Comparison of MR/ultrasound fusion-guided biopsy with ultrasound-guided biopsy for the diagnosis of prostate cancer

Histopathologic Features and Transcriptomic Signatures Do Not Solve the Issue of Magnetic Resonance Imaging-Invisible Prostate Cancers: A Matched-Pair Analysis

BACKGROUND

Multiparametric magnetic resonance imaging (mpMRI) is pivotal in prostate cancer (PCa) diagnosis, but some clinically significant (cs) PCa remain undetected. This study aims to understand the pathological and molecular basis for csPCa visibility at mpMRI.

METHODS

We performed a retrospective matched-pair cohort study, including patients undergoing radical prostatectomy (RP) for csPCa (i.e., ISUP grade group ≥ 2) from 2015 to 2020, in our tertiary-referral center. We screened for inclusion in the "mpMRI-invisible" cohort all consecutive men (N = 45) having a negative preoperative mpMRI. The "mpMRI-visible" cohort was matched based on age, PSA, prostate volume, ISUP grade group. Included patients underwent radiological and pathological open-label revisions and characterization of the tumor mRNA expression profile (analyzing 780 gene transcripts, signaling pathways, and cell-type profiling). We compared the clinical-pathological variables and the gene expression profile between matched pairs. The analysis was stratified according to histological characteristics and lesion diameter.

RESULTS

We included 34 patients (17 per cohort); mean age at RP and PSA were 70.5 years (standard deviation [SD] = 7.7), 7.1 ng/mL (SD = 3.3), respectively; 65% of men were ISUP 2. Overall, no significant differences in histopathological features, tumor diameter and location, mRNA profile, pathways, and cell-type scores emerged between cohorts. In the stratified analysis, an upregulation of cell adhesion and motility, of extracellular matrix remodeling and of metastatic process pathways was present in specific subgroups of mpMRI-invisible cancers.

CONCLUSIONS

No PCa pathological or gene-expression hallmarks explaining mp-MRI invisibility were identified. Aggressive features can be present both in mpMRI-invisible and -visible tumors.

PSA Density and Lesion Volume: Key Factors in Avoiding Unnecessary Biopsies for PI-RADS 3 Lesions

INTRODUCTION

The use of multiparametric magnetic resonance imaging (MRI) to guide prostate biopsies has improved cancer detection rates, particularly for high-grade tumors. However, despite guidelines recommending biopsies for lesions with a Prostate Imaging-Reporting and Data System (PI-RADS) score ≥ 3, the clinical significance of PI-RADS 3 lesions remains uncertain. This uncertainty, coupled with the cost and potential complications of biopsies, underscores the need for more accurate risk stratification strategies to avoid unnecessary procedures. Prostate-specific antigen density (PSAD) and index lesion volume are emerging as potential contributors to improve risk assessment.

MATERIALS AND METHODS

This was a retrospective analysis of patients who had undergone an MRI-guided transrectal ultrasound (TRUS) prostate biopsy at a tertiary care institution. Patients with PI-RADS 3 lesions were included, and data on demographics, prostate-specific antigens (PSA), PSAD, lesion diameter, and pathology results were collected. The relationships between PSAD, lesion volume, and pathology outcomes were statistically analyzed.

RESULTS

Of the 213 patients included, 40 were diagnosed with prostate cancer. PSAD and PSAD x lesion diameter were significantly higher in the patients diagnosed with prostate cancer than those with benign lesions. Among the prostate cancer patients, clinically significant prostate cancer (csPCa) had a higher mean PSAD value than clinically insignificant prostate cancer (cisPCa). ROC analysis found PSAD x lesion diameter to have the highest discriminatory power for detecting csPCa.

DISCUSSION

MRI-guided biopsies offer targeted sampling but the clinical significance of PI-RADS 3 lesions remains uncertain. Index lesion volume and PSAD are promising adjunctive markers for risk assessment. Combining these factors could facilitate the avoidance of unnecessary biopsies and improve the detection of csPCa.

CONCLUSION

Incorporating PSAD and index lesion volume into biopsy decision-making may enhance risk stratification, particularly for PI-RADS 3 lesions. Further research is needed to validate these findings and enhance the risk assessment strategies used in making decisions regarding prostate biopsy.

Role of MRI in Active Surveillance of Prostate Cancer

Magnetic resonance imaging (MRI) plays an important role in the management of patients with prostate cancer on active surveillance. In this review, we will explore the incorporation of MRI into active surveillance protocols, detailing its impact on clinical decision-making and patient management and discussing how it aligns with current guidelines and practice patterns. The role of MRI in this patient population continues to evolve over time, and we will discuss some of the recent advancements in the field and highlight potential areas for future research endeavors.

Urologic Imaging of the Prostate: Cancer and Mimics

This article provides a comprehensive overview of prostate cancer imaging, including detection of clinically significant cancer and initial staging. The role of multiparametric MRI in detection and local staging is discussed, along with the use of conventional imaging and advanced techniques such as Prostate-Specific Membrane Antigen-Positron Emission Tomography (PSMA-PET) for staging of nodal and distant metastases. The article also highlights the importance of differentiating benign prostatic conditions from prostate cancer on imaging to improve diagnostic accuracy and reduce false-positive interpretations.

The Role of Prostate-Specific Membrane Antigen-Radioligand and Magnetic Resonance Imaging in Patients with Prostate Cancer Biochemical Recurrence

A significant proportion of men with prostate cancer will experience biochemical recurrence (BCR), which is characterized by an elevation in prostate-specific antigen (PSA) levels after receiving treatment with curative intent. Imaging plays an important role in the management of patients with BCR. It can help identify sites of recurrence to determine the most appropriate management strategies, ranging from salvage treatment for local recurrences to systemic treatments for those with advanced, distant disease. PET/CT with prostate-specific membrane antigen (PSMA)-radioligands is the most sensitive method for the detection of prostate cancer recurrence, with significantly higher cancer detection rates compared to conventional imaging techniques such as bone scan and computed tomography, even at lower PSA levels. Nevertheless, interpretation of PSMA PET/CT images can be challenging, particularly for the evaluation of local recurrence due to urinary activity that can mimic or mask the presence of cancer. Furthermore, some prostate cancers may not express PSMA and have false negative results. Multiparametric prostate MRI is an excellent method for the evaluation of local recurrence and can overcome some of the limitations of PSMA PET/CT. In this review, we discuss the role of imaging in managing patients with prostate cancer BCR and describe the potential benefits of MRI in the PSMA-radioligand imaging era, emphasizing the assessment of local recurrence.

Optimizing Prostate Cancer Diagnostic Work-Up Through Micro-Ultrasound: Minimizing Unnecessary Procedures and Reducing Overdiagnoses

INTRODUCTION

We aim to critically assess Microultrasound (mUS) clinical performance in an outpatient setting, focusing on its ability to reduce unnecessary diagnostic procedures, potentially reshape prostate cancer (PCa) diagnostic protocols, and increase the ability to rule out clinically significant (Gleason Score ≥ 3 + 4) PCa (csPCa).

MATERIALS AND METHODS

Between November 2018 and April 2022, we conducted a prospective study involving men who underwent mUS examination due to clinical symptoms, PSA elevation, or opportunistic early detection of PCa. Experienced urologists performed mUS assessments in an outpatient setting using the prostate risk identification using micro-ultrasound (PRI-MUS) protocol to identify lesions suspicious of csPCa (PRI-MUS score ≥ 3). Men with negative mUS results were followed through consistent phone follow-up calls and visits until October 2023 to assess their diagnostic and therapeutic pathways. Using Cox regression models adjusted for PSA levels, DRE results, age, and previous biopsy history, we calculated the hazard ratio (HR) for biopsy-free (BFS), defined as the time from mUS to biopsy or last follow-up, cancer-free survival (CFS), and clinically significant cancer-free survival (csCFS) within the cohort based on mUS results.

RESULTS

Overall, 425 men were enrolled. The median (IQR) age was 66 (59-72) years, PSA levels were 5.7 (4.0-7.9) ng/mL, prostate volume was 44 (31.5-62.1) mL, and the median follow-up was 39 months (27-53). mUS identified lesions suggesting csPCa in 201/425 (47.3%) men. Overall, mUS resulted negative in 224/425 (52.7%) men, of whom 207/224 (92.4%) did not undergo subsequent mpMRI, while 22/224 (9.8%) proceeded with mpMRI according to the referring physician's decision. The latter detected suspicious lesions in 12/22 cases (54.5%), but only 2/12 (16.7%) were confirmed by biopsy as csPCa. Among those with negative mUS results, 192/224 (85.7%) men avoided additional biopsies during follow-up. Men with negative mUS results exhibited superior BFS (aHR: 0.17; p < 0.001), CFS (aHR:0.12; p < 0.001), and csCFS (aHR:0.09; p < 0.001) survival rates compared to their mUS-positive counterparts.

CONCLUSIONS

Our findings suggest that mUS can potentially refine patient stratification and transform PCa screening and diagnostic protocols. Pending validation by other studies, a wider implementation of mUS could optimize resource allocation, minimize wastage, and reserve additional costly tests.

Performance of MR fusion biopsy, systematic biopsy and combined biopsy on prostate cancer detection rate in 1229 patients stratified by PI-RADSv2 score on 3T multi-parametric MRI

PURPOSE

We analyzed the additional value of systematic biopsy (SB) to MR-Ultrasound fusion biopsy (MRgFbx) for detection of clinically significant prostate cancer (csPCa), as increased sampling may cause increased morbidity.

MATERIALS AND METHODS

This retrospective study cohort was comprised of 1229 biopsy sessions between July 2016 and May 2020 in men who had a Prostate Imaging-Reporting and Data System (PI-RADSv2) category ≥ 3 lesion on 3 Tesla multiparametric MRI (3TmpMRI) and subsequent combined biopsy (CB; MRgFbx and SB) for suspected prostate cancer (PCa). Cancer detection rates (CDR) were calculated for CB, MRgFbx and SB in the study cohort and sub-cohorts stratified by biopsy history and PI-RADSv2 category. For 927 men with unilateral MR-visible lesions, SB CDR was additionally calculated for contralateral (SBc) and ipsilateral (SBi) subcohorts.

