI-RR score supports its wide use in the clinical practice to standardize recurrence reporting. The detection rate of PI-RR was superior to that of PET, but was linked to the PSA level.

Magnetic Resonance Imaging and Targeted Biopsies Compared to Transperineal Mapping Biopsies Before Focal Ablation in Localised and Metastatic Recurrent Prostate Cancer After Radiotherapy

BACKGROUND

Recurrent prostate cancer after radiotherapy occurs in one in five patients. The efficacy of prostate magnetic resonance imaging (MRI) in recurrent cancer has not been established. Furthermore, high-quality data on new minimally invasive salvage focal ablative treatments are needed.

OBJECTIVE

To evaluate the role of prostate MRI in detection of prostate cancer recurring after radiotherapy and the role of salvage focal ablation in treating recurrent disease.

DESIGN, SETTING, AND PARTICIPANTS

The FORECAST trial was both a paired-cohort diagnostic study evaluating prostate multiparametric MRI (mpMRI) and MRI-targeted biopsies in the detection of recurrent cancer and a cohort study evaluating focal ablation at six UK centres. A total of 181 patients were recruited, with 155 included in the MRI analysis and 93 in the focal ablation analysis.

INTERVENTION

Patients underwent choline positron emission tomography/computed tomography and a bone scan, followed by prostate mpMRI and MRI-targeted and transperineal template-mapping (TTPM) biopsies. MRI was reported blind to other tests. Those eligible underwent subsequent focal ablation. An amendment in December 2014 permitted focal ablation in patients with metastases.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary outcomes were the sensitivity of MRI and MRI-targeted biopsies for cancer detection, and urinary incontinence after focal ablation. A key secondary outcome was progression-free survival (PFS).

RESULTS AND LIMITATIONS

Staging whole-body imaging revealed localised cancer in 128 patients (71%), with involvement of pelvic nodes only in 13 (7%) and metastases in 38 (21%). The sensitivity of MRI-targeted biopsy was 92% (95% confidence interval [CI] 83-97%). The specificity and positive and negative predictive values were 75% (95% CI 45-92%), 94% (95% CI 86-98%), and 65% (95% CI 38-86%), respectively. Four cancer (6%) were missed by TTPM biopsy and six (8%) were missed by MRI-targeted biopsy. The overall MRI sensitivity for detection of any cancer was 94% (95% CI 88-98%). The specificity and positive and negative predictive values were 18% (95% CI 7-35%), 80% (95% CI 73-87%), and 46% (95% CI 19-75%), respectively. Among 93 patients undergoing focal ablation, urinary incontinence occurred in 15 (16%) and five (5%) had a grade ≥3 adverse event, with no rectal injuries. Median follow-up was 27 mo (interquartile range 18-36); overall PFS was 66% (interquartile range 54-75%) at 24 mo.

CONCLUSIONS

Patients should undergo prostate MRI with both systematic and targeted biopsies to optimise cancer detection. Focal ablation for areas of intraprostatic recurrence preserves continence in the majority, with good early cancer control.

PATIENT SUMMARY

We investigated the role of magnetic resonance imaging (MRI) scans of the prostate and MRI-targeted biopsies in outcomes after cancer-targeted high-intensity ultrasound or cryotherapy in patients with recurrent cancer after radiotherapy. Our findings show that these patients should undergo prostate MRI with both systematic and targeted biopsies and then ablative treatment focused on areas of recurrent cancer to preserve their quality of life. This trial is registered at ClinicalTrials.gov as NCT01883128.

Diagnostic Accuracy and Observer Agreement of the MRI Prostate Imaging for Recurrence Reporting Assessment Score

