The role of multiparametric resonance and biopsy in prostate cancer detection: comparison with definitive histological report after laparoscopic/robotic radical prostatectomy

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.

Transrectal Prostate Biopsy Approach in Men Undergoing Kidney Transplant: A Retrospective Cohort Study at Three Referral Academic Centers

BACKGROUND

Currently, there are no studies evaluating the feasibility of a prostate biopsy approach in men undergoing a kidney transplant (KT). Owing to this evidence, we planned a retrospective population-based study to evaluate our experience of a transrectal prostate biopsy (TR-PB) approach and studied the impact on the complication rate and outcomes in patients undergoing KT with suspected prostate cancer (PCa).

METHODS

We collected data from KT patients who underwent PB with a transrectal approach. One week and two weeks after the PB, patients' information was collected regarding possible complications during the post-biopsy period.

RESULTS

A total of 121 patients were included in this study. Among them, Group 1 was composed of 59 patients undergoing TR-PB with an ultrasound (US) standard technique, and Group 2 consisted of 62 patients undergoing TR-PB with an MRI-US cognitive technique. We observed a 28.9% Clavien-Dindo grade ≤ 2 of early side effect rates (mostly rectal bleeding and other minor hematuria), with a very low rate of hospital re-admission for acute urinary retention (3.3%); only one man required hospitalization for rectal bleeding, and there were no major complications.

CONCLUSIONS

We can affirm that TR-PB can be a safe procedure with a low risk of severe complications when performed by skilled specialists with a standardized procedural pathway.

Morbidity of Transrectal MRI-Fusion Targeted Prostate Biopsy at a Tertiary Referral Academic Centre: An Audit to Guide the Transition to the Transperineal Approach

Despite transrectal prostate biopsy (TRPB) being still widespread globally, the EAU Guidelines strongly recommend the transperineal approach, due to the reported lower infectious risk. Our study aims to evaluate the impact of a standardized clinical pathway for TRPB on post-operative complications. We prospectively collected data from all patients undergoing mpMRI-targeted TRPB at our Academic Centre from January 2020 to December 2022. All patients followed a standardized, structured multistep pathway. Post-procedural complications were collected and classified according to the Clavien-Dindo (CD) Classification. Among 458 patients, post-procedural adverse events were reported by 203 (44.3%), of which 161 (35.2%) experienced CD grade 1 complications (hematuria [124, 27.1%], hematochezia [22, 4.8%], hematospermia [14, 3.1%], or a combination [20, 4.4%]), and 45 (9.0%) reported CD grade 2 complications (acute urinary retention or hematuria needing catheterization, as well as urinary tract infections, of which 2 cases required hospitalization). No major complications, including sepsis, were observed. At uni- and multivariable analysis, age > 70 years and BMI > 25 kg/ m2 for patients were identified as predictors of post-operative complications. The results of our study confirm that TRPB is a safe and cost-effective procedure with a low risk of severe adverse events in experienced hands and following a standardized pathway.

Clinical and prostate multiparametric magnetic resonance imaging findings as predictors of general and clinically significant prostate cancer risk: A retrospective single-center study

Background

To evaluate the predictive values of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2), prostate-specific antigen (PSA) level, PSA density (PSAD), digital rectal examination findings, and prostate volume, individually and in combination, for the detection of prostate cancer (PCa) in biopsy-naive patients.

Methods

We retrospectively analyzed 630 patients who underwent transrectal systematic prostate biopsy following prostate multiparametric magnetic resonance imaging. A standard 12-core biopsy procedure was performed. Univariate and multivariate analyses were performed to determine the significant predictors of clinically significant cancer but not PCa.

Results

The median age, PSA level, and PSAD were 70 years, 8.6 ng/mL, and 0.18 ng/mL/mL, respectively. A total of 374 (59.4%) of 630 patients were biopsy-positive for PCa, and 241 (64.4%) of 374 were diagnosed with clinically significant PCa (csPCa). The PI-RADS v2 score and PSAD were independent predictors of PCa and csPCa. The PI-RADS v2 score of 5 regardless of the PSAD value, or PI-RADS v2 score of 4 plus a PSAD of <0.3 ng/mL/mL, was associated with the highest csPCa detection rate (36.1%-82.1%). Instead, the PI-RADS v2 score of <3 and PSAD of <0.3 ng/mL/mL yielded the lowest risk of csPCa.

Conclusion

The combination of the PI-RADS v2 score and PSAD could prove to be a helpful and reliable diagnostic tool before performing prostate biopsies. Patients with a PI-RADS v2 score of <3 and PSAD of <0.3 ng/mL/mL could potentially avoid a prostate biopsy.