RESULTS

On CB, the CDR for csPCa was 54.8% (673/1229). CDR for csPCa was significantly higher for MRgFbx (50.0%, CI 47.1-52.8%) compared to SB (35.3%, CI 32.6-38.1%) for all PI-RADSv2 ≥ 3 categories (p < .05). The MRgFbx CDR for PI-RADSv2 categories 3, 4, and 5 were 81.5%, 88.5%, and 95.6% respectively. For unilateral lesion cases, significantly more csPCa was detected in the SBi compared to the SBc subcohort (30.1% (279/927) vs. 10.4%, (96/927), p < 0.001). The combination of MRgFbx and SBi detected csPCa in 97.0% (480) of the 495 csPCa detected by CB.

CONCLUSION

MRgFbx had a higher CDR for csPCa than SB. While CB detected more csPCa than either method alone, in patients with a PI-RADSv2 category of 5, MRgFbx approximated the performance of CB. In unilateral lesion cases, SBc provided minimal added benefit.

Clinical feasibility of MRI-guided in-bore prostate biopsies at 0.55T

OBJECTIVE

In-bore MRI-guided biopsy allows direct visualization of suspicious lesions, biopsy needles, and trajectories, allowing accurate sampling when MRI-ultrasound fusion biopsy is not feasible. However, its use has been limited. Wide-bore, lower-field, and lower-cost scanners could help address these issues, but their feasibility for prostate biopsy is unknown. The purpose of our study was to evaluate the feasibility of in-bore MRI-guided prostate biopsy using a large-bore (80 cm), 0.55T scanner.

MATERIALS AND METHODS

Nineteen participants (68 ± 10 years) with suspected prostate cancer (PCa) were recruited for this Institutional Review Board (IRB) approved study (May 2023 -October 2024). Prebiopsy diagnostic scans and intra-procedural T2-weighted images were used for lesion localization. PSA levels, lesion sizes, cancer detection rates, positive core volume percentage, ISUP (International Society of Urological Pathology) grade groups (GG), positive volume cores, skin to target distances, and procedure durations were reported.

RESULTS

Seventeen participants underwent biopsies (four transrectal, thirteen percutaneous). Two participants were excluded. Twenty lesions (mean size 1.9 ± 1.2 cm) were biopsied which showed various GG cancers (GG1, GG2, GG3, GG4, and GG5), with positive cores ranging from 10 to 100%. 20% of the lesions were benign. Compared to previous biopsies, 22.2% (2/9) had new cancer detections, 22.2% (2/9) showed a GG upgrade, and 33.3% (3/9) had increased positive core volume, while 11.1% (1/9) showed no upgrade and 11.1% (1/9) had benign findings. Among biopsy-naïve participants, 75% (6/8) had cancer detected, and 25% (2/8) had benign findings. One new cancer was detected near a hip prosthesis due to reduced imaging artifacts. Average total procedure time was 77 ± 21 min for transrectal and 74 ± 22 min for percutaneous biopsies, with times to first core at 45 ± 15 and 53 ± 14 min, respectively.

CONCLUSION

Identifying and accurately targeting suspicious prostate lesions is feasible using a 0.55T MRI scanner.

Evaluation of the current status, significance, and availability of prostate MRI und MRI guided biopsy in Germany

Evaluation of the current status, significance and availability of multiparametric prostate MRI and MRI-guided biopsy in Germany.A voluntary web-based questionnaire with 26 distinct items was emailed to members of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR). The questions referred to personal qualification, acquisition, quality, and management of prostate MRI, and assessment of the importance of the method.In total 182 questionnaires were captured from all 10 german postal regions (over 60% of the university hospitals, almost 50% of the maximum care hospitals and approx. 12% of the practices or medical service centers). 43% of the respondents had a Q1 or Q2 quality certificate from the DRG, 10% had a certificate from the BDR, respectively. The majority (90%) criticized inadequate reimbursement of the examination. In 47% MRI cases were discussed in an interdisciplinary tumor board, in 44% case discussions happened rarely, and 12% never had interdisciplinary discussions. On a scale from 0-100 (0%: low; 100%: high) the estimation of the clinical relevance of prostate MRIs received an average of 84% (± 16%) and the estimated approval by urologists was 75% (± 21%). Lacking clinical feedback (59%) and clinical information (42%) were perceived as the largest problems.In this representative survey the respondents estimated multiparametric MRI of the prostate as highly diagnostic and relevant with an increased approval by urologists. There is still a perceived need for continuous professional education of the method for urologists and for more widespread coverage of fusion biopsy. Prostate MRI is currently primarily offered by high volume centers. Current challenges are particularly insufficient interdisciplinary communication and inadequate reimbursement. · Prostate MRI is perceived as highly diagnostic and clinically relevant.The method is currently primarily offered by high volume centers.. · Bigger current problems are insufficient interdisciplinary communication (e.g., clinical information, biopsy results) and inadequate reimbursement.. · Continuous education for urologists and expanded coverage by fusion biopsy are desirable.. · Ullrich T, Boschheidgen M, Schweyen CM et al. Evaluation of the current status, significance, and availability of prostate MRI und MRI guided biopsy in germany. Fortschr Röntgenstr 2024; DOI 10.1055/a-2416-1343.

A contemporary review: mpMRI in prostate cancer screening and diagnosis

Prostate cancer (PCa) screening has evolved beyond PSA and digital rectal exam to include multiparametric prostate MRI (mpMRI). Incorporating this advanced imaging tool has further limited the well-established problem of overdiagnosis, aiding in the identification of higher grade, clinically significant cancers. For this reason, mpMRI has become an important part of the diagnostic pathway and is recommended across guidelines in biopsy naïve patients or for patients with prior negative biopsy. This contemporary review evaluates the most recent literature on the role of mpMRI in the screening and diagnosis of prostate cancer. Barriers to utilization of mpMRI still exist including variable access, high cost, and requisite expertise, encouraging evaluation of novel techniques such as biparametric MRI. Future screening and diagnostic practice patterns will undoubtedly evolve as our understanding of novel biomarkers and artificial intelligence improves.

Diagnostic Accuracy of PSMA PET-Guided Prostate Biopsy in Prostate Cancer-A Systematic Review and Meta-analysis

PURPOSE

Early diagnosis and treatment of prostate cancer (PC) are crucial for effective management and improved patient outcomes. Newer imaging modalities like prostate-specific membrane antigen PET have shown superior diagnostic performance in detecting PC and clinically significant PC (csPC). This systematic review and meta-analysis aims to synthesize evidence on the diagnostic performance of PSMA PET-guided prostate biopsy in detecting PC and csPC.

PATIENTS AND METHODS

The study followed the PRISMA-DTA guidelines. Using a predefined search strategy, 3 databases (PubMed, Embase, and Web of Science) were systematically searched using appropriate keywords. A meta-analysis was conducted using diagnostic accuracy parameters of the included studies. Risk of bias assessment was done using the QUADAS-2 tool.

RESULTS

Out of 378 articles, 20 were assessed for full-text screening and 10 articles with 874 patients were finally included. Eight studies reported a pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of 0.90 (95%confidence interval [CI], 0.82-0.95), 0.93 (95% CI, 0.57-0.99), 12.3 (95% CI, 1.5-98.9), 0.10 (95% CI, 0.05-0.20), and 117 (95% CI, 12-1178), respectively, for detecting PC using PSMA PET-guided prostate biopsy with an area under the summary receiver operating characteristics curve of 0.94 (95% CI, 0.92-0.96). Similarly, 6 studies reported a pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of 0.89 (95% CI, 0.82-0.94), 0.65 (95% CI, 0.49-0.79), 2.6 (95% CI, 1.6-4.1), 0.17 (95% CI, 0.09-0.31), and 15 (95% CI, 6-41), respectively, for detecting csPC using PSMA PET-guided prostate biopsy with area under summary receiver operating characteristics curve of 0.86 (95% CI, 0.82-0.88).

CONCLUSIONS

PSMA PET-guided prostate biopsy has a high diagnostic accuracy in detecting PC and csPC in patients with clinical suspicion of PC, and provides a 1-stop solution for early diagnosis and staging of PC.

How Many Cores Should Be Collected per Region of Interest in Fusion Targeted Prostate Biopsy? A Retrospective Single Institution Statistical Simulation

OBJECTIVE

To determine how many cores should be collected per region of interest (ROI) in magnetic resonance imaging-guided fusion prostate biopsy. Magnetic resonance imaging-guided targeted prostate biopsy has led to improved detection of clinically significant prostate cancer (csPC); however, data is limited regarding the optimal number of biopsy cores that should be taken. An ideal number of cores maximizes clinically significant cancer detection while minimizing cost, discomfort, and procedure time.

METHODS

Patients receiving targeted prostate biopsy (4 cores per ROI) combined with systematic 12-core prostate at our institution between January 2017 and June 2022 were retrospectively identified. Statistical simulation was used to model scenarios in which 1, 2, 3, or 4 cores were taken from the ROI, and the rate of grade group ≥2 prostate cancer (csPC) detection was determined for targeted and combined targeted plus systematic biopsy.

RESULTS

483 patients were identified. Transrectal (96%) and transperineal (4%) biopsies were included. For targeted biopsy, csPC was present in 21% (1 core), 26% (2 cores; P = .048), 29% (3 cores; P = .002), and 31% (4 cores; P < .001) of cases. For combined biopsy, csPC was present in 33% (1 core), 35% (2 cores; P = .4), 37% (3 cores; P = .2), and 38% (4 cores; P = .12) of cases.

CONCLUSION

If targeted biopsy is performed without systematic biopsy, 2 or more cores is superior to 1 core for detecting csPC. This effect is mitigated when targeted and systematic biopsy are combined.

Is ipsilateral systematic biopsy combined with targeted biopsy the optimal substitute for bilateral systematic biopsy combined with targeted biopsy: A systematic review and meta-analysis

BACKGROUND

The current standard prostate biopsy method, which combine systematic biopsy (SB) with targeted biopsy (TB), has shortcomings such as overdiagnosis and overtreatment. To evaluate the effectiveness of ipsilateral systematic biopsy (ips-SB) combined with targeted biopsy (ips-SB+TB) and contralateral SB (con-SB) combined with TB (con-SB+TB) as potential alternatives to SB+TB.

METHODS

A comprehensive literature search was conducted in Cochrane, Embase, Ovid, and PubMed databases until September 2024. 2,732 references were identified, and 11 records were included.