Background Prostate cancer local recurrence location and extent must be determined in an accurate and timely manner. Because of the lack of a standardized MRI approach after whole-gland treatment, a panel of international experts recently proposed the Prostate Imaging for Recurrence Reporting (PI-RR) assessment score. Purpose To determine the diagnostic accuracy of PI-RR for detecting local recurrence in patients with biochemical recurrence (BCR) after radiation therapy (RT) or radical prostatectomy (RP) and to evaluate the interreader variability of PI-RR scoring. Materials and Methods This retrospective observational study included patients who underwent multiparametric MRI between September 2016 and May 2021 for BCR after RT or RP. MRI scans were analyzed, and a PI-RR score was assigned independently by four radiologists. The reference standard was defined using histopathologic findings, follow-up imaging, or clinical response to treatment. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated to assess PI-RR performance for each reader. The intraclass correlation coefficient was used to determine interreader agreement. Results A total of 100 men were included: 48 patients after RT (median age, 76 years [IQR, 70-82 years]) and 52 patients after RP (median age, 70 years [IQR, 66-74 years]). After RT, with PI-RR of 3 or greater as a cutoff (assigned when recurrence is uncertain), diagnostic performance ranges were 71%-81% sensitivity, 74%-93% specificity, 71%-89% PPV, 79%-86% NPV, and 77%-88% accuracy across the four readers. After RP, with PI-RR of 3 or greater as a cutoff, performance ranges were 59%-83% sensitivity, 87%-100% specificity, 88%-100% PPV, 66%-80% NPV, and 75%-85% accuracy. The intraclass correlation coefficient was 0.87 across the four readers for both the RT and RP groups. Conclusion MRI scoring with the Prostate Imaging for Recurrence Reporting assessment provides structured, reproducible, and accurate evaluation of local recurrence after definitive therapy for prostate cancer. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Haider in this issue.

Dynamic contrast-enhanced (DCE) imaging: state of the art and applications in whole-body imaging

Dynamic contrast-enhanced (DCE) imaging is a non-invasive technique used for the evaluation of tissue vascularity features through imaging series acquisition after contrast medium administration. Over the years, the study technique and protocols have evolved, seeing a growing application of this method across different imaging modalities for the study of almost all body districts. The main and most consolidated current applications concern MRI imaging for the study of tumors, but an increasing number of studies are evaluating the use of this technique also for inflammatory pathologies and functional studies. Furthermore, the recent advent of artificial intelligence techniques is opening up a vast scenario for the analysis of quantitative information deriving from DCE. The purpose of this article is to provide a comprehensive update on the techniques, protocols, and clinical applications - both established and emerging - of DCE in whole-body imaging.

The role of MRI in the detection of local recurrence: Added value of multiparametric approach and Signal Intensity/Time Curve analysis

OBJECTIVE

The aim of the study was to evaluate the accuracy of multiparametric Magnetic Resonance Imaging (mpMRI) in the detection of local recurrence of prostate cancer (PCa) with the evaluation of the added value of signal Intensity/Time (I/T) curves.

MATERIALS AND METHODS

A retrospective analysis of 22 patients undergoing mpMRI from 2015 to 2020 was carried out, with the following inclusion criteria: performing transrectal ultrasound guided biopsy within 3 months in the case of positive or doubtful findings and undergoing biopsy and/or clinical follow-up for 24 months in the case of negative results. The images were reviewed, and the lesions were catalogued according to morphological, diffusion-weighted imaging (DWI) and dynamic contrast- enhanced (DCE) features.

RESULTS

The presence of local recurrence was detected in 11/22 patients (50%). Greater diameter, hyperintensity on DWI, positive contrast enhancement and type 2/3 signal I/T curves were more frequently observed in patients with local recurrence (all p < 0.05). Of all the sequences, DCE was the most accurate; however, the combination of DCE and DWI showed the best results, with a sensitivity of 100%, a specificity of 82%, a negative predictive value of 100% and a positive predictive value of 85%.

CONCLUSIONS

The utility of MRI in the detection of local recurrence is tied to the multiparametric approach, with all sequences providing useful information. A combination of DCE and DWI is particularly effective. Moreover, specificity could be additionally improved using analysis of the signal I/T curves.

Role of multiparametric MRI in long-term surveillance following focal laser ablation of prostate cancer

OBJECTIVE

Determine the multiparametric magnetic resonance imaging (mpMRI) appearance of the prostate following focal laser ablation (FLA) for PCa and to identify imaging characteristics associated with recurrent disease.

METHODS

Retrospective analysis of patients who underwent FLA for low-intermediate risk PCa between 2010 and 2014 was performed. Early (median 4 months) and late mpMRI (median 49 months) follow-up were qualitatively assessed for T₂-weighted, dynamic contrast enhanced (DCE) and diffusion weighted imaging (DWI) appearances and also compared to corresponding PSA values and biopsy results.