Study on the transferability of the knowledge-based VMAT model to predict IMRT plans in prostate cancer radiotherapy

OBJECTIVE

The aim of this study was to investigate the feasibility of VMAT library-derived model transfer in the prediction of IMRT plans by dosimetry comparison among with three groups of IMRT plans: two groups of automatic IMRT plans generated by the knowledge-based the volumetric modulated arc therapy (VMAT) model and intensity-modulated radiation therapy (IMRT) model and one group of manual IMRT plans.

METHODS

52 prostate cancer patients who had completed radiotherapy were selected and randomly divided into 2 groups with 40 and 12 separately. Then both VMAT and IMRT plans were manually designed for all patients. The total plans in the group with 40 cases as training datasets were added to the knowledge-based planning (KBP) models for learning and finally obtained VMAT and IMRT training models. Another 12 cases were selected as the validation group to be used to generated auto IMRT plans by KBP VMAT and IMRT models. At last, the radiotherapy plans from three groups were obtained: the automated IMRT plan (V-IMRT) predicted by the VMAT model, the automated IMRT plan (I-IMRT) predicted by the IMRT model and the manual IMRT plan (M-IMRT) designed before. The dosimetric parameters of planning target volume (PTV) and organ at risks (OARs) as well as the time parameters (monitor unit, MU) were statistically analyzed.

RESULTS

The dose limit of all plans in the training datasets met the clinical requirements. Compared with the training plans added to VMAT model, the dosimetry parameters have no statistical differences in PTV (P > 0.05); the dose of X% volume (Dx%) with D25% and D35% in rectal and the maximum dose (Dmax) in the right femoral head were lower (P = 0.04, P = 0.01, P = 0.00) while D50% in rectal was higher (< 0.05) in the IMRT model plans. In the 12 validation cases, both automated plans showed better dose distribution compared with the M-IMRT plan: the Dmax of PTV in the I-IMRT plans and the dose in volume of interesting (VOI) of bladder and bilateral femoral heads were lower with a statistically significant difference (P < 0.05). Compared with the I-IMRT plans, dosimetric parameters in PTV and VOI of all OARs had no statistically significant differences (P > 0.05), but the Dmax in left femoral heard and D15% in the right femoral head were lower and have significant differences (P < 0.05). Furthermore, the low-dose regions, which was defined as all volumes outside of the PTV (RV) with the statistical parameters of mean dose (Dmean), the volume of covering more than 5 Gy dose (V5Gy), and also the time parameter (MU) required to perform the plan were considered. The results showed that Dmean in V-IMRT was smaller than that in the I-IMRT plan (P = 0.02) and there was no significant difference in V5Gy and MU (P > 0.05).

CONCLUSION

Compared with the manual plan, the IMRT plans generated by the KBP models had a significant advantage in dose control of both OARs and PTV. Compared to the I-IMRT plans, the V-IMRT plans was not only without significant disadvantages, but it also achieved slightly better control of the low-dose region, which meet the clinical requirements and can used in the clinical treatment. This study demonstrates that it is feasible to transfer the KBP VMAT model in the prediction of IMRT plans.

Prostate MRI and PSMA-PET in the Primary Diagnosis of Prostate Cancer

Over the last years, prostate magnetic resonance imaging (MRI) has gained a key role in the primary diagnosis of clinically significant prostate cancer (csPCa). While a negative MRI can avoid unnecessary prostate biopsies and the overdiagnosis of indolent cancers, a positive examination triggers biopsy samples targeted to suspicious imaging findings, thus increasing the diagnosis of csPCa with a sensitivity and negative predictive value of around 90%. The limitations of MRI, including suboptimal positive predictive values, are fueling debate on how to stratify biopsy decisions and management based on patient risk and how to correctly estimate it with clinical and/or imaging findings. In this setting, "next-generation imaging" imaging based on radiolabeled Prostate-Specific Membrane Antigen (PSMA)-Positron Emission Tomography (PET) is expanding its indications both in the setting of primary staging (intermediate-to-high risk patients) and primary diagnosis (e.g., increasing the sensitivity of MRI or acting as a problem-solving tool for indeterminate MRI cases). This review summarizes the current main evidence on the role of prostate MRI and PSMA-PET as tools for the primary diagnosis of csPCa, and the different possible interaction pathways in this setting.

Advancements in MRI-Based Radiomics and Artificial Intelligence for Prostate Cancer: A Comprehensive Review and Future Prospects

The use of multiparametric magnetic resonance imaging (mpMRI) has become a common technique used in guiding biopsy and developing treatment plans for prostate lesions. While this technique is effective, non-invasive methods such as radiomics have gained popularity for extracting imaging features to develop predictive models for clinical tasks. The aim is to minimize invasive processes for improved management of prostate cancer (PCa). This study reviews recent research progress in MRI-based radiomics for PCa, including the radiomics pipeline and potential factors affecting personalized diagnosis. The integration of artificial intelligence (AI) with medical imaging is also discussed, in line with the development trend of radiogenomics and multi-omics. The survey highlights the need for more data from multiple institutions to avoid bias and generalize the predictive model. The AI-based radiomics model is considered a promising clinical tool with good prospects for application.