MAIN FINDINGS

The study included a total of 5,249 patients and revealed that ips-SB+TB detected slightly less PCa than SB+TB with a relative risk (RR) of 0.95 (95% CI 0.91, 1.00), P = 0.05. In terms of csPCa detection, ips-SB+TB showed a comparable detection rate with SB+TB (RR 0.98 [95% CI 0.94, 1.01], P = 0.60). There was a statistically significant difference in csPCa detection between con-SB+TB and SB+TB (RR 0.92 [95% CI 0.86, 0.99], P = 0.02). The detection rates of clinically insignificant PCa (ciPCa) were comparable between con-SB+TB vs. SB+TB (con-SB+TB vs. SB+TB: RR 0.90 [95% CI 0.79, 1.04], P = 0.15). However, fewer ciPCa cases were detected in ips-SB+TB compared to SB+TB (RR 0.86 [95% CI 0.75, 0.99], P = 0.04).

CONCLUSIONS

In this review, our analysis highlights ips-SB+TB has the comparable detection efficiency of PCa and csPCa compared to SB+TB, and its potential to be the substitute of the SB+TB with less cores and less detection of ciPCa.

Risks of grade reclassification among patients with Gleason grade group 1 prostate cancer and PI-RADS 5 findings on prostate MRI

BACKGROUND AND OBJECTIVE

As most Prostate Imaging Reporting and Data System (PI-RADS) 5 lesions on MRI harbor Gleason grade (GG) group ≥2 disease on biopsy, optimal management of patients with imaging-biopsy discordance remains unclear. To estimate grade misclassification, we evaluated the incidence of Gleason upgrading among patients with GG1 disease in the setting of a PI-RADS 5 lesion.

METHODS

We conducted a single-institution retrospective analysis to identify patients with GG1 prostate cancer on fusion biopsy with MRI demonstrating ≥1 PI-RADS 5 lesion. Primary study outcome was identification of ≥GG2 disease on subsequent active surveillance (AS) biopsy or radical prostatectomy (RP). We used multivariable models to examine factors associated with reclassification.

RESULTS

We identified 110 patients with GG1 disease on initial biopsy and ≥1 PI-RADS 5 lesion. There were 104 patients (94.6%) initially managed with AS and 6 (5.5%) received treatment. Sixty-one patients (58.7%) on AS underwent additional biopsies. Of these, 43 (70.5%) patients had tumor upgrading, with 32 (74.4%) upgraded on first surveillance biopsy. Forty-four (40%) patients ultimately received treatment, including prostatectomy in 15 (13.6%) and radiation in 25 (22.7%). Two patients (1.8%) developed metastases. In multivariable models, genomic classifier score was associated with upgrading. Limitations include a lack of multi-institutional data and long-term outcomes data.

CONCLUSIONS

Most patients diagnosed with GG1 prostate cancer on MRI-Ultrasound fusion biopsy in the setting of a PI-RADS 5 lesion were found to have ≥GG2 disease on subsequent tissue sampling, suggesting substantial initial misclassification and reinforcing the need for confirmatory testing.

The number of involved regions by prostate adenocarcinoma predicts histopathology concordance between radical prostatectomy specimens and MRI/ultrasound-fusion targeted prostate biopsy

Introduction

The prostate biopsy (PB) results should be concordant with prostatectomy histopathology to avoid overestimating or underestimating the disease, leading to inappropriate or undertreatment of prostate cancer (PCa) patients. Since the introduction of multiparametric Magnetic Resonance Imaging (mpMRI) in the diagnostic pathway of PCa, most studies have shown that MRI/Ultrasound fusion-guided (MRI-fusion) PB improves concordance with histopathology of radical prostatectomy specimens. This study aimed to evaluate the improvement in concordance of prostatectomy specimens with PB histopathology obtained using the MRI-fusion approach compared with the 12-core TRUS-Bx and to identify the variables influencing this.

Patients and methods

The study included 218 men who were diagnosed with PCa by PB and underwent radical prostatectomy between 2016 and 2023. The patients were grouped based on the biopsy method: 115 underwent TRUS-Bx, and 103 underwent MRI-fusion PB. The histopathological grading of these biopsy approaches was compared with that of radical prostatectomy specimens. Multivariate logistic regression analyses were conducted to evaluate the impact of various criteria on histopathological concordance.

Results

In patients with unfavorable intermediate- and high-risk PCa, MRI-fusion PB showed significantly better concordance with prostatectomy histopathology than TRUS-Bx (73.1% vs. 42.9%, p = 0.018). MRI-fusion PB had a significantly lower downgrading of prostatectomy histopathology than TRUS-Bx in all grade categories. The number of cancer-involved regions of the prostate is an independent predictor for concordance (OR = 1.24, 95%CI = 1.04-1.52, p = 0.02) and downgrading (OR = 0.46, 95%CI = 0.24-0.83, p = 0.01).

Conclusions

Using an MRI-fusion PB improves histopathological concordance in patients with unfavorable intermediate and high-risk PCa. It reduces the downgrading rate of prostatectomy histopathology compared with TRUS-Bx in all grade categories. The number of cancer-involved regions is an independent predictor of the concordance between biopsy and final histopathology after prostatectomy and post-prostatectomy histopathology downgrading. Our findings could assist in selecting PCa patients for AS and focal treatment based on the histopathology obtained from the MRI-fusion PB.

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.

Patients' anxieties and fears: a comparison between transrectal prostate biopsy and prostate MRI

Background

Prostate biopsies are an invasive procedure that can lead to anxieties and fear before the examination. Prostate magnetic resonance imaging (MRI) is seen as a non-invasive test although it is known that "scanxiety" affects many patients. Transrectal ultrasound (TRUS)-guided prostate biopsies and multiparametric prostate MRI (mpMRI) are commonly used methods in patients with suspected prostate cancer (PCa). This study investigates fears and anxieties towards the TRUS and mpMRI.

Methods

All patients scheduled for mpMRI or TRUS biopsy between January and December 2018 were asked to participate in this single-center study. A total of 196 completed questionnaires were returned and included.

Results

On a 5-point Likert scale the fear of the examination was lower for the mpMRI [1.53; 95% confidence interval (CI): 1.38 to 1.69] than for a TRUS biopsy (2.47; 95% CI: 2.21 to 2.71). In detail, patients with a scheduled TRUS biopsy had significantly higher levels for fear of pain [2.49 (95% CI: 2.19 to 2.78) vs. 1.51 (95% CI: 1.35 to 1.67); P<0.001] and fear of complications [2.71 (95% CI: 2.45 to 2.98) vs. 2.11 (95% CI: 1.89 to 2.32); P=0.001]. There was no relevant difference about the fact that patients knew what to expect [3.02 (95% CI: 2.68 to 3.35) vs. 2.99 (95% CI: 2.70 to 3.26); P=0.47] and the expectation that the examination will go over well [3.24 (95% CI: 2.92 to 3.57) vs. 3.27 (95% CI: 3.00 to 3.58); P=0.55].

Conclusions

On average, fear levels were moderate before mpMRI and TRUS biopsy. Patients are more afraid of TRUS biopsy than mpMRI but the differences were low. The biggest fear remains the fear of the result of the examinations independently of the method.

Established focal therapy-HIFU, IRE, or cryotherapy-where are we now?-a systematic review and meta-analysis

INTRODUCTION

Focal Therapy (FT) is a treatment option for the treatment of limited volume clinically significant prostate cancer (csPCa). We aim to systematically review outcomes of established FT modalities to assess the contemporary baseline and identify gaps in evidence that will aid in further trial and study design.

METHODS

We conducted a systematic review and meta-analysis of all primary studies reporting outcomes of FT using cryotherapy, high-intensity focused ultrasound (HIFU), and irreversible electroporation (IRE). We described patient inclusion criteria, selection tools, treatment parameters, and surveillance protocols, and pooled overall survival (OS), cancer-specific survival (CSS), metastasis-free survival (MFS), biochemical progression (BP), biopsy, secondary treatment, sexual, and urinary function outcomes. Composite failure was defined as salvage whole gland ablation, radical treatment, hormonal therapy or transition to watchful waiting.

SYNTHESIS

We identified 49 unique cohorts of men undergoing FT between 2008 and 2024 (21 cryotherapy, 20 HIFU, and 8 IRE). Median follow-up ranged from 6 to 63 months. Pooled OS was 98.0%, CSS 99.3%, and MFS 98.5%. Pooled BP was 9.4%/year. Biopsy was mandated post-FT within 24 months in 36/49 (73.5%) cohorts, with pooled csPCa (GG ≥ 2) rates of 22.2% overall, 8.9% infield, and 12.3% outfield. The pooled rate of secondary FT was 5.0%, radical treatment 10.5%, and composite failure 14.1%. Of 35 studies reporting sexual function, 45.7% reported a low, 48.6% moderate, and 5.7% severe impact. For 34 cohorts reporting urinary function, 97.1% reported a low impact. No differences were noted between cryotherapy, HIFU, or IRE in any of the outcomes.

CONCLUSION

FT with cryotherapy, HIFU, and IRE is associated with good short-intermediate term oncological and functional outcomes. However, outcome reporting is heterogeneous and often incomplete. Long-term follow-up and standardized reporting are required to better define and report FT outcomes.

Machine learning-based prediction of pulmonary embolism to reduce unnecessary computed tomography scans in gastrointestinal cancer patients: a retrospective multicenter study

This study aimed to develop a machine learning (ML) model for predicting pulmonary embolism (PE) in patients with gastrointestinal cancers, a group at increased risk for PE. We conducted a retrospective, multicenter study analyzing patients who underwent computed tomographic pulmonary angiography (CTPA) between 2010 and 2020. The study utilized demographic and clinical data, including the Wells score and D-dimer levels, to train a random forest ML model. The model's effectiveness was assessed using the area under the receiver operating curve (AUROC). In total, 446 patients from hospital A and 139 from hospital B were included. The training set consisted of 356 patients from hospital A, with internal validation on 90 and external validation on 139 patients from hospital B. The model achieved an AUROC of 0.736 in hospital A and 0.669 in hospital B. The ML model significantly reduced the number of patients recommended for CTPA compared to the conventional diagnostic strategy (hospital A; 100.0% vs. 91.1%, P < 0.001, hospital B; 100.0% vs. 93.5%, P = 0.003). The results indicate that an ML-based prediction model can reduce unnecessary CTPA procedures in gastrointestinal cancer patients, highlighting its potential to enhance diagnostic efficiency and reduce patient burden.

