The Transatlantic Recommendations for Prostate Gland Evaluation with Magnetic Resonance Imaging After Focal Therapy (TARGET): A Systematic Review and International Consensus Recommendations

BACKGROUND AND OBJECTIVE

Magnetic resonance imaging (MRI) can detect recurrences after focal therapy for prostate cancer but there is no robust guidance regarding its use. Our objective was to produce consensus recommendations on MRI acquisition, interpretation, and reporting after focal therapy.

METHODS

A systematic review was performed in July 2022 to develop consensus statements. A two-round consensus exercise was then performed, with a consensus meeting in January 2023, during which 329 statements were scored by 23 panellists from Europe and North America spanning urology, radiology, and pathology with experience across eight focal therapy modalities. Using RAND Corporation/University of California-Los Angeles methodology, the Transatlantic Recommendations for Prostate Gland Evaluation with MRI after Focal Therapy (TARGET) were based on consensus for statements scored with agreement or disagreement.

KEY FINDINGS AND LIMITATIONS

In total, 73 studies were included in the review. All 20 studies (100%) reporting suspicious imaging features cited focal contrast enhancement as suspicious for cancer recurrence. Of 31 studies reporting MRI assessment criteria, the Prostate Imaging-Reporting and Data System (PI-RADS) score was the scheme used most often (20 studies; 65%), followed by a 5-point Likert score (six studies; 19%). For the consensus exercise, consensus for statements scored with agreement or disagreement increased from 227 of 295 statements (76.9%) in round one to 270 of 329 statements (82.1%) in round two. Key recommendations include performing routine MRI at 12 mo using a multiparametric protocol compliant with PI-RADS version 2.1 standards. PI-RADS category scores for assessing recurrence within the ablation zone should be avoided. An alternative 5-point scoring system is presented that includes a major dynamic contrast enhancement (DCE) sequence and joint minor diffusion-weighted imaging and T2-weighted sequences. For the DCE sequence, focal nodular strong early enhancement was the most suspicious imaging finding. A structured minimum reporting data set and minimum reporting standards for studies detailing MRI data after focal therapy are presented.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The TARGET consensus recommendations may improve MRI acquisition, interpretation, and reporting after focal therapy for prostate cancer and provide minimum standards for study reporting.

PATIENT SUMMARY

Magnetic resonance imaging (MRI) scans can detect recurrent of prostate cancer after focal treatments, but there is a lack of guidance on MRI use for this purpose. We report new expert recommendations that may improve practice.

Diagnostic yields in patients with suspected prostate cancer undergoing MRI as the first-line investigation in routine practice

AIM

To document cancer yields of magnetic resonance imaging (MRI)-directed biopsies in men with suspected prostate cancer referred to secondary care.

MATERIALS AND METHODS

Men with suspected cancer undergoing multiparametric prostate MRI as the first-line investigation were included in the present study. Systematic transrectal prostate biopsies with/without cognitive targeted biopsies were performed. Diagnostic yields of International Society of Urological Pathology (ISUP) ≥2 cancers by the Prostate Imaging Reporting and Data System (PI-RADS) category were recorded. Impacts of prostate-specific antigen (PSA) density on biopsy results and yields of non-targeted biopsies in MRI non-suspicious prostate sextants assessed.

RESULTS

Of 262 men (90.5% biopsy naive), 86 (33%) MRI examinations were negative (PI-RADS 1-2) and 176 (67%) positive (PI-RADS 3: 8%; PI-RADS 4: 21%; PI-RADS 5: 38%). Two hundred and thirteen of 262 patients underwent a biopsy. ISUP ≥2 cancer detection rates were 8% (5/61) for PI-RADS 1-2, 18% (3/17) for PI-RADS 3, 49% (22/45) for PI-RADS 4, and 80% (72/90) for PI-RADS 5. Proportions of ISUP ≥2 increased with higher PSA densities in positive patients (%ISUP ≥2 for PSA density groups <0.12, 0.12 to <0.15 and ≥ 0.15 was 0%, 0%, 25% for PI-RADS 3, 21%, 33%, 68% for PI-RADS 4 and 40%, 83%, 89% for PI-RADS 5 respectively). ISUP ≥2 cancers were twice as likely in tumour adjacent sextants (52% versus 24%), without upgrading of gland level histology from insignificant to clinically significant prostate cancer by the sampling of normal-appearing tumour non-adjacent sextants.