Reliability of Multiparametric Magnetic Resonance Imaging in Patients with a Previous Negative Biopsy: Comparison with Biopsy-Naïve Patients in the Detection of Clinically Significant Prostate Cancer

Background: Multiparametric magnetic resonance is an established imaging utilized in the diagnostic pathway of prostate cancer. The aim of this study is to evaluate the accuracy and reliability of multiparametric magnetic resonance imaging (mpMRI) in the detection of clinically significant prostate cancer, defined as Gleason Score ≥ 4 + 3 or a maximum cancer core length 6 mm or longer, in patients with a previous negative biopsy. Methods: The study was conducted as a retrospective observational study at the University of Naples "Federico II", Italy. Overall, 389 patients who underwent systematic and target prostate biopsy between January 2019 and July 2020 were involved and were divided into two groups: Group A, which included biopsy-naïve patients; Group B, which included re-biopsy patients. All mpMRI images were obtained using three Tesla instruments and were interpreted according to PIRADS (Prostate Imaging Reporting and Data System) version 2.0. Results: 327 patients were biopsy-naïve, while 62 belonged to the re-biopsy group. Both groups were comparable in terms of age, total PSA (prostate-specific antigen), and number of cores obtained at the biopsy. 2.2%, 8.8%, 36.1%, and 83.4% of, respectively, PIRADS 2, 3, 4, and 5 biopsy-naïve patients reported a clinically significant prostate cancer compared to 0%, 14.3%, 39%, and 66.6% of re-biopsy patients (p < 0.0001-p = 0.040). No difference was reported in terms of post-biopsy complications. Conclusions: mpMRI confirms its role as a reliable diagnostic tool prior to performing prostate biopsy in patients who underwent a previous negative biopsy, reporting a comparable detection rate of clinically significant prostate cancer.

Optimizing multiparametric magnetic resonance imaging-targeted biopsy and prostate cancer grading accuracy

PURPOSE

To assess the most efficient biopsy method to improve International Society of Urological Pathology (ISUP) grade group accuracy with final pathology of the radical prostatectomy (RP) specimen in the era of magnetic resonance imaging (MRI)-driven pathway.

METHODS

A total of 753 patients diagnosed by transrectal MRI-targeted and systematic biopsies (namely "standard method"), treated by RP, between 2016 and 2021 were evaluated. Biopsy methods included MRI-targeted biopsy, side-specific systematic biopsies relative to index MRI lesion and combination of both. Number of MRI-targeted biopsy cores and positive cores needed per index MRI lesion were assessed. Multivariable analysis was performed to analyze predictive factors of upgrading using MRI targeted and ipsilateral systematic biopsies method.

RESULTS

Overall, ISUP grade group accuracy varied among biopsy methods with upgrading rate of 35%, 49%, 27%, and 24% for MRI targeted, systematic, MRI targeted and ipsilateral systematic biopsies and standard methods, respectively (p < 0.001). A minimum of two positive MRI-targeted biopsies cores per index MRI lesion were required when testing MRI targeted and ipsilateral systematic biopsies method to reach equivalent accuracy compared to standard method. Omitting contralateral systematic biopsies spared an average of 5.9 cores per patient. At multivariable analysis, only the number of positive MRI-targeted biopsy cores per index MRI lesion was predictive of upgrading.

CONCLUSION

MRI targeted and ipsilateral systematic biopsies allowed an accurate definition of ISUP grade group and appears to be an interesting alternative when compared with standard method, reducing total number of biopsy cores needed.

Diagnostic performance of transperineal prostate targeted biopsy alone according to the PI-RADS score based on bi-parametric magnetic resonance imaging

Purpose

To compare the diagnostic performance of transperineal targeted biopsy (TB) or systematic biopsy (SB) alone based on combined TB+SB and radical prostatectomy (RP) specimen for detecting prostate cancer (PCa) according to the prostate imaging reporting and data system (PI-RADS) score.

Materials and methods

This study included 1077 men who underwent transperineal bi-parametric (bp) magnetic resonance imaging (MRI)-ultrasound (US) fusion TB+SB (bpMRI-US FTSB) between April 2019 and March 2022. To compare the performance of each modality (TB, SB, and combined TB+SB) with the RP specimen (as the standard) for detecting PCa and clinically significant PCa (csPCa), receiver operating characteristic (ROC) curves were plotted.