Advanced Imaging for Localized Prostate Cancer

BACKGROUND/OBJECTIVES

Prostate cancer is a prevalent malignancy often presenting without early symptoms. Advanced imaging technologies have revolutionized its diagnosis and management. This review discusses the principles, benefits, and clinical applications of multiparametric magnetic resonance imaging (mpMRI), micro-ultrasound (microUS), and prostate-specific membrane antigen positron emission tomography-computed tomography (PSMA PET/CT) in localized prostate cancer.

METHODS

We conducted a comprehensive literature review of recent studies and guidelines on mpMRI, microUS, and PSMA PET/CT in prostate cancer diagnosis, focusing on their applications in biopsy-naïve patients, those with previous negative biopsies, and patients under active surveillance.

RESULTS

MpMRI has demonstrated high sensitivity and negative predictive value in detecting clinically significant prostate cancer (csPCa). MicroUS, a newer technology, has shown promising results in early studies, with sensitivity and specificity comparable to mpMRI. PSMA PET/CT has emerged as a highly sensitive and specific imaging modality, particularly valuable for staging and detecting metastatic disease. All three technologies have been incorporated into urologic practice for prostate cancer diagnosis and management, with each offering unique advantages in different clinical scenarios.

CONCLUSIONS

Advanced imaging techniques, including mpMRI, microUS, and PSMA PET/CT, have significantly improved the accuracy of prostate cancer diagnosis, staging, and management. These technologies enable more precise targeting of suspicious lesions during biopsy and therapy planning. However, further research, especially randomized controlled trials, is needed to fully establish the optimal use and inclusion of these imaging modalities in various stages of prostate cancer care.

Surveillance after Focal Therapy - a Comprehensive Review

BACKGROUND

to date, no standardized, evidence-based follow-up schemes exist for the monitoring of patients who underwent focal therapy (FT) and expert centers rely mainly on their own experience and/or institutional protocols. We aimed to perform a comprehensive review of the most advantageous follow-up strategies and their rationale after FT for prostate cancer (PCa).

METHODS

a narrative review of the literature was conducted to investigate different follow-up protocols of FT for PCa. Outcomes of interest were post-ablation oncological and functional outcomes and complications.

RESULTS

Oncological success after FT was generally defined as the biopsy-confirmed absence of clinically significant PCa in the treated zone. De novo PCa in the untreated area usually reflects an inaccurate patient selection and should be treated as primary PCa. During follow-up, oncological outcomes should be evaluated with periodic PSA, multiparametric MRI and prostate biopsy. The use of PSA derivatives and new biomarkers is still controversial and therefore not recommended. The first MRI after FT should be performed between 6-12 months to avoid ablation-related artifacts and diagnostic delay in case of FT failure. Other imaging modalities, such as PSMA PET/CT scan, are promising but still need to be validated in the post-FT setting. A 12-month "for-protocol" prostate biopsy, including targeted and systematic biopsy, was generally considered the preferred biopsy method to rule out tumor persistence/recurrence. Subsequent mpMRIs and biopsies should follow a risk-adapted approach depending on the clinical scenario. Functional outcomes should be periodically assessed using validated questionnaires within the first year, when typically recover to a new baseline. Complications, despite uncommon, should be strictly monitored mainly in the first month.

CONCLUSIONS

FT follow-up is a multifaceted process involving clinical, radiological, and histological assessment. Studies evaluating the impact of different follow-up strategies and ideal timings are needed to produce standardized protocols following FT.

Fluorine-18-labelled Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography or Magnetic Resonance Imaging to Diagnose and Localise Prostate Cancer. A Prospective Single-arm Paired Comparison (PEDAL)

BACKGROUND AND OBJECTIVE

Multiparametric magnetic resonance imaging (mpMRI) of the prostate is used for prostate cancer diagnosis. However, mpMRI has lower sensitivity for small tumours. Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) offers increased sensitivity over conventional imaging. This study aims to determine whether the diagnostic accuracy of 18F-DCFPyL PSMA-PET/CT was superior to that of mpMRI for detecting prostate cancer (PCa) at biopsy.

METHODS

Between 2020 and 2021, a prospective multicentre single-arm phase 3 imaging trial enrolled patients with clinical suspicion for PCa to have both mpMRI and PSMA-PET/CT (thorax to thigh), with reviewers blinded to the results of other imaging. Multiparametric MRI was considered positive for Prostate Imaging Reporting and Data System (PIRADS) 3-5. PSMA-PET/CT was assessed quantitatively (positive maximum standardised uptake value [SUVmax] >7) and qualitatively (five-point lexicon of certainty). Patients underwent targeted and systematic biopsy, with the technique at the discretion of the treating urologist. Clinically significant PCa (csPCa) was defined as International Society of Urological Pathology grade group (GG) ≥2. The primary outcome was the diagnostic accuracy for detecting PCa, reported as sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the receiver operating curve. The secondary endpoints included a comparison of the diagnostic accuracy for detecting csPCa, assessing gains in combining PMSA-PET/CT with mpMRI to mpMRI alone.

KEY FINDINGS AND LIMITATIONS

Of the 236 patients completing both mpMRI and PSMA-PET/CT, 184 (76.7%) had biopsy. Biopsy histology was benign (n = 73), GG 1 (n = 27), and GG ≥2 (n = 84). The diagnostic accuracy of mpMRI for detecting PCa (AUC 0.76; 95% confidence interval [CI] 0.69, 0.82) was higher than that of PSMA-PET/CT (AUC 0.63; 95% CI 0.56, 0.70, p = 0.03). The diagnostic accuracy of mpMRI for detecting csPCa (AUC 0.72; 95% CI 0.67, 0.78) was higher than that of PSMA-PET/CT (AUC 0.62; 95% CI 0.55, 0.69) but not statistically significant (p = 0.27). A combination of PSMA-PET/CT and mpMRI showed excellent sensitivity (98.8%, 95% CI 93.5%, 100%) and NPV (96%, 95% CI 79.6%, 99.9%) over mpMRI alone (86.9% and 80.7%, respectively, p = 0.01). Thirty-two patients (13.6%) had metastatic disease. They tended to be older (68.4 vs 65.1 yr, p = 0.023), and have higher prostate-specific antigen (PSA; median PSA 9.6 vs 6.2ng/ml, p < 0.001) and abnormal prostate on digital rectal examination (78.2% vs 44.1%, p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Multiparametric MRI had superior diagnostic accuracy to PSMA-PET/CT for detecting PCa, though the difference is not significant in case of csPCa detection. A combination of mpMRI and PSMA-PET/CT showed improved sensitivity and NPV. PSMA-PET/CT could be considered for diagnostic use in patients unable to have mpMRI or those with concerning clinical features but negative mpMRI.

PATIENT SUMMARY

In this trial, we compared the ability of 18F-labelled prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) with that of multiparametric magnetic resonance imaging (mpMRI) to diagnose prostate cancer by biopsy in a prostate-specific antigen screening population. We found that MRI was superior to PSMA to diagnose prostate cancer, though there was no difference in ability to diagnose clinically significant prostate cancer. PSMA-PET/CT could be considered for diagnostic use in patients unable to have mpMRI or those with concerning clinical features but negative mpMRI. Combining MRI with PSMA-PET increases the negative predictive value over MRI alone and may help men avoid invasive prostate biopsy.

Recent Advances in Image-Guided Tissue Sampling

Recent advances in image-guided tissue sampling have enhanced diagnostic medicine, particularly in oncology. Traditional techniques, such as computed tomography (CT)-, ultrasound (US)-, and magnetic resonance imaging (MRI)-guided biopsies, remain the cornerstone of diagnostic interventions, each offering unique advantages based on tissue characteristics. CT-guided biopsies excel in deeper complex lesions, while US-guided biopsies provide real-time imaging ideal for superficial tissues. MRI-guided biopsies are invaluable for soft tissue evaluations. The emergence of fusion imaging, which combines modalities such as positron emission tomography (PET)/CT or MRI/US, has demonstrated enhanced diagnostic accuracy. Despite these advantages, image co-registration and cost are the main drawbacks. Emerging techniques such as molecular breast imaging (MBI) and shear wave elastography (SWE) have been evaluated, particularly for breast cancer; however, research suggests that US is likely to remain the most effective modality due to both its cost and ease of use. Innovations in biopsy navigation, including augmented reality, "hot needles," and robotic assistance, demonstrate promise in closing the gap between operator dependency and procedural consistency; however, further research is required. While liquid biopsies show promise in non-invasive early cancer detection, they are not yet ready to replace tissue biopsies. Collectively, these advancements indicate a future where image-guided tissue sampling is more targeted, less invasive, and diagnostically accurate, although cost and technology access remain challenges.

Biopsy strategies in the era of mpMRI: a comprehensive review

BACKGROUND

Since its initial description the prostate biopsy technique for detection of prostate cancer (PCA) has constantly evolved. Multiparametric magnetic resonance imaging (mpMRI) has been proven to have a sensitivity exceeding 90% to detect the index lesion. This narrative review discusses the evidence around several biopsy strategies, especially in the context of patients that might be eligible for focal therapy.

METHOD

A non-systematic literature research was performed on February 15th 2024 using the Medical Literature Analysis and Retrieval System Online (Medline), Web of Science and Google Scholar.

RESULTS

The transrectal (TR) route is associated with an increased postoperative sepsis rate, even with adequate antibiotic prophylaxis. The transperineal (TP) route is now recommended by international guidelines, firstly for its decreased rate of urosepsis. Recent evidence shows a non-inferiority of TP compared to TR route, and even a higher detection rate of clinically significant PCA (csPCA) in the anterior and apical region, that are usually difficult to target using the TR route. Several targeting techniques (cognitive, software-fusion or in-bore) enhance our ability to provide an accurate risk assessment of prostate cancer aggressiveness and burden, while reducing the number of cores and reducing the number of clinically insignificant prostate cancer (ciPCA). While MRI-TB have proven their role, the role of systematic biopsies (SB) is still important because it detects 5-16% of csPCA that would have been missed by MRI-TB alone. The strategies of SB depend mainly on the route used (TR vs. TP) and the number of cores to be collected (10-12 cores vs. saturation biopsies vs. trans-perineal template mapping-biopsies or Ginsburg Protocol vs. regional biopsies).

CONCLUSION

Several biopsy strategies have been described and should be known when assessing patients for focal therapy. Because MRI systematically under evaluates the lesion size, systematic biopsies, and especially perilesional biopsies, can help to increase sensitivity at the cost of an increased number of cores.