RESULTS

55 cancers were treated in 54 men (mean age 61.0 years). Early mpMRI was performed in 30 (54.5%) patients while late follow-up mpMRI in 42 (84%). Ill-defined scarring with and without atrophy at the treatment site were the most common appearances. In patients with paired MRI and biopsy, one of four patients with clinically significant PCa on biopsy (≥GG2 or≥6 mm GG1) showed hyperenhancement or restricted diffusion at early follow-up. At late follow-up, positive biopsies were seen in 5/8 (63%) cases with hyperenhancement and 5/6 (83%) cases with restricted diffusion at the treatment site. PSA change was not associated with biopsy results at either time point.

CONCLUSION

mpMRI is able to document the morphological and temporal changes following focal therapy. It has limited ability to detect recurrent disease in early months following treatment. Late-term mpMRI is sensitive at identifying patients with recurrent disease. Small sample size is, however, a limitation of the study.

ADVANCES IN KNOWLEDGE

Implementing MRI in follow-up after FT may be useful in predicting residual or recurrent PCa and therefore provide reliable outcome data.

Acute and subacute prostate MRI findings after MRI-guided transurethral ultrasound ablation of prostate cancer

BACKGROUND

Magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) is an emerging method for treatment of localized prostate cancer (PCa). TULSA-related subacute MRI findings have not been previously characterized.

PURPOSE

To evaluate acute and subacute MRI findings after TULSA treatment in a treat-and-resect setting.

MATERIAL AND METHODS

Six men with newly diagnosed MRI-visible and biopsy-concordant clinically significant PCa were enrolled and completed the study. Eight lesions classified as PI-RADS 3-5 were focally ablated using TULSA. One- and three-week follow-up MRI scans were performed between TULSA and robot-assisted laparoscopic prostatectomy.

RESULTS

TULSA-related hemorrhage was detected as a subtle T1 hyperintensity and more apparent T2 hypointensity in the MRI. Both prostate volume and non-perfused volume (NPV) markedly increased after TULSA at one week and three weeks after treatment, respectively. Lesion apparent diffusion coefficient values increased one week after treatment and decreased nearing the baseline values at the three-week MRI follow-up.

CONCLUSION

The optimal timing of MRI follow-up seems to be at the earliest at three weeks after treatment, when the post-procedural edema has decreased and the NPV has matured. Diffusion-weighted imaging has little or no added diagnostic value in the subacute setting.

Minimally invasive magnetic resonance image-guided prostate interventions

Whole gland prostate cancer treatment, i.e. radical prostatectomy or radiation therapy, is highly effective but also comes with a significant impact on quality of life and possible overtreatment in males with low to intermediate risk disease. Minimal-invasive treatment strategies are emerging techniques. Different sources of energy are used to aim for targeted treatment in order to reduce treatment-related complications and morbidity. Imaging plays an important role in targeting and monitoring of treatment approaches preserving parts of the prostatic tissue. Multiparametric magnetic resonance imaging (mpMRI) is widely used during image-guided interventions due to the multiplanar and real-time anatomical imaging while providing an improved treatment accuracy. This review evaluates the available image-guided prostate cancer treatment options using MRI or magnetic resonance imaging/transrectal ultrasound (MRI/TRUS)-fusion guided imaging. The discussed minimal invasive image-guided prostate interventions may be considered as safe and feasible partial gland ablation in patients with (recurrent) prostate cancer. However, most studies focusing on minimally invasive prostate cancer treatments only report early stages of research and subsequent high-level evidence is still needed. Ensuring a safe and appropriate utilization in patients that will benefit the most, and applied by physicians with relevant training, has become the main challenge in minimally invasive prostate cancer treatments.