Results

PCa was detected in 581 of 1077 men (53.9%) using bpMRI-US FTSB. CsPCa was detected in 383 of 1077 men (35.6%), 17 of 285 (6.0%) with PI-RADS 0 to 2, 35 of 277 (12.6%) with PI-RADS 3, 134 of 274 (48.9%) with PI-RADS 4, and 197 of 241 (81.7%) with PI-RADS 5, respectively. The additional diagnostic value of TB vs. SB compared to combined TB+SB for diagnosing csPCa were 4.3% vs. 3.2% (p=0.844), 20.4% vs 5.1% (p<0.001), and 20.3% vs. 0.7% (p<0.001) with PI-RADS 3, 4, and 5, respectively. TB alone showed no significant difference in diagnostic performance for csPCa with combined TB+SB based on RP specimens in patients with PI-RADS 5 (p=0.732).

Conclusion

A need for addition of SB to TB in patients with PI-RADS 3 and 4 lesions, however, TB alone may be performed without affecting the management of patients with PI-RADS 5.

The Role of Curcumin in Prostate Cancer Cells and Derived Spheroids

A major challenge in the clinical management of prostate cancer (PC) is to inhibit tumor growth and prevent metastatic spreading. In recent years, considerable efforts have been made to discover new compounds useful for PC therapy, and promising advances in this field were reached. Drugs currently used in PC therapy frequently induce resistance and PC progresses toward metastatic castration-resistant forms (mCRPC), making it virtually incurable. Curcumin, a commercially available nutritional supplement, represents an attractive therapeutic agent for mCRPC patients. In the present study, we compared the effects of chemotherapeutic drugs such as docetaxel, paclitaxel, and cisplatin, to curcumin, on two PC cell lines displaying a different metastatic potential: DU145 (moderate metastatic potential) and PC-3 (high metastatic potential). Our results revealed a dose-dependent reduction of DU145 and PC-3 cell viability upon treatment with curcumin similar to chemotherapeutic agents (paclitaxel, cisplatin, and docetaxel). Furthermore, we explored the EGFR-mediated signaling effects on ERK activation in DU145 and PC-3 cells. Our results showed that DU145 and PC-3 cells overexpress EGFR, and the treatment with chemotherapeutic agents or curcumin reduced EGFR expression levels and ERK activation. Finally, chemotherapeutic agents and curcumin reduced the size of DU145 and PC-3 spheroids and have the potential to induce apoptosis and also in Matrigel. In conclusion, despite different studies being carried out to identify the potential synergistic curcumin combinations with chemopreventive/therapeutic efficacy for inhibiting PC growth, the results show the ability of curcumin used alone, or in combinatorial approaches, to impair the size and the viability of PC-derived spheroids.

Liquid Biopsy in Prostate Cancer Management—Current Challenges and Future Perspectives

Simple Summary

Prostate cancer (PCa) is a widespread malignancy, representing the second leading cause of cancer-related death in men. In the last years, liquid biopsy has emerged as an attractive and promising strategy complementary to invasive tissue biopsy to guide PCa diagnosis, follow-up and treatment response. Liquid biopsy is employed to assess several body fluids biomarkers, including circulating tumor cells (CTCs), extracellular vesicles (EVs), circulating tumor DNA (ctDNA) and RNA (ctRNA). This review dissects recent advancements and future perspectives of liquid biopsy, highlighting its strength and weaknesses in PCa management.

Abstract

Although appreciable attempts in screening and diagnostic approaches have been achieved, prostate cancer (PCa) remains a widespread malignancy, representing the second leading cause of cancer-related death in men. Drugs currently used in PCa therapy initially show a potent anti-tumor effect, but frequently induce resistance and PCa progresses toward metastatic castration-resistant forms (mCRPC), virtually incurable. Liquid biopsy has emerged as an attractive and promising strategy complementary to invasive tissue biopsy to guide PCa diagnosis and treatment. Liquid biopsy shows the ability to represent the tumor microenvironment, allow comprehensive information and follow-up the progression of the tumor, enabling the development of different treatment strategies as well as permitting the monitoring of therapy response. Liquid biopsy, indeed, is endowed with a significant potential to modify PCa management. Several blood biomarkers could be analyzed for diagnostic, prognostic and predictive purposes, including circulating tumor cells (CTCs), extracellular vesicles (EVs), circulating tumor DNA (ctDNA) and RNA (ctRNA). In addition, several other body fluids may be adopted (i.e., urine, sperm, etc.) beyond blood. This review dissects recent advancements and future perspectives of liquid biopsies, highlighting their strength and weaknesses in PCa management.