Role of Systematic Biopsy in the Era of Targeted Biopsy: A Review

Prostate cancer (PCa) is a major public health issue, as the second most common cancer and the fifth leading cause of cancer-related deaths among men. Many PCa cases are indolent and pose minimal risk, making active surveillance a suitable management approach. However, clinically significant prostate carcinoma (csPCa) can lead to serious health issues, including progression, metastasis, and death. Differentiating between insignificant prostate cancer (inPCa) and csPCa is crucial for determining appropriate treatment. Diagnosis of PCa primarily involves trans-perineal and transrectal systematic biopsies. Systematic transrectal prostate biopsy, which typically collects 10-12 tissue samples, is a standard method, but it can miss csPCa and is associated with some complications. Recent advancements, such as magnetic resonance imaging (MRI)-targeted biopsies, have been suggested to improve risk stratification and reduce overtreatment of inPCa and undertreatment of csPCa, thereby enhancing patient quality of life and treatment outcomes. Guided biopsies are increasingly recommended for their ability to better detect high-risk cancers while reducing identification of low-risk cases. MRI-targeted biopsies, especially when used as an initial biopsy in biopsy-naïve patients and those under active surveillance, have become more common. Utilization of MRI-TB alone can decrease septic complications; however, the combining of targeted biopsies with perilesional sampling is recommended for optimal detection of csPCa. Future advancements in imaging and biopsy techniques, including AI-augmented lesion detection and robotic-assisted sampling, promise to further improve the accuracy and effectiveness of PCa detection.

VISION: An Individual Patient Data Meta-analysis of Randomised Trials Comparing Magnetic Resonance Imaging Targeted Biopsy with Standard Transrectal Ultrasound Guided Biopsy in the Detection of Prostate Cancer

BACKGROUND AND OBJECTIVE

The PRECISION and PRECISE trials compared magnetic resonance imaging targeted biopsy (MRI ± TB) with the standard transrectal ultrasound (TRUS) guided biopsy for the detection of clinically significant prostate cancer (csPCa). PRECISION demonstrated superiority of MRI ± TB over TRUS guided biopsy, while PRECISE demonstrated noninferiority. The VISION study is a planned individual patient data meta-analysis (IPDMA) comparing MRI ± TB with TRUS guided biopsy for csPCa diagnosis.

METHODS

MEDLINE, EMBASE, Web of Science, Cochrane Central of Registered Trials, and ClinicalTrials.gov were searched on the November 12, 2023 for randomised controlled trials of biopsy-naïve patients with a clinical suspicion of prostate cancer undergoing MRI or standard TRUS. Studies were included if its participants with suspicious MRI underwent targeted biopsy alone and those with nonsuspicious lesion avoided biopsy. The primary outcome is the proportion of men diagnosed with csPCa (Gleason ≥3 + 4).

KEY FINDINGS AND LIMITATIONS

Two studies, PRECISION and PRECISE (953 patients), were included in the IPDMA. In the MRI ± TB arm, 32.2% of patients avoided biopsy due to nonsuspicious MRI. MRI ± TB detected 8.7 percentage points (36.3% vs 27.6%; 95% confidence interval [CI] 2.8-14.6, p = 0.004) more csPCa than TRUS biopsy and 12.3 percentage points (9.6% vs 21.9%; 95% CI 7.8-16.9, p < 0.001) less clinically insignificant prostate cancer (cisPCa; Gleason 3 + 3). The overall risk of bias for the included studies were found to be low after assessment using the QUADAS-2, QUADAS-C, and ROB 2.0 tools.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The MRI ± TB pathway is superior to TRUS biopsy in detecting csPCa and avoiding the diagnosis of cisPCa. MRI should be included in the standard of care pathway for prostate cancer diagnosis.

Image-guided multiparametric magnetic resonance imaging-transrectal ultrasound fusion biopsy augmented with a sextant versus an extended template random biopsy: Comparison of cancer detection rates, complication and functional outcomes

PURPOSE

To compare the efficacy of a novel fusion template "reduced six-core systemic template and multiparametric magnetic resonance imaging/transrectal ultrasound (mpMRI/TRUS) fusion targeted biopsy" (TBx+6c), with mpMRI/TRUS fusion-targeted biopsy and 12-core systematic biopsy template (TBx+12c) in the diagnosis of prostate cancer (PCa).

MATERIALS AND METHODS

This is an institutional review board approved single-center observational study involving adult men undergoing fusion-targeted biopsies for the diagnosis of PCa. Patients were sorted into cohorts of TBx+6c or TBx+12c based on the systematic biopsy template used. The study's main objective was to determine the cancer detection rate (CDR) for overall PCa and clinically significant PCa (csPCa) and the secondary objectives were to compare complication rates and functional outcome differences between the cohort.

RESULTS

A total of 204 patients met study's inclusion criteria. TBx+6c group had 120 patients, while TBx+12c cohort had 84 patients. The groups had similar baseline characteristics and overall CDR in the TBx+6c cohort was 71.7% versus 79.8%, compared to the TBx+12c (p = 0.18) whereas, the csPCa detection rate in the TBx+6c group was 50.8% versus 54.8% in the TBx+12c group (p = 0.5). TBx+6c cohort had lower overall complication rate of 3% versus 13%, (p = 0.01) and ≥ grade 2 complication rates (1 (1%) vs. 3(4%), p = 0.03) compared to the TBx+12c cohort. There were no differences in IIEF-5 (p = 0.5) or IPSS (p = 0.1) scores at baseline and 2-weeks and 6-weeks post-biopsy.

CONCLUSION

TBx+6c cohort, when compared to the TBx+12c cohort, demonstrated comparable diagnostic performance along with similar functional outcomes and lower complication rates. These results suggest the importance of further exploring the clinical implications of adopting a TBx+6c schema for PCa diagnosis in comparison to the widely used TBx+12c schema through a multicenter randomized controlled trial.

A modified sampling method for the precise detection of prostate cancer tissues using a three-dimensional stereotaxic location technique

Background

The rapid and accurate acquisition of prostate cancer pathological tissue is critical to prostate cancer research but has traditionally proven challenging. However, the gradual application of three-dimensional (3D) modeling in medical practice has overcome many of the related limitations. This cohort study aimed to compare the difference between a 3D stereotaxic sampling method and traditional cognitive sampling method to clarify the factors affecting sampling.

Methods

An analysis of 111 men who received radical prostatectomy for prostate cancer at The First Affiliated Hospital of Soochow University between November 2020 and April 2022 was conducted. The positive rate of the cognitive sampling method and the 3D stereotaxic sampling method and their respective influencing factors, such as age, body mass index (BMI), prostate-specific antigen (PSA), PSA density (PSAD), International Society of Urological Pathology (ISUP) grade, tumor volume, number of positive needles from perineal puncture, clinical T stage, and tumor image location, were compared and analyzed, and a cohort study was conducted.

Results

Among the 111 patients, there were 57 cases of cognitive sampling and 54 cases of 3D stereotaxic sampling. In this study, the positive rate of cognitive sampling was 29.82% (17/57,), and the positive rate of 3D stereotaxic sampling was 61.11% (33/54), with the positive rate of 3D stereotaxic sampling being significantly higher than that of cognitive sampling (P=0.001). In cognitive sampling, tumor volume [odds ratio (OR) =1.10; 95% confidence interval (CI): 1.02-1.20], number of positive biopsy cores (OR =1.30; 95% CI: 1.06-1.60), Prostate Imaging Report and Data System (PI-RADS) score (OR =5.54; 95% CI: 1.60-19.12), and clinical T stage (OR =2.36; 95% CI: 1.31-4.25) were identified as influencing factors; in 3D stereotaxic sampling, these influencing factors were eliminated, with ORs of 1.22 (95% CI: 0.78-1.90), 0.88 (95% CI: 0.72-1.09), 1.09 (95% CI: 0.62-1.92), and 1.51 (95% CI: 0.86-2.65), respectively, representing a statistically significant difference (P<0.05).

Conclusions

The 3D stereotaxic sampling method can accurately obtain the required prostate cancer tissue from the prostate in vitro within a short time, and the factors affecting the positive rate of sampling can be eliminated.

The detection rate for prostate cancer in systematic and targeted prostate biopsy in biopsy-naive patients, according to the localization of the lesion at the mpMRI: A single-center retrospective observational study

OBJECTIVE

Evaluate the detection rates of systematic, targeted and combined cores at biopsy according to tumor positions in biopsy-naïve patients.

MATERIAL AND METHODS

A retrospective analysis of a single-center patient cohort (n = 501) that underwent transrectal prostate biopsy between January 2017 and December 2019 was performed. Multi-parametric MRI was executed as a prebiopsy investigation. Biopsy protocol included, for each patient, 12 systematic cores plus 3 to 5 targeted cores per lesion identified at the mpMRI. Pearson and McNemar chi-squared tests were used for statistical analysis to compare tumor location-related detection rates of systematic, targeted and combined (systematic + targeted) cores at biopsy.

RESULTS

Median age of patients was 70 years (IQR 62-72), with a median PSA of 8.5 ng/ml (IQR 5.7-15.6). Positive biopsies were obtained in 67.7% of cases. Overall, targeted cores obtained higher detection rates compared to systematic cores (54.3% vs. 43.1%, p < 0.0001). Differences in detection rates were, however, higher for tumors located at the apex (61.1% vs. 26.3%, p < 0.05) and anteriorly (44.4% vs. 19.3%, p < 0.05). Targeted cores similarly obtained higher detection rates in the posterior zone of the prostate gland for clinically significant prostate cancer. A poor agreement was reported between targeted and systematic cores for the apex and anterior zone of the prostate with, respectively κ = 0.028 and κ = -0.018.

CONCLUSION

A combined approach of targeted and systematic biopsy delivers the highest detection rate in prostate cancer (PCa). The location of the tumor could however greatly influence overall detection rates, indicating the possibility to omit (as for the base or posterior zone of the gland) or add (as for the apex or anterior zone of the gland) further targeted cores.

Utility of transperineal template-guided mapping prostate biopsy in biopsy-naïve men with PI-RADS 1-2 on multiparametric magnetic resonance imaging

Objective

To analyze the outcomes of transperineal template-guided mapping biopsy (TTMB) in biopsy-naïve men with multiparametric magnetic resonance imaging (mpMRI) results of Prostate Imaging-Reporting and Data System (PI-RADS) 1-2.