The Reproducibility of Deep Learning-Based Segmentation of the Prostate Gland and Zones on T2-Weighted MR Images

Volume of interest segmentation is an essential step in computer-aided detection and diagnosis (CAD) systems. Deep learning (DL)-based methods provide good performance for prostate segmentation, but little is known about the reproducibility of these methods. In this work, an in-house collected dataset from 244 patients was used to investigate the intra-patient reproducibility of 14 shape features for DL-based segmentation methods of the whole prostate gland (WP), peripheral zone (PZ), and the remaining prostate zones (non-PZ) on T2-weighted (T2W) magnetic resonance (MR) images compared to manual segmentations. The DL-based segmentation was performed using three different convolutional neural networks (CNNs): V-Net, nnU-Net-2D, and nnU-Net-3D. The two-way random, single score intra-class correlation coefficient (ICC) was used to measure the inter-scan reproducibility of each feature for each CNN and the manual segmentation. We found that the reproducibility of the investigated methods is comparable to manual for all CNNs (14/14 features), except for V-Net in PZ (7/14 features). The ICC score for segmentation volume was found to be 0.888, 0.607, 0.819, and 0.903 in PZ; 0.988, 0.967, 0.986, and 0.983 in non-PZ; 0.982, 0.975, 0.973, and 0.984 in WP for manual, V-Net, nnU-Net-2D, and nnU-Net-3D, respectively. The results of this work show the feasibility of embedding DL-based segmentation in CAD systems, based on multiple T2W MR scans of the prostate, which is an important step towards the clinical implementation.

Prostate minimally invasive procedures: complications and normal vs. abnormal findings on multiparametric magnetic resonance imaging (mpMRI)

Minimally invasive alternatives to traditional prostate surgery are increasingly utilized to treat benign prostatic hyperplasia and localized prostate cancer in select patients. Advantages of these treatments over prostatectomy include lower risk of complication, shorter length of hospital stay, and a more favorable safety profile. Multiparametric magnetic resonance imaging (mpMRI) has become a widely accepted imaging modality for evaluation of the prostate gland and provides both anatomical and functional information. As prostate mpMRI and minimally invasive prostate procedure volumes increase, it is important for radiologists to be familiar with normal post-procedure imaging findings and potential complications. This paper reviews the indications, procedural concepts, common post-procedure imaging findings, and potential complications of prostatic artery embolization, prostatic urethral lift, irreversible electroporation, photodynamic therapy, high-intensity focused ultrasound, focal cryotherapy, and focal laser ablation.

Computerized Tomography (CT) Updates and Challenges in Diagnosis of Bone Metastases During Prostate Cancer

Prostate cancer is one of the most common cancers in men. This cancer is often associated with indolent tumors with little or no lethal potential. Some of the patients with aggressive prostate cancer have increased morbidity and early deaths. A major complication in advanced prostate cancer is bone metastasis that mainly results in pain, pathological fractures, and compression of spinal nerves. These complications in turn cause severe pain radiating to the extremities and possibly sensory as well as motor disturbances. Further, in patients with a high risk of metastases, treatment is limited to palliative therapies. Therefore, accurate methods for the detection of bone metastases are essential. Technical advances such as single-photon emission computed tomography/ computed tomography (SPECT/CT) have emerged after the introduction of bone scans. These advanced methods allow tomographic image acquisition and help in attenuation correction with anatomical co-localization. The use of positron emission tomography/CT (PET/CT) scanners is also on the rise. These PET scanners are mainly utilized with 18F-sodium-fluoride (NaF), in order to visualize the skeleton and possible changes. Moreover, NaF PET/CT is associated with higher tracer uptake, increased target-to-background ratio and has a higher spatial resolution. However, these newer technologies have not been adopted in clinical guidelines due to lack of definite evidence in support of their use in bone metastases cases. The present review article is focused on current perspectives and challenges of computerized tomography (CT) applications in cases of bone metastases during prostate cancer.

Salvage interstitial laser thermal therapy under MRI guidance (MRgFLA) for high-intensity focal ultrasound (HIFU) recurrences: feasibility study

While focal therapy (FT) is increasingly endorsed for treating localized prostate cancer in the appropriately selected patient, management of recurrences following FT is not well-established in the literature. This case series describes three patients who received high-intensity focal ultrasound (HIFU) for primary treatment followed by focal laser interstitial thermal therapy (FLTT) for salvage therapy treated in the context of an ongoing clinical trial. Evaluation of these reported patients demonstrates that FLTT is feasible in the salvage setting with promising short-term oncologic outcomes and with the potential to preserve functional outcomes. Repeat focal therapy for previous failures is feasible however, it requires sophisticated imaging modalities for the accurate identification of recurrence and treatment of the tumor.

Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence after Radiation Therapy and Radical Prostatectomy

BACKGROUND

Imaging techniques are used to identify local recurrence of prostate cancer (PCa) for salvage therapy and to exclude metastases that should be addressed with systemic therapy. For magnetic resonance imaging (MRI), a reduction in the variability of acquisition, interpretation, and reporting is required to detect local PCa recurrence in men with biochemical relapse after local treatment with curative intent.

OBJECTIVE

To propose a standardised method for image acquisition and assessment of PCa local recurrence using MRI after radiation therapy (RP) and radical prostatectomy (RT).

EVIDENCE ACQUISITION

Prostate Imaging for Recurrence Reporting (PI-RR) was formulated using the existing literature. An international panel of experts conducted a nonsystematic review of the literature. The PI-RR system was created via consensus through a combination of face-to-face and online discussions.

EVIDENCE SYNTHESIS

Similar to with PI-RADS, based on the best available evidence and expert opinion, the minimum acceptable MRI parameters for detection of recurrence after radiation therapy and radical prostatectomy are set. Also, a simplified and standardised terminology and content of the reports that use five assessment categories to summarise the suspicion of local recurrence (PI-RR) are designed. PI-RR scores of 1 and 2 are assigned to lesions with a very low and low likelihood of recurrence, respectively. PI-RR 3 is assigned if the presence of recurrence is uncertain. PI-RR 4 and 5 are assigned for a high and very high likelihood of recurrence, respectively. PI-RR is intended to be used in routine clinical practice and to facilitate data collection and outcome monitoring for research.

CONCLUSIONS

This paper provides a structured reporting system (PI-RR) for MRI evaluation of local recurrence of PCa after RT and RP.

PATIENT SUMMARY

A new method called PI-RR was developed to promote standardisation and reduce variations in the acquisition, interpretation, and reporting of magnetic resonance imaging for evaluating local recurrence of prostate cancer and guiding therapy.

Role of MRI for the detection of prostate cancer

The use of multiparametric MRI has been hastened under expanding, novel indications for its use in the diagnostic and management pathway of men with prostate cancer. This has helped drive a large body of the literature describing its evolving role over the last decade. Despite this, prostate cancer remains the only solid organ malignancy routinely diagnosed with random sampling. Herein, we summarize the components of multiparametric MRI and interpretation, and present a critical review of the current literature supporting is use in prostate cancer detection, risk stratification, and management.

Health-related quality of life after ultrafocal salvage high-dose-rate brachytherapy for radiorecurrent prostate cancer: reporting the patient’s perspective

•

We analyzed patient-reported quality of life in 100 patients who underwent ultrafocal salvage HDR-brachytherapy.

•

Patient-reported bowel symptoms were neglible.

•

Urinary complaints increased and sexual functioning declined over time.

•

Lower impact is predicted for patients with favorable function at baseline and lower dose to the urethra.

Purpose

For patients with a localized prostate cancer recurrence after radiotherapy, focal salvage treatment offers a less toxic alternative to whole-gland treatments, with the potential of preserving health-related quality of life (HR-QoL). With a focus on the patient’s perspective of treatment, this study aims to describe HR-QoL after ultrafocal salvage high-dose-rate brachytherapy (HDR-BT), and to explore predictive factors affecting HR-QoL.

Material and methods

We included 100 patients treated with ultrafocal salvage HDR-BT. Prostate cancer-related HR-QoL was assessed by the EORTC QLQ-PR25 questionnaire. Domains were urinary symptoms, bowel symptoms and sexual activity/functioning. For each domain, a mixed effects model was made to estimate HR-QoL trends over time. For domains showing clinically relevant change (≥10 points difference), the mixed effects model was used to explore potential predictors (age, baseline HR-QoL score, T-stage, tumor location, CTV size, dose to organs at risk and history of ADT).

Results

Median follow-up was 20 months (IQR 13–30). Mean questionnaire response rate was 86% (range 72–100%). Median baseline scores were 12 (urinary), 0 (bowel) and 67/50 (sexual activity/functioning). Urinary symptoms and sexual functioning showed clinically relevant deterioration over time (maximum difference of 11 and 12 points, respectively). Worse baseline score and higher administered dose to the urethra (≥16 Gy) were predictive of increased urinary symptoms (p < 0.01 and p = 0.03). Better baseline score was predictive of better sexual functioning (p < 0.01).