MRI/Transrectal Ultrasound Fusion-Guided Targeted Biopsy and Transrectal Ultrasound-Guided Systematic Biopsy for Diagnosis of Prostate Cancer: A Systematic Review and Meta-analysis

Purpose

For men suspected of having prostate cancer (PCa), the transrectal ultrasound (TRUS)-guided systematic biopsy (SB) was performed. MRI/TRUS fusion guided-targeted biopsy (MRI-TB) could enhance PCa detection, allowing sampling of sites at higher risk which were not obvious with TRUS alone. The aim of this systematic review and meta-analysis was to compare the detection rates of prostate cancer by MRI-TB or MRI-TB plus SB versus SB, mainly for diagnosis of high-risk PCa.

Methods

A literature Search was performed on PubMed, Cochrane Library, and Embase databases. We searched from inception of the databases up to January 2021.

Results

A total of 5831 patients from 26 studies were included in the present meta-analysis. Compared to traditional TRUS-guided biopsy, MRI-TB had a significantly higher detection rate of clinically significant PCa (RR=1.27; 95%CI 1.15-1.40; p<0.001) and high-risk PCa (RR=1.41; 95% CI 1.22-1.64; p<0.001), while the detection rate of clinically insignificant PCa was lower (RR=0.65; 95%CI 0.55-0.77; p<0.001). MRI-TB and SB did not significantly differ in the detection of overall prostate cancer (RR=1.04; 95%CI 0.95-1.12; p=0.41). Compared with SB alone, we found that MRI-TB plus SB diagnosed more cases of overall, clinically significant and high-risk PCa (p<0.001).

Conclusion

Compared with systematic protocols, MRI-TB detects more clinically significant and high-risk PCa cases, and fewer clinically insignificant PCa cases. MRI-TB combined with SB enhances PCa detection in contrast with either alone but did not reduce the diagnosis rate of clinically insignificant PCa.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#searchadvanced, CRD42021218475.

Prostate health index (PHI) as a reliable biomarker for prostate cancer: a systematic review and meta-analysis

OBJECTIVES

Prostate cancer (PCa) represents the second most common solid cancer in men worldwide. In the last decades, the prostate health index (PHI) emerged as a reliable biomarker for detecting PCa and differentiating between non-aggressive and aggressive forms. However, before introducing it in clinical practice, more evidence is required. Thus, we performed a systematic review and meta-analysis for assessing the diagnostic performance of PHI for PCa and for detecting clinically significant PCa (csPCa).

METHODS

Relevant publications were identified by a systematic literature search on PubMed and Web of Science from inception to January 11, 2022.

RESULTS

Sixty studies, including 14,255 individuals, met the inclusion criteria for our meta-analysis. The pooled sensitivity and specificity of PHI for PCa detection was 0.791 (95%CI 0.739-0.834) and 0.625 (95%CI 0.560-0.686), respectively. The pooled sensitivity and specificity of PHI for csPCa detection was 0.874 (95%CI 0.803-0.923) and 0.569 (95%CI 0.458-0.674), respectively. Additionally, the diagnostic odds ratio was 6.302 and 9.206, respectively, for PCa and csPCa detection, suggesting moderate to good effectiveness of PHI as a diagnostic test.

CONCLUSIONS

PHI has a high accuracy for detecting PCa and discriminating between aggressive and non-aggressive PCa. Thus, it could be useful as a biomarker in predicting patients harbouring more aggressive cancer and guiding biopsy decisions.

Negative mpMRI Rules Out Extra-Prostatic Extension in Prostate Cancer before Robot-Assisted Radical Prostatectomy

Background: The accuracy of multi-parametric MRI (mpMRI) in the pre-operative staging of prostate cancer (PCa) remains controversial. Objective: The purpose of this study was to evaluate the ability of mpMRI to accurately predict PCa extra-prostatic extension (EPE) on a side-specific basis using a risk-stratified 5-point Likert scale. This study also aimed to assess the influence of mpMRI scan quality on diagnostic accuracy. Patients and Methods: We included 124 men who underwent robot-assisted RP (RARP) as part of the NeuroSAFE PROOF study at our centre. Three radiologists retrospectively reviewed mpMRI blinded to RP pathology and assigned a Likert score (1-5) for EPE on each side of the prostate. Each scan was also ascribed a Prostate Imaging Quality (PI-QUAL) score for assessing the quality of the mpMRI scan, where 1 represents the poorest and 5 represents the best diagnostic quality. Outcome measurements and statistical analyses: Diagnostic performance is presented for the binary classification of EPE, including 95% confidence intervals and the area under the receiver operating characteristic curve (AUC). Results: A total of 231 lobes from 121 men (mean age 56.9 years) were evaluated. Of these, 39 men (32.2%), or 43 lobes (18.6%), had EPE. A Likert score ≥3 had a sensitivity (SE), specificity (SP), NPV, and PPV of 90.4%, 52.3%, 96%, and 29.9%, respectively, and the AUC was 0.82 (95% CI: 0.77-0.86). The AUC was 0.76 (95% CI: 0.64-0.88), 0.78 (0.72-0.84), and 0.92 (0.88-0.96) for biparametric scans, PI-QUAL 1-3, and PI-QUAL 4-5 scans, respectively. Conclusions: MRI can be used effectively by genitourinary radiologists to rule out EPE and help inform surgical planning for men undergoing RARP. EPE prediction was more reliable when the MRI scan was (a) multi-parametric and (b) of a higher image quality according to the PI-QUAL scoring system.