Patients and methods

We retrospectively reviewed TTMB outcomes in biopsy naïve patients with PI-RADS 1-2 at a single center from August 2018 to May 2023. The patients' clinicopathologic data were reviewed, clinically significant prostate cancer (csPCa) detection rates were identified. We determined significant predictive factors and determined those optimal cutoff point using receiver operating characteristic (ROC) curves.

Results

255 biopsy naïve patients with PI-RADS 1-2 underwent TTMB. 72 (28.2%) were diagnosed with prostate cancer and 30 (11.8%) were diagnosed with csPCa. ROC curves were used to identify predictive factors for diagnosing csPCa. Age (area under ROC curve [AUC]: 0.74, 95% CI: 0.65-0.83, P < 0.001) and prostate specific antigen density (PSAD) (AUC: 0.63, 95% CI: 0.53-0.72, P = 0.025) were significant predictive factors, and the optimal cutoff points determined using the Youden index were 65 years and 0.15 ng/mL/mL, respectively.

Conclusion

Of biopsy-naïve patients classified as PI-RADS 1-2, 11.8% were diagnosed with csPCa, and we identified age and PSAD as significant predictive factors. Our study will help determine the biopsy method for patients with PI-RADS 1-2 without biopsy experience.

Enhancing prostate MRI expertise: educational strategies for radiologists

The adoption of multiparametric MRI (mpMRI) and the Prostate Imaging Reporting and Data System has significantly changed prostate cancer diagnosis and management. These advancements, alongside novel biomarkers and updated International Society of Uropathology grade groups, have improved cancer detection and prognostication. Despite this progress, varying levels of expertise in mpMRI among radiologists have resulted in inconsistent assessments, potentially leading to unnecessary procedures and diminished confidence in the modality. This review assesses the educational landscape for prostate MRI, highlighting available resources for radiologists at all professional stages. It emphasizes the need for targeted educational strategies to bridge knowledge gaps and improve patient care outcomes in prostate cancer management.

Comparison of systematic and combined biopsy for the detection of prostate cancer

ABSTRACT

Systematic prostate biopsy has limitations, such as overdiagnosis of clinically insignificant prostate cancer and underdiagnosis of clinically significant prostate cancer. Magnetic resonance imaging (MRI)-guided biopsy, a promising alternative, might improve diagnostic accuracy. To compare the cancer detection rates of systematic biopsy and combined biopsy (systematic biopsy plus MRI-targeted biopsy) in Asian men, we conducted a retrospective cohort study of men who underwent either systematic biopsy or combined biopsy at two medical centers (Queen Mary Hospital and Tung Wah Hospital, Hong Kong, China) from July 2015 to December 2022. Descriptive statistics were calculated, and univariate and multivariate logistic regression analyses were performed. The primary and secondary outcomes were prostate cancer and clinically significant prostate cancer. A total of 1391 participants were enrolled. The overall prostate cancer detection rates did not significantly differ between the two groups (36.3% vs 36.6%, odds ratio [OR] = 1.01, 95% confidence interval [CI]: 0.81-1.26, P = 0.92). However, combined biopsy showed a significant advantage in detecting clinically significant prostate cancer (Gleason score ≥ 3+4) in patients with a total serum prostate-specific antigen (tPSA) concentration of 2-10 ng ml -1 (systematic vs combined: 11.9% vs 17.5%, OR = 1.58, 95% CI: 1.08-2.31, P = 0.02). Specifically, in the transperineal biopsy subgroup, combined biopsy significantly outperformed systematic biopsy in the detection of clinically significant prostate cancer (systematic vs combined: 12.6% vs 24.0%, OR = 2.19, 95% CI: 1.21-3.97, P = 0.01). These findings suggest that in patients with a tPSA concentration of 2-10 ng ml -1 , MRI-targeted biopsy may be of greater predictive value than systematic biopsy in the detection of clinically significant prostate cancer.

Targeted Prostate Biopsy: How, When, and Why? A Systematic Review

OBJECTIVE

Prostate cancer, the second most diagnosed cancer among men, requires precise diagnostic techniques to ensure effective treatment. This review explores the technological advancements, optimal application conditions, and benefits of targeted prostate biopsies facilitated by multiparametric magnetic resonance imaging (mpMRI).

METHODS

A systematic literature review was conducted to compare traditional 12-core systematic biopsies guided by transrectal ultrasound with targeted biopsy techniques using mpMRI. We searched electronic databases including PubMed, Scopus, and Web of Science from January 2015 to December 2024 using keywords such as "targeted prostate biopsy", "fusion prostate biopsy", "cognitive prostate biopsy", "MRI-guided biopsy", and "transrectal ultrasound prostate biopsy". Studies comparing various biopsy methods were included, and data extraction focused on study characteristics, patient demographics, biopsy techniques, diagnostic outcomes, and complications.

CONCLUSION

mpMRI-guided targeted biopsies enhance the detection of clinically significant prostate cancer while reducing unnecessary biopsies and the detection of insignificant cancers. These targeted approaches preserve or improve diagnostic accuracy and patient outcomes, minimizing the risks associated with overdiagnosis and overtreatment. By utilizing mpMRI, targeted biopsies allow for precise targeting of suspicious regions within the prostate, providing a cost-effective method that reduces the number of biopsies performed. This review highlights the importance of integrating advanced imaging techniques into prostate cancer diagnosis to improve patient outcomes and quality of life.

Tailoring biopsy strategy in the MRI-fusion prostate biopsy era: systematic, targeted or neither?

BACKGROUND

Magnetic  resonance imaging (MRI) followed by targeted biopsy (TBx) is utilized for prostate cancer (PCa) detection. However, the value of adding systematic biopsies (SBx) to targeted biopsy procedures (combined biopsy; CBx) in men with suspicious MRI findings has not been determined.

METHODS

We analysed biopsy outcomes in 429 men with MRI lesions in the prospective multicenter STHLM3MRI pilot study, planned for prostate biopsy. Participants underwent 1.5T biparametric MRI without contrast enhancement, reported according to the PI-RADS v2, and with TBx plus SBx if the MRI lesion score was ≥ 3. The endpoints were clinically nonsignificant (nsPCa) and clinically significant PCa (csPCa), defined as ISUP grade groups 1 and ≥ 2, respectively.

RESULTS

The median age was 65 years (59-70), and the median PSA 6.0 ng/ml (4.1-9.0). The detection rates of csPCa when using TBx or SBx combined were 18%, 46%, and 85% in men with PIRADS scores of 3 (n = 195), 4 (n = 121), and 5 (n = 113), respectively. This combined strategy detected csPCa in more men than TBx alone (43.6% vs 39.2%, p < 0.02), with similar detection of nsPCa (19.3% vs 17.7%, p = 0.2). In men with equivocal lesions (PI-RADS 3), the detection rates for csPCa were similar for the combined strategy and for TBx alone (17.9% and 15.4%, p = 0.06). However, there was an increase in the detection of nsPCa when using the combined strategy (21.0% vs 15.4%, p < 0.02). Men with equivocal lesions and a PSA density < 0.1 ng/ml2 or a Stockholm 3 test < 0.11 had a low risk of harboring csPCa.

CONCLUSIONS

Supplementing targeted with systematic biopsies enhances clinically significant cancer detection. However, in men with equivocal lesions, this combination has potential for detecting nonsignificant disease. A subgroup of men with equivocal MRI findings may be identified as having a low risk for significant cancer and spared unnecessary biopsies.

Intraoperative Imaging Techniques in Oncology

Imaging-based procedures have become well integrated into the diagnosis and management of oncological patients and play a significant role in reducing morbidity and mortality rates. Here we describe the established and upcoming surgical oncological imaging techniques and their impact on cancer management.

Are systematic prostate biopsy still necessary in biopsy naive men?

PURPOSE

Multiparametric MRI and the transperineal approach have become standard in the diagnostic pathway for suspected prostate cancer. Targeting of MRI lesions is performed at most centers, but the routine use of systematic cores is controversial. We aim to assess the value of obtaining systematic cores in patients undergoing cognitive fusion targeted double-freehand transperineal prostate biopsy.

MATERIALS AND METHODS

Patients who underwent a cognitive fusion, freehand TPB at a single tertiary urology service (Perth, Australia) between November 2020 and November 2021 were retrospectively reviewed. Patients were included if they were biopsy naive and had a clinical suspicion of prostate cancer, based on their mpMRI results. Both targeted and systematic cores were taken at the time of their biopsy.

RESULTS

One hundred forty patients suited the selection criteria. Clinically significant cancer was identified in 63% of patients. Of those that had clinically significant cancer, the target lesion identified 91% of the disease, missing 9% of patients whom the target biopsy detected non-clinically significant cancer but was identified in the systematic cores. Higher PI-RADS category patients were also found to be associated with an increasing likelihood of identifying clinically significant cancer within the target.

CONCLUSIONS

In patients with PI-RADS 3 and higher, the target biopsy can miss up to 9% of clinically significant cancer. Systematic cores can add value as they can also change management by identifying a high-risk disease where only intermediate cancer was identified in the target. A combination of targeted and systematic cores is still required to detect cancer.

Prior Negative Biopsy, PSA Density, and Anatomic Location Impact Cancer Detection Rate of MRI-Targeted PI-RADS Index Lesions

BACKGROUND

MRI fusion prostate biopsy has improved the detection of clinically significant prostate cancer (CSC). Continued refinements in predicting the pre-biopsy probability of CSC are essential for optimal patient counseling. We investigated potential factors related to improved cancer detection rates (CDR) of CSC in patients with PI-RADS ≥ 3 lesions.

METHODS

The pathology of 980 index lesions in 980 patients sampled by transrectal mpMRI-targeted prostate biopsy across four medical centers between 2017-2020 was reviewed. PI-RADS lesion distribution included 291 PI-RADS-5, 374 PI-RADS-4, and 315 PI-RADS-3. We compared CDR of index PI-RADS ≥ 3 lesions based on location (TZ) vs. (PZ), PSA density (PSAD), and history of prior negative conventional transrectal ultrasound-guided biopsy (TRUS).

RESULTS

Mean age, PSA, prostate volume, and level of prior negative TRUS biopsy were 66 years (43-90), 7.82 ng/dL (5.6-11.2), 54 cm3 (12-173), and 456/980 (46.5%), respectively. Higher PSAD, no prior history of negative TRUS biopsy, and PZ lesions were associated with higher CDR. Stratified CDR highlighted significant variance across subgroups. CDR for a PI-RADS-5 score, PZ lesion with PSAD ≥ 0.15, and prior negative biopsy was 77%. Conversely, the CDR rate for a PI-RADS-4 score, TZ lesion with PSAD < 0.15, and prior negative biopsy was significantly lower at 14%.