Conclusion

Ultrafocal salvage HDR-BT has negligible impact on bowel symptoms but does affect urinary symptoms and sexual functioning. Lower impact is predicted for patients with favorable urinary and sexual function at baseline. Urethral dose constraints should be closely monitored.

What You Need to Know Before Reading Multiparametric MRI for Prostate Cancer

OBJECTIVE. Multiparametric MRI (mpMRI) has become the main imaging modality for the detection, localization, and local staging of prostate cancer over the past decade. For radiologists to achieve consistent and reproducible reporting of prostate mpMRI, a comprehensive evaluation of the gland including detailed knowledge of anatomy, pathology, and clinical data is required. This article familiarizes radiologists with common pitfalls and conditions that affect mpMRI performance during readouts. CONCLUSION. Consistent, accurate, and reproducible reporting of prostate mpMRI is vital. Additionally, radiologists should be aware of common diagnostic pitfalls that can hinder mpMRI performance.

Current Imaging Techniques for and Imaging Spectrum of Prostate Cancer Recurrence and Metastasis: A Pictorial Review

Relapsing level of prostate-specific antigen (PSA) after initial curative-intent local therapy for organ-confined prostate cancer is often the first sign of recurrence. However, PSA level recurrence does not enable accurate differentiation of locally recurrent tumor from metastatic disease or a combination of both. Metastatic prostate cancer most frequently involves bones and lymph nodes, followed by other organs such as the liver, lung, pleura, adrenal gland, ureter, peritoneum, penis, testis, and meninges. Conventional imaging including CT and bone scintigraphy has long been the standard of care but has limited sensitivity in depicting early local recurrence or metastatic disease. Multiparametric MRI has been shown to be more sensitive in detecting locally recurrent tumor in the prostatectomy bed as well as in situ recurrence in a prostate gland that has been treated with radiation therapy or thermal ablation. In addition, lesions detected with multiparametric MRI may be amenable to targeted biopsy for definitive diagnosis of recurrence. PET/CT or PET/MRI using the U.S. Food and Drug Administration (FDA)-approved tracers carbon 11 choline or fluorine 18 fluciclovine has demonstrated markedly increased sensitivity and specificity for diagnosis of early metastatic disease such as small-volume lymph node metastasis, as have a range of investigational gallium 68 prostate-specific membrane antigen (PSMA) radioactive PET tracers. With recent advances in imaging modalities and techniques, more accurate early detection, localization, and characterization of recurrent prostate cancer have become possible. The authors present a contemporary review of the strengths and limitations of conventional and advanced imaging modalities in evaluation of patients with recurrent prostate cancer and a systematic review of the clinical and imaging features of locally recurrent and metastatic disease.^©RSNA, 2020See discussion on this article by Barwick and Castellucci.

Magnetic Resonance Imaging Assessment After Therapy in Prostate Cancer

Prostate cancer is the fifth leading cause of death worldwide. A variety of treatment options is available for localized prostate cancer and may range from active surveillance to focal therapy or whole gland treatment, that is, surgery or radiotherapy. Serum prostate-specific antigen levels are an important tool to monitor treatment success after whole gland treatment, unfortunately prostate-specific antigen is unreliable after focal therapy. Multiparametric magnetic resonance imaging of the prostate is rapidly gaining field in the management of prostate cancer and may play a crucial role in the evaluation of recurrent prostate cancer. This article will focus on postprocedural magnetic resonance imaging after different forms of local therapy in patients with prostate cancer.

[Contrast-agent free imaging of the prostate : Ready for clinical practice?]

BACKGROUND

Multiparametric MRI (mpMRI) is currently the most accurate imaging modality for detection and local staging of prostate cancer (PCa). Disadvantages of this modality are high costs, time consumption and the need for a contrast medium.

AIMS

The aim of the work was to provide an overview of the current state of fast and contrast-free MRI imaging of the prostate.

RESULTS

Biparametric examination protocols and the use of three-dimensional T2-weighted sequences are readily available methods that can be used to shorten the examination time without sacrificing diagnostic accuracy.

Salvage reirradiation for local prostate cancer recurrence after radiation therapy. For who? When? How?

PURPOSE

Literature review reporting results of salvage brachytherapy and stereotactic body radiotherapy for prostate recurrence only after radiotherapy for prostate cancer.