Multiparametric Magnetic Resonance Imaging Grades the Aggressiveness of Prostate Cancer

We sought to find further evidence showing the increase in PCa aggressiveness as PI-RADS score increases from four surrogates of PCa aggressiveness: i. prostate biopsy GG (≤3 vs. >3), ii. type of pathology in surgical specimens (favourable vs. unfavourable), iii. clinical stage (localised vs. advanced), and risk of recurrence of localised PCa after primary treatment (low-intermediate vs. high). A group of 692 PCa patients were diagnosed after 3-T multiparametric MRI (mpMRI) and guided and/or systematic biopsies, showing csPCa (GG ≥ 2) in 547 patients (79%) and insignificant PCa (iPCa) in 145 (21%). The csPCa rate increased from 32.4% in PI-RADS < 3 to 95.5% in PI-RADS 5 (p < 0.001). GG ≥ 3 was observed in 7.6% of PCa with PI-RADS < 3 and 32.6% in those with PI-RADS > 3 (p < 0.001). Unfavourable pathology was observed in 38.9% of PCa with PI-RAD < 3 and 68.3% in those with PI-RADS > 3 (p = 0.030). Advanced disease was not observed in PCa with PI-RADS ≤ 3, while it existed in 12.7% of those with PI-RADS > 3 (p < 0.001). High-risk recurrence localised PCa was observed in 9.5% of PCa with PI-RADS < 3 and 35% in those with PI-RADS > 3 (p = 0.001). The PI-RADS score was an independent predictor of all surrogates of PCa aggressiveness as PSA density. We confirmed that mpMRI grades PCa aggressiveness.

The Barcelona Predictive Model of Clinically Significant Prostate Cancer

A new and externally validated MRI-PM for csPCa was developed in the metropolitan area of Barcelona, and a web-RC designed with the new option of selecting the csPCa probability threshold. The development cohort comprised 1486 men scheduled to undergo a 3-tesla multiparametric MRI (mpMRI) and guided and/or systematic biopsies in one academic institution of Barcelona. The external validation cohort comprised 946 men in whom the same diagnostic approach was carried out as in the development cohort, in two other academic institutions of the same metropolitan area. CsPCa was detected in 36.9% of men in the development cohort and 40.8% in the external validation cohort (p = 0.054). The area under the curve of mpMRI increased from 0.842 to 0.897 in the developed MRI-PM (p < 0.001), and from 0.743 to 0.858 in the external validation cohort (p < 0.001). A selected 15% threshold avoided 40.1% of prostate biopsies and missed 5.4% of the 36.9% csPCa detected in the development cohort. In men with PI-RADS <3, 4.3% would be biopsied and 32.3% of all existing 4.2% of csPCa would be detected. In men with PI-RADS 3, 62% of prostate biopsies would be avoided and 28% of all existing 12.4% of csPCa would be undetected. In men with PI-RADS 4, 4% of prostate biopsies would be avoided and 0.6% of all existing 43.1% of csPCa would be undetected. In men with PI-RADS 5, 0.6% of prostate biopsies would be avoided and none of the existing 42.0% of csPCa would be undetected. The Barcelona MRI-PM presented good performance on the overall population; however, its clinical usefulness varied regarding the PI-RADS category. The selection of csPCa probability thresholds in the designed RC may facilitate external validation and outperformance of MRI-PMs in specific PI-RADS categories.

Semi-Automatic MRI Feature Assessment in Small- and Medium-Volume Benign Prostatic Hyperplasia after Prostatic Artery Embolization