CONCLUSIONS

For index PI-RADS ≥ 3 lesions, CDR varied significantly based on location, prior history of negative TRUS biopsy, and PSAD. Such considerations are critical when counseling on the merits and potential yield of prostate needle biopsy.

A Novel Liquid Biopsy Method Based on Specific Combinations of Vesicular Markers Allows Us to Discriminate Prostate Cancer from Hyperplasia

BACKGROUND

Prostate cancer is the second most common cancer in males worldwide, and its incidence is rising. Early detection is crucial for improving the outcomes, but the current screening methods have limitations. While prostate-specific antigen (PSA) testing is the most widely used screening tool, it has poor specificity, leading to a high rate of false positives and unnecessary biopsies. The existing biopsy techniques are invasive and are associated with complications. The liquid biopsy methods that analyze the biomarkers in blood or other bodily fluids offer a non-invasive and more accurate alternative for detecting and characterizing prostate tumors.

METHODS

Here, we present a novel liquid biopsy method for prostate cancer based on the identification of specific proteins in the extracellular vesicles isolated from the blood of patients with prostate cancer.

RESULTS

We observed that a specific combination of sEV proteins is a sensitive indicator of prostate cancer. Indeed, we found that the number of clusters expressed by specific combinations of either intra-vesicular (STAT3 and CyclinD1) or surface proteins (ERBB3, ALK, and CD81) allowed us to significantly discriminate the patients with prostate cancer from the individuals with hyperplasia.

CONCLUSION

This new liquid biopsy method has the potential to improve prostate cancer screening by providing a non-invasive and more accurate diagnostic tool.

Lifetime Health and Economic Outcomes of Biparametric Magnetic Resonance Imaging as First-Line Screening for Prostate Cancer : A Decision Model Analysis

BACKGROUND

Contemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative.

OBJECTIVE

To evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening.

DESIGN

Decision analysis using a microsimulation model.

DATA SOURCES

Surveillance, Epidemiology, and End Results database; randomized trials.

TARGET POPULATION

U.S. men aged 55 years with no prior screening or PCa diagnosis.

TIME HORIZON

Lifetime.

PERSPECTIVE

U.S. health care system.

INTERVENTION

Biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography.

OUTCOME MEASURES

Screening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs.

RESULTS OF BASE-CASE ANALYSIS

For 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits.

RESULTS OF SENSITIVITY ANALYSIS

First-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial.

LIMITATION

Performance of first-line bpMRI was based on second-line mpMRI data.

CONCLUSION

Decision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Clinical characteristics and pathological features of undetectable clinically significant prostate cancer on multiparametric magnetic resonance imaging: A single-center and retrospective study

Objectives

The objectives of this study were to clarify the pathological features of clinically significant prostate cancer (csPC) that is undetectable on multiparametric magnetic resonance imaging (mpMRI).

Material and Methods

This single-center and retrospective study enrolled 33 men with prostate cancer (PC), encompassing 109 PC lesions, who underwent mpMRI before radical prostatectomy. Two radiologists independently assessed the mpMR images of all lesions and compared them with the pathological findings of PC. All PC lesions were marked on resected specimens using prostate imaging reporting and data system version 2.1 and classified into magnetic resonance imaging (MRI)-detectable and MRI-undetectable PC lesions. Each lesion was classified into csPC and clinically insignificant PC. Pathological characteristics were compared between MRI-detectable and MRI-undetectable csPC. Statistical analysis was performed to identify factors associated with MRI detectability. A logistic regression model was used to determine the factors associated with MRI-detectable and MRI-undetectable csPC.

Results

Among 109 PC lesions, MRI-detectable and MRI-undetectable PCs accounted for 31% (34/109) and 69% (75/109) of lesions, respectively. All MRI-detectable PCs were csPC. MRI-undetectable PCs included 30 cases of csPC (40%). The detectability of csPC on mpMRI was 53% (34/64). The MRI-undetectable csPC group had a shorter major diameter (10.6 ± 6.6 mm vs. 19.0 ± 6.9 mm, P < 0.001), shorter minor diameter (5.7 ± 2.9 mm vs. 10.7 ± 3.4 mm, P < 0.001), and lower percentage of lesions with Gleason pattern 5 (17% vs. 71%, P < 0.001). Shorter minor diameter (odds ratio [OR], 2.62; P = 0.04) and lower percentage of Gleason pattern 5 (OR, 24; P = 0.01) were independent predictors of MRI-undetectable csPC.

Conclusion

The pathological features of MRI-undetectable csPC included shorter minor diameter and lower percentage of Gleason pattern 5. csPC with shorter minor diameter may not be detected on mpMRI. Some MRI-undetectable csPC lesions exhibited sufficient size and Gleason pattern 5, emphasizing the need for further understanding of pathological factors contributing to MRI detectability.

Recursive Deformable Pyramid Network for Unsupervised Medical Image Registration

Complicated deformation problems are frequently encountered in medical image registration tasks. Although various advanced registration models have been proposed, accurate and efficient deformable registration remains challenging, especially for handling the large volumetric deformations. To this end, we propose a novel recursive deformable pyramid (RDP) network for unsupervised non-rigid registration. Our network is a pure convolutional pyramid, which fully utilizes the advantages of the pyramid structure itself, but does not rely on any high-weight attentions or transformers. In particular, our network leverages a step-by-step recursion strategy with the integration of high-level semantics to predict the deformation field from coarse to fine, while ensuring the rationality of the deformation field. Meanwhile, due to the recursive pyramid strategy, our network can effectively attain deformable registration without separate affine pre-alignment. We compare the RDP network with several existing registration methods on three public brain magnetic resonance imaging (MRI) datasets, including LPBA, Mindboggle and IXI. Experimental results demonstrate our network consistently outcompetes state of the art with respect to the metrics of Dice score, average symmetric surface distance, Hausdorff distance, and Jacobian. Even for the data without the affine pre-alignment, our network maintains satisfactory performance on compensating for the large deformation. The code is publicly available at https://github.com/ZAX130/RDP.

Gold nanoshells for prostate cancer treatment: evidence for deposition in abdominal organs

PURPOSE

Gold-silica nanoshell therapy [AuroShells with subsequent focal laser therapy (AuroLase)] is an emerging targeted treatment modality for prostate cancer. We reviewed pre- and post-treatment unenhanced CT imaging to assess for retained gold-silica nanoshells in the abdomen and pelvis.

METHODS

This single-institution retrospective study identified patients in the AuroLase pilot who underwent pre- and post-treatment unenhanced abdominopelvic CT. The attenuation, before and after gold-silica nanoshell administration, of the liver, spleen, pancreas, kidneys, prostate, blood pool, paraspinal musculature, and abnormal lymph nodes were manually measured by two readers. After inter-reader agreement was calculated using intraclass correlation (ICC), a permutation test was used to assess pre- and post-therapy attenuation differences.

RESULTS

Four patients met the inclusion criteria. Mean age was 72.3 ± 5.9 years. Median time interval between pre-treatment CT and treatment, and between treatment and post-treatment CT, was 232 days and 236.5 days, respectively. The two readers' attenuation measurements had very high agreement (ICC = 0.99, p < 0.001). The highest differences in organ attenuation between pre- and post-therapy scans were seen in all four patients in the liver and spleen (liver increased by an average of 28.9 HU, p = 0.010; spleen increased by an average of 63.7 HU, p = 0.012). A single measured lymph node increased by an average of 58.9 HU. In the remainder of the measured sites, the change in attenuation from pre- to post-therapy scans ranged from -0.1 to 3.8 HU (p > 0.05).

CONCLUSION

Increased attenuation of liver and spleen at CT can be an expected finding in patients who have received gold-silica nanoshell therapy.

Learning curve for fusion magnetic resonance imaging targeted prostate biopsy and three-dimensional transrectal ultrasonography segmentation

OBJECTIVE

To report the learning curve of multiple operators for fusion magnetic resonance imaging (MRI) targeted biopsy and to determine the number of cases needed to achieve proficiency.

MATERIALS AND METHODS

All adult males who underwent fusion MRI targeted biopsy between February 2012 and July 2021 for clinically suspected prostate cancer (PCa) in a single centre were included. Fusion transrectal MRI targeted biopsy was performed under local anaesthesia using the Koelis platform. Learning curves for segmentation of transrectal ultrasonography (TRUS) images and the overall MRI targeted biopsy procedure were estimated with locally weighted scatterplot smoothing by computing each operator's timestamps for consecutive procedures. Non-risk-adjusted cumulative sum (CUSUM) methods were used to create learning curves for clinically significant (i.e., International Society of Urological Pathology grade ≥ 2) PCa detection.

RESULTS

Overall, 1721 patients underwent MRI targeted biopsy in our centre during the study period. The median (interquartile range) times for TRUS segmentation and for the MRI targeted biopsy procedure were 4.5 (3.5, 6.0) min and 13.2 (10.6, 16.9) min, respectively. Among the 14 operators with experience of more than 50 cases, a plateau was reached after 40 cases for TRUS segmentation time and 50 cases for overall MRI targeted biopsy procedure time. CUSUM analysis showed that the learning curve for clinically significant PCa detection required 25 to 45 procedures to achieve clinical proficiency. Pain scores ranged between 0 and 1 for 84% of patients, and a plateau phase was reached after 20 to 100 cases.

CONCLUSIONS

A minimum of 50 cases of MRI targeted biopsy are necessary to achieve clinical and technical proficiency and to reach reproducibility in terms of timing, clinically significant PCa detection, and pain.

The Impact of Prostate Volume on Prostate Cancer Detection: Comparing Magnetic Resonance Imaging with Transrectal Ultrasound in Biopsy-naïve Men

Background and objective

This study aimed to determine the difference in prostate volume (PV) derived from transrectal ultrasound (TRUS) and multiparametric magnetic resonance imaging (mpMRI), and to further investigate the role of TRUS prostate-specific antigen density (PSAD) and mpMRI-PSAD in prostate cancer (PCa) detection in biopsy-naïve men.