MATERIALS AND METHODS

A total of 38 studies (including at least 15 patients per study) were analysed: 19 using low-dose-rate brachytherapy, nine high-dose-rate brachytherapy and ten stereotactic body radiotherapy. Only five studies were prospective. The median numbers of patients were 30 for low-dose-rate brachytherapy, 34 for high-dose-rate brachytherapy, and 30 for stereotactic body radiotherapy. The median follow-up were 47months for low-dose-rate brachytherapy, 36months for high-dose-rate brachytherapy and 21months for stereotactic body radiotherapy.

RESULTS

Late genitourinary toxicity rates ranged, for grade 2: from 4 to 42% for low-dose-rate brachytherapy, from 7 to 54% for high-dose-rate brachytherapy and from 3 to 20% for stereotactic body radiotherapy, and for grade 3 or above: from 0 to 24% for low-dose-rate brachytherapy, from 0 to 13% for high-dose-rate brachytherapy and from 0 to 3% for grade 3 or above (except 12% in one study) for stereotactic body radiotherapy. Late gastrointestinal toxicity rates ranged, for grade 2: from 0 to 6% for low-dose-rate brachytherapy, from 0 to 14% for high-dose-rate brachytherapy and from 0 to 11% for stereotactic body radiotherapy, and for grade 3 or above: from 0 to 6% for low-dose-rate brachytherapy, and from 0 to 1% for high-dose-rate brachytherapy and stereotactic body radiotherapy. The 5-year biochemical disease-free survival rates ranged from 20 to 77% for low-dose-rate brachytherapy and from 51 to 68% for high-dose-rate brachytherapy. The 2- and 3-year disease-free survival rates ranged from 40 to 82% for stereotactic body radiotherapy. Prognostic factors of biochemical recurrence have been identified.

CONCLUSION

Despite a lack of prospective data, salvage reirradiation for prostate cancer recurrence can be proposed to highly selected patients and tumours. Prospective comparative studies are needed.

Feasibility and Initial Results: Fluciclovine Positron Emission Tomography/Ultrasound Fusion Targeted Biopsy of Recurrent Prostate Cancer

PURPOSE

We assessed the feasibility and cancer detection rate of fluciclovine (¹⁸F) positron emission tomography-ultrasound fusion targeted biopsy vs standard template biopsy in the same patient with biochemical failure after nonsurgical therapy for prostate cancer.

MATERIALS AND METHODS

A total of 21 patients with a mean ± SD prostate specific antigen of 7.4 ± 6.8 ng/ml and biochemical failure after nonoperative prostate cancer treatment underwent fluciclovine (¹⁸F) positron emission tomography-computerized tomography (mean 364.1 ± 37.7 MBq) and planning transrectal prostate ultrasound with 3-dimensional image reconstruction. Focal prostatic activity on positron emission tomography was delineated and co-registered with planning ultrasound. During the subsequent biopsy session computer generated 12-core template biopsies were performed and then fluciclovine defined targets were revealed and biopsied. Histological analysis of template and targeted cores were completed.

RESULTS

Template biopsy was positive for malignancy in 6 of 21 patients (28.6%), including 10 of 124 regions and 11 of 246 cores, vs targeted biopsy in 10 of 21 (47.6%), including 17 of 50 regions and 40 of 125 cores. Five of 21 patients had positive findings on targeted biopsy only and 1 of 21 had positive findings on template biopsy only. An additional case was upgraded from Grade Group 2 to 3 on targeted biopsy. Extraprostatic disease was detected in 8 of 21 men (38.1%) with histological confirmation in all 3 who underwent lesion biopsy.

CONCLUSIONS

Fluciclovine positron emission tomography real-time ultrasound fusion guidance for biopsy is feasible in patients with biochemical failure after nonsurgical therapy for prostate cancer. It identifies more recurrent prostate cancer using fewer cores compared with template biopsy in the same patient. Further study is required to determine in what manner targeted biopsy may augment template biopsy of recurrent prostate cancer.