(1) Background: To assess the treatment response of benign prostatic syndrome (BPS) following prostatic artery embolization (PAE) using a semi-automatic software analysis of magnetic resonance imaging (MRI) features and clinical indexes. (2) Methods: Prospective, monocenter study of MRI and clinical data of n = 27 patients with symptomatic BPS before and (1, 6, 12 months) after PAE. MRI analysis was performed using a dedicated semi-automatic software for segmentation of the central and the total gland (CG, TG), respectively; signal intensities (SIs) of T1-weighted (T1w), T2-weighted (T2w), and diffusion-weighted images (DWI), as well as intravesical prostatic protrusion (IPP) and prostatic volumes (CGV, TGV), were evaluated at each time point. The semi-automatic assessed TGV was compared to conventional TGV by an ellipse formula. International prostate symptom score (IPSS) and international consultation on incontinence questionnaire−urinary incontinence short form (ICIQ-UI SF) questionnaires were used as clinical indexes. Statistical testing in the form of ANOVA, pairwise comparisons using Bonferroni correction, and multiple linear correlations, were conducted using SPSS. (3) Results: TGV was significantly reduced one, six, and 12 months after PAE as assessed by the semi-automatic approach and conventional ellipse formula (p = 0.005; p = 0.025). CGV significantly decreased after one month (p = 0.038), but showed no significant differences six and 12 months after PAE (p = 0.191; p = 0.283). IPP at baseline was demonstrated by 25/27 patients (92.6%) with a significant decrease one, six, and 12 months after treatment (p = 0.028; p = 0.010; p = 0.008). Significant improvement in IPSS and ICIQ-UI SF (p = 0.002; p = 0.016) after one month correlated moderately with TGV reduction (p = 0.031; p = 0.05, correlation coefficients 0.52; 0.69). Apparent diffusion coefficient (ADC) values of CG significantly decreased one month after embolization (p < 0.001), while there were no significant differences in T1w and T2w SIs before and after treatment at each time point. (4) Conclusions: The semi-automatic approach is appropriate for the assessment of volumetric and morphological changes in prostate MRI following PAE, able to identify significantly different ADC values post-treatment without the need for manual identification of infarct areas. Semi-automatic measured TGV reduction is significant and comparable to the TGV calculated by the conventional ellipse formula, confirming the clinical response after PAE.

Multiparametric MRI and Machine Learning Based Radiomic Models for Preoperative Prediction of Multiple Biological Characteristics in Prostate Cancer

Objectives

This study aims to develop and evaluate multiparametric MRI (MP-MRI)-based radiomic models as a noninvasive diagnostic method to predict several biological characteristics of prostate cancer.

Methods

A total of 252 patients were retrospectively included who underwent radical prostatectomy and MP-MRI examinations. The prediction characteristics of this study were as follows: Ki67, S100, extracapsular extension (ECE), perineural invasion (PNI), and surgical margin (SM). Patients were divided into training cohorts and validation cohorts in the ratio of 4:1 for each group. After lesion segmentation manually, radiomic features were extracted from MP-MRI images and some clinical factors were also included. Max relevance min redundancy (mRMR) and recursive feature elimination (RFE) based on random forest (RF) were adopted to select features. Six classifiers were included (SVM, KNN, RF, decision tree, logistic regression, XGBOOST) to find the best diagnostic performance among them. The diagnostic efficiency of the construction models was evaluated by ROC curves and quantified by AUC.

Results

RF performed best among the six classifiers for the four groups according to AUC values (Ki67 = 0.87, S100 = 0.80, ECE = 0.85, PNI = 0.82). The performance of SVM was relatively the best for SM (AUC = 0.77). The number and importance of DCE features ranked first in the models of each group. The combined models of MP-MRI and clinical characteristics showed no significant difference compared with MP-MRI models according to Delong’s tests.

Conclusions

Radiomics models based on MP-MRI have the potential to predict biological characteristics and are expected to be a noninvasive method to evaluate the risk stratification of prostate cancer.

Construction and Validation of a Clinical Predictive Nomogram for Improving the Cancer Detection of Prostate Naive Biopsy Based on Chinese Multicenter Clinical Data

Objectives

Prostate biopsy is a common approach for the diagnosis of prostate cancer (PCa) in patients with suspicious PCa. In order to increase the detection rate of prostate naive biopsy, we constructed two effective nomograms for predicting the diagnosis of PCa and clinically significant PCa (csPCa) prior to biopsy.

Materials and Methods

The data of 1,428 patients who underwent prostate biopsy in three Chinese medical centers from January 2018 to June 2021 were used to conduct this retrospective study. The KD cohort, which consisted of 701 patients, was used for model construction and internal validation; the DF cohort, which consisted of 385 patients, and the ZD cohort, which consisted of 342 patients, were used for external validation. Independent predictors were selected by univariate and multivariate binary logistic regression analysis and adopted for establishing the predictive nomogram. The apparent performance of the model was evaluated via internal validation and geographically external validation. For assessing the clinical utility of our model, decision curve analysis was also performed.