CONCLUSIONS

One third of men can avoid biopsy after negative MRI. Cancer detection rates increase with PSA density values within positive MRI suspicion categories. Sampling normal-appearing tumour non-adjacent sextants may be unnecessary for whole-gland therapy.

Dual-energy CT for imaging of pulmonary hypertension: challenges and opportunities

Computed tomography (CT) is routinely used in the evaluation of patients with pulmonary hypertension (PH) to assess vascular anatomy and parenchymal morphology. The introduction of dual-energy CT (DECT) enables additional qualitative and quantitative insights into pulmonary hemodynamics and the extent and variability of parenchymal enhancement. Lung perfusion assessed at pulmonary blood volume imaging correlates well with findings at scintigraphy, and pulmonary blood volume defects seen in pulmonary embolism studies infer occlusive disease with increased risk of right heart dysfunction. Similarly, perfusion inhomogeneities seen in patients with PH closely reflect mosaic lung changes and may be useful for severity assessment and prognostication. The use of DECT may increase detection of peripheral thromboembolic disease, which is of particular prognostic importance in patients with chronic thromboembolic PH with microvascular involvement. Other DECT applications for imaging of PH include low-kilovoltage images with greater inherent iodine conspicuity and iodine-selective color-coded maps of vascular perfusion (both of which can improve visualization of vascular enhancement), virtual nonenhanced imaging (which better depicts vascular calcification), and, potentially, ventricular perfusion maps (to assess myocardial ischemia). In addition, quantitative assessment of central vascular and parenchymal enhancement can be used to evaluate pulmonary hemodynamics in patients with PH. The current status and potential advantages and limitations of DECT for imaging of PH are reviewed, and current evidence is supplemented with data from a tertiary referral center for PH.

Stage T3a renal cell carcinoma: staging accuracy of CT for sinus fat, perinephric fat or renal vein invasion

OBJECTIVE

To study the accuracy of CT for staging T3a (TNM 2009) renal cell carcinoma (RCC).

METHODS

Unenhanced and nephrographic phase CT studies of 117 patients (male:female = 82:35; age range, 21-86 years) with T1-T3a RCC were independently reviewed by 2 readers. The presence of sinus or perinephric fat, or renal vein invasion and tumour characteristics were noted.

RESULTS

Median (range) tumour size was 5.5 (0.9-19.0) cm; and 46 (39%), 16 (14%) and 55 (47%) tumours were pT1, pT2 and pT3a RCC, respectively. The sensitivity/specificity for sinus fat, perinephric fat and renal vein invasion were 71/79%, 83/76% and 59/93% (Reader 1) and 88/71%, 68/72% and 69/91% (Reader 2) with κ = 0.41, 0.43 and 0.61, respectively. Sinus fat invasion was seen in 47/55 (85%) cases with T3a RCC vs 16/55 (29%) and 33/55 (60%) for perinephric fat and renal vein invasion. Tumour necrosis, irregularity of tumour edge and direct tumour contact with perirenal fascia or sinus fat increased the odds of local invasion [odds ratio (OR), 2.5-3.7; p < 0.05; κ = 0.42-0.61]. Stage T3a tumours were centrally located (OR, 3.9; p = 0.0009).

CONCLUSION

Stage T3a RCC was identified with a sensitivity of 59-88% and specificity of 71-93% (κ = 0.41-0.61). Sinus fat invasion was the most common invasive feature.

ADVANCES IN KNOWLEDGE

Centrally situated renal tumours with an irregular tumour edge, inseparable from sinus structures or the perirenal fascia and CT features of tumour necrosis should alert the reader to the possibility of Stage T3a RCC (OR, 2.5-3.9).