18F-Fluciclovine Parameters on Targeted Prostate Biopsy Associated with True Positivity in Recurrent Prostate Cancer

We evaluated ¹⁸F-fluciclovine uptake parameters that correlate with true positivity for local recurrence in non-prostatectomy-treated patients. Methods: Twenty-one patients (prostate-specific antigen level, 7.4 ± 6.8 ng/mL) with biochemical recurrence after nonprostatectomy local therapy (radiotherapy and cryotherapy) underwent dual-time-point ¹⁸F-fluciclovine (364.1 ± 37.7 MBq) PET/CT from pelvis to diaphragm. Prostatic uptake over background was delineated and coregistered to a prostate-biopsy-planning ultrasound. Transrectal biopsies of ¹⁸F-fluciclovine-defined targets were completed using a 3-dimensional visualization and navigation platform. Histologic analyses of lesions were completed. Lesion characteristics including SUV_max, target-to-background ratio (TBR), uptake pattern, and subjective reader's suspicion level were compared between true-positive (malignant) and false-positive (benign) lesions. Univariate analysis was used to determine the association between PET and histologic findings. Receiver-operating-characteristic curves were plotted to determine discriminatory cutoffs for TBR. Statistical significance was set at a P value of less than 0.05. Results: Fifty lesions were identified in 21 patients on PET. Seventeen of 50 (34.0%) targeted lesions in 10 of 21 patients were positive for malignancy. True-positive lesions had a significantly higher SUV_max (6.62 ± 1.70 vs. 4.92 ± 1.27), marrow TBR (2.57 ± 0.81 vs. 1.69 ± 0.51), and blood-pool TBR (4.10 ± 1.17 vs. 2.99 ± 1.01) than false-positive lesions at the early time point (P < 0.01) and remained significant at the delayed time point, except for blood-pool TBR. Focal uptake (odds ratio, 12.07; 95% confidence interval, 2.98-48.80; P < 0.01) and subjective highest suspicion level (odds ratio, 10.91; 95% confidence interval, 1.19-99.69; P = 0.03) correlated with true positivity. Using the receiver-operating-characteristic curve, optimal cutoffs for marrow TBR were 1.9 (area under the curve, 0.82) and 1.8 (area under the curve, 0.85) at early and delayed imaging, respectively. With these cutoffs, 15 of 17 malignant lesions were identified at both time points; however, fewer false-positive lesions were detected at the delayed time point (5/33) than at the early time point (11/33). Conclusion: True positivity of ¹⁸F-fluciclovine-targeted prostate biopsy in non-prostatectomy-treated patients correlates with focal uptake, TBR (blood pool and marrow), and subjective highest suspicion level. A marrow TBR of 1.9 at the early time point and 1.8 at the delayed time point had optimal discriminating capabilities. Despite the relatively low intraprostate positive predictive value (34.0%) with ¹⁸F-fluciclovine, application of these parameters to interpretative criteria may improve true positivity in the treated prostate.

Focal Salvage Treatment of Radiorecurrent Prostate Cancer: A Narrative Review of Current Strategies and Future Perspectives

Over the last decades, primary prostate cancer radiotherapy saw improving developments, such as more conformal dose administration and hypofractionated treatment regimens. Still, prostate cancer recurrences after whole-gland radiotherapy remain common, especially in patients with intermediate- to high-risk disease. The vast majority of these patients are treated palliatively with androgen deprivation therapy (ADT), which exposes them to harmful side-effects and is only effective for a limited amount of time. For patients with a localized recurrent tumor and no signs of metastatic disease, local treatment with curative intent seems more rational. However, whole-gland salvage treatments such as salvage radiotherapy or salvage prostatectomy are associated with significant toxicity and are, therefore, uncommonly performed. Treatments that are solely aimed at the recurrent tumor itself, thereby better sparing the surrounding organs at risk, potentially provide a safer salvage treatment option in terms of toxicity. To achieve such tumor-targeted treatment, imaging developments have made it possible to better exclude metastatic disease and accurately discriminate the tumor. Currently, focal salvage treatment is being performed with different modalities, including brachytherapy, cryotherapy, high-intensity focused ultrasound (HIFU), and stereotactic body radiation therapy (SBRT). Oncologic outcomes seem comparable to whole-gland salvage series, but with much lower toxicity rates. In terms of oncologic control, these results will improve further with better understanding of patient selection. Other developments, such as high-field diagnostic MRI and live adaptive MRI-guided radiotherapy, will further improve precision of the treatment.