Methods

Patients who underwent an initial prostate biopsy within 3 mo after mpMRI between January 2016 and December 2021 were analyzed retrospectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of both TRUS-PSAD and mpMRI-PSAD for PCa detection were calculated and compared. The Pearson correlation coefficient, Bland-Altman plot, and receiver operating characteristic curve were also utilized to explore the interests of this study.

Key findings and limitations

The median prostate-specific antigen level of 875 patients was 9.79 (interquartile range [IQR]: 7.09-13.50) ng/ml. The median mpMRI-PV and TRUS-PV were 41.92 (IQR: 29.29-60.73) and 41.04 (IQR: 29.24-57.27) ml, respectively, demonstrating a strong linear correlation (r = 0.831, 95% confidence interval: 0.809, 0.850; p < 0.01) and sufficient agreement. No significant difference was observed in terms of the sensitivity, specificity, PPV, and NPV between TRUS-PSAD and mpMRI-PSAD for any PCa and clinically significant PCa (csPCa) detection. The overall discriminative ability of TRUS-PSAD for detecting PCa or non-PCa, as well as csPCa and non-csPCa, was comparable with that of mpMRI-PSAD, and similar results were also observed in the subsequent analysis stratified by mpMRI-PV quartiles, prostate-specific antigen level, and age. The limitations include the retrospective and single-center nature and a lack of follow-up information.

Conclusions and clinical implications

TRUS-PV and MRI-PV exhibited a strong linear correlation and reached sufficient agreement. The efficiency of TRUS-PSAD and mpMRI-PSAD for PCa detection was comparable. TRUS could be used for PV estimation and dynamic monitoring of PSAD, and TRUS-PSAD could effectively guide clinical decision-making and optimize diagnostic strategies.

Patient summary

In this work, prostate volume (PV) derived from transrectal ultrasound (TRUS) exhibited a strong linear correlation with the PV derived from multiparametric magnetic resonance imaging (mpMRI). The efficiency of TRUS prostate-specific antigen density (PSAD) and mpMRI-PSAD for the detection of prostate cancer was comparable. TRUS could be used for PV estimation and TRUS-PSAD could help in clinical decision-making and optimizing diagnostic strategies.

Fast and accessible T2 mapping using off-resonance corrected DESPOT2 with application to 3D prostate

PURPOSE

Most T1 and T2 mapping take long acquisitions or needs specialized sequences not widely accessible on clinical scanners. An available solution is DESPOT1/T2 (Driven equilibrium single pulse observation of T1/T2). DESPOT1/T2 uses Spoiled gradient-echo (SPGR) and balanced Steady-State Free Precession (bSSFP) sequences, offering an accessible and reliable way for 3D accelerated T1/T2 mapping. However, bSSFP is prone to off-resonance artifacts, limiting the application of DESPOT2 in regions with high susceptibility contrasts, like the prostate. Our proposal, DESPO+, employs the full bSSFP and SPGR models with a dictionary-based method to reconstruct 3D T1/T2 maps in the prostate region without off-resonance banding.

METHODS

DESPO+ modifies the bSSFP acquisition of the original variable flip angle DESPOT2. DESPO+ uses variable repetition and echo times, employing a dictionary-based method of the full bSSFP and SPGR models to reconstruct T1, T2, and Proton Density (PD) simultaneously. The proposed DESPO+ method underwent testing through simulations, T1/T2 phantoms, and on fourteen healthy subjects.

RESULTS

The results reveal a significant reduction in T2 map banding artifacts compared to the original DESPOT2 method. DESPO+ approach reduced T2 errors by up to seven times compared to DESPOT2 in simulations and phantom experiments. We also synthesized in-vivo T1-weighted/T2-weighted images from the acquired maps using a spin-echo model to verify the map's quality when lacking a reference. For in-vivo imaging, the synthesized images closely resemble those from the clinical MRI protocol, reducing scan time by around 50% compared to traditional spin-echo T1-weighted/T2-weighted acquisitions.

CONCLUSION

DESPO+ provides an off-resonance insensitive and clinically available solution, enabling high-resolution 3D T1/T2 mapping and synthesized T1-weighted/T2-weighted images for the entire prostate, all achieved within a short scan time of 3.6 min, similar to DESPOT1/T2.

Nonsurgical Interventions to Prevent Disease Progression in Prostate Cancer Patients on Active Surveillance: A Systematic Review and Meta-analysis

CONTEXT

Active surveillance (AS) is a standard of care for patients with low-risk and selected intermediate-risk prostate cancer (PCa). Nevertheless, there is a lack of summary evidence on how to impact disease trajectory during AS.

OBJECTIVE

To assess which interventions prevent PCa progression effectively during AS.

EVIDENCE ACQUISITION

We queried PubMed, Scopus, and Web of Science databases to identify studies examining the impact of interventions aimed at slowing disease progression during AS. The primary endpoint was PCa progression, the definition of which must have included pathological upgrading. The secondary endpoint included treatment toxicities.

EVIDENCE SYNTHESIS

We identified 22 studies, six randomized controlled trials and 16 observational studies, which analyzed the association between different interventions and PCa progression during AS. The interventions considered in the studies included 5-alpha reductase inhibitors (5-ARIs), statins, diet, exercise, chlormadinone, fexapotide triflutate (FT), enzalutamide, coffee, vitamin D3, and PROSTVAC. We found that administration of 5-ARIs was associated with improved progression-free survival (PFS; hazard ratio: 0.59; 95% confidence interval 0.48-0.72), with no increased toxicity signals. Therapies such as vitamin D3, chlormadinone, FT, and enzalutamide have shown some efficacy. However, these anticancer drugs have been associated with treatment-related adverse events in up to 88% of patients.

CONCLUSIONS

The use of 5-ARIs in PCa patients on AS is associated with longer PFS. However, for the other interventions, it is difficult to draw clear conclusions based on the weak available evidence.

PATIENT SUMMARY

Patients with prostate cancer managed with active surveillance (AS) who are treated with 5-alpha reductase inhibitors have a lower risk of disease progression, with minimal adverse events. Other interventions require more studies to determine their efficacy and safety profile in men on AS.

Accuracy of MRI-ultrasound fusion-guided and systematic biopsy of the prostate

OBJECTIVES

Prostate multiparametric MRI (mpMRI) with subsequent targeted biopsy of suspicious lesions has a critical role in the diagnostic workup of prostate cancer. The objective was to evaluate the diagnostic accuracy of systematic biopsies, targeted biopsies, and the combination of both in prostate cancer detection.

METHODS

From January 1, 2013 to June 1, 2022, biopsy-naïve and prior biopsy-negative patients who underwent both systematic and targeted biopsies were included. MRIs were evaluated according to PI-RADS with biopsy threshold set at PI-RADS ≥3. Systematic biopsies consisted of 8-12 cores, based on prostate volume. Overall prostate cancer and clinically significant cancer (Gleason Score ≥3 + 4) detection rates were stratified based on PI-RADS and location within the prostate, and compared between biopsy types using McNemar test.

RESULTS

Among 867 patients, 615 had prostate cancer, with 434 clinically significant cases. Overall detection rates were: PI-RADS 3 48%, PI-RADS 4 72%, and PI-RADS 5 90%. Detection rates for clinically significant cancer were 21%, 53%, and 72%, respectively. The combination of biopsy methods was most accurate in detecting clinically significant prostate cancer (P < .001). Targeted biopsies alone detected more clinically significant prostate cancer than systematic biopsies alone (43.1% vs 40.3%, P = .046). For posterior PI-RADS 5 lesions, no statistically significant difference was found between all biopsy methods.

CONCLUSIONS

In the detection of clinically significant prostate cancer, the combination of systematic and targeted biopsies proves most effective. Targeted biopsies rarely missed significant cancer for posterior PI-RADS 5 lesions, suggesting systematic biopsies could be reserved for instances where targeted biopsy results are negative.

ADVANCES IN KNOWLEDGE

This study emphasizes on the efficacy of mpMRI and targeted biopsies in suspected prostate cancer in real-world clinical context. For PI-RADS 5 lesions, systematic biopsies provide limited clinical benefit and may only be necessary when targeted biopsy results are negative.

Targeted biopsy added to systematic biopsy improves cancer detection in prostate cancer screening

BACKGROUND

Magnetic resonance imaging (MRI)/ultrasound targeted biopsy has frequently been used together with a 12-core systematic biopsy for prostate cancer screening in the past few years. However, the efficacy of targeted biopsy compared to systematic biopsy, as well as its clinical-histologic correlation, has been assessed by a limited number of studies and is further investigated in this study.

DESIGN

We collected 960 cases with both targeted and systematic prostate biopsies from 04/2019 to 04/2022 (Table 1). We compared cancer detection rates between targeted and systematic prostate biopsies in different grade groups. Correlations with the size of prostate lesions, prostate-specific antigen (PSA) level, and Prostate Imaging-Reporting and Data System (PI-RADS) scale were also analyzed for each of these biopsy methods.

RESULTS

Among the 960 men who underwent targeted biopsy with systematic biopsy, prostatic adenocarcinoma was diagnosed in 652 (67.9%) cases. 489 (50.9%) cases were diagnosed by targeted biopsy and 576 (60.0%) cases were diagnosed by systematic biopsy. In the 384 cases diagnosed negative by systematic biopsy, targeted biopsy identified cancer in 76 (8%) cases. Systematic biopsy was able to detect 163 cancer cases that were missed by targeted biopsy. Systematic biopsy detected more grade group 1 cancers compared to targeted biopsy. However, for higher grade cancers, the differences between the cancer detection rates of targeted biopsy and systematic biopsy became negligible. Targeted biopsy upgraded the grade group categorized by systematic biopsy in several cases (3.8%, 7.0%, 2.6%, 1.1% and 0.9% in Grade Groups 1, 2, 3, 4, and 5 respectively). Targeted biopsy was more likely to detect cancer in larger lesions (13.17 mm VS 11.41 mm, P=0.0056) and for higher PI-RADS scales (4.19 VS 3.68, P<0.0001). The cancers detected by targeted biopsy also had higher PSA levels (10.38 ng/ml VS 6.39 ng/ml, P=0.0026).

CONCLUSION

Targeted biopsy with systematic biopsy improved cancer detection rate compared to systematic biopsy alone. Targeted biopsy is not more sensitive for grade groups 1, 4, or 5 cancers but is as sensitive as systematic biopsy for detecting grade group 2 and 3 cancers. Targeted biopsy is more effective at detecting cancers when patients have larger lesions, higher PI-RADS scales, and higher PSA levels.