Results

The results of univariate and multivariate logistic regression analysis showed prostate-specific antigen density (PSAD) (P<0.001, OR:2.102, 95%CI:1.687-2.620) and prostate imaging-reporting and data system (PI-RADS) grade (P<0.001, OR:4.528, 95%CI:2.752-7.453) were independent predictors of PCa before biopsy. Therefore, a nomogram composed of PSAD and PI-RADS grade was constructed. Internal validation in the developed cohort showed that the nomogram had good discrimination (AUC=0.804), and the calibration curve indicated that the predicted incidence was consistent with the observed incidence of PCa; the brier score was 0.172. External validation was performed in the DF and ZD cohorts. The AUC values were 0.884 and 0.882, in the DF and ZD cohorts, respectively. Calibration curves elucidated greatly predicted the accuracy of PCa in the two validation cohorts; the brier scores were 0.129 in the DF cohort and 0.131 in the ZD cohort. Decision curve analysis showed that our model can add net benefits for patients. A separated predicted model for csPCa was also established and validated. The apparent performance of our nomogram for PCa was also assessed in three different PSA groups, and the results were as good as we expected.

Conclusions

In this study, we put forward two simple and convenient clinical predictive models comprised of PSAD and PI-RADS grade with excellent reproducibility and generalizability. They provide a novel calculator for the prediction of the diagnosis of an individual patient with suspicious PCa.

Influence of operative time and blood loss on surgical margins and functional outcomes for laparoscopic versus robotic-assisted radical prostatectomy: a prospective analysis

Introduction

The aim of this article was to analyze whether operative time and blood loss during radical prostatectomy (RP) can significantly influence surgical margins (SM) status and post-operative functional outcomes.

Material and methods

We prospectively analyzed prostate cancer (PC) patients undergoing RP, using robot-assisted (RARP) or laparoscopic (LRP) procedures. Blood loss was defined using the variation in hemoglobin (Hb, g/dl) values from the day before surgery and no later than 4 hours after surgery.

Results

From a whole population of 413 cases considered for RP, 67% underwent LRP and 33.0% RARP. Positive SM (SM+) were found in 33.9% of cases. Mean surgical operative time was 172.3 ±76 min (range 49–485), whereas blood loss was 2.3 ±1.2 g/dl (range 0.3–7.6). Operative time and blood loss at RP were not significantly correlated (r = -0.028275; p = 0.684). SM+ rates significantly (p = 0.002) varied by operative time; a higher SM+ rate was found in cases with an operative time <120 min (41.2%) and >240 min (53.4%). The risk of SM+ significantly increased 1.70 and 1.94 times in cases with an operative time <120 min and >240 min, respectively, independently to the surgical approach. The rate of erectile disfunction (ED) varied from 22.4% to 60.3% between <120 min and >240 min procedures (p = 0.001). According to blood loss, SM+ rates slightly but significantly (p = 0.032) varied; a higher rate of SM+ was found in cases with a Hb variation between 2–4 g/dl (35.9%).

Conclusions

Independently to the surgical approach, operative time, more than blood loss at RP, represents a significant variable able to influence SM status and post-operative ED.

Radiomics in prostate cancer: an up-to-date review

Prostate cancer (PCa) is the most common worldwide diagnosed malignancy in male population. The diagnosis, the identification of aggressive disease, and the post-treatment follow-up needs a more comprehensive and holistic approach. Radiomics is the extraction and interpretation of images phenotypes in a quantitative manner. Radiomics may give an advantage through advancements in imaging modalities and through the potential power of artificial intelligence techniques by translating those features into clinical outcome prediction. This article gives an overview on the current evidence of methodology and reviews the available literature on radiomics in PCa patients, highlighting its potential for personalized treatment and future applications.

Significant Inter- and Intralaboratory Variation in Gleason Grading of Prostate Cancer: A Nationwide Study of 35,258 Patients in The Netherlands

Simple Summary

Gleason grading of prostate cancer is essential for treatment strategies and patient prognosis. Previous studies showed grading variation between pathologists when grading prostate cancer. Our study analyzed the presence and extent of grading variation between and within pathology laboratories in The Netherlands. In our nationwide retrospective study, we analyzed prostate needle biopsy reports of 35,258 patients in The Netherlands graded by 40 pathology laboratories. We found a considerable variation between and within pathology laboratories, as over half of the laboratories graded significantly different from the national mean. This likely affects treatment strategy and prognosis assessment of prostate cancer patients.

Abstract

Purpose: Our aim was to analyze grading variation between pathology laboratories and between pathologists within individual laboratories using nationwide real-life data. Methods: We retrieved synoptic (n = 13,397) and narrative (n = 29,377) needle biopsy reports from the Dutch Pathology Registry and prostate-specific antigen values from The Netherlands Cancer Registration for prostate cancer patients diagnosed between January 2017 and December 2019. We determined laboratory-specific proportions per histologic grade and unadjusted odds ratios (ORs) for International Society of Urological Pathologists Grades 1 vs. 2–5 for 40 laboratories due to treatment implications for higher grades. Pathologist-specific proportions were determined for 21 laboratories that consented to this part of analysis. The synoptic reports of 21 laboratories were used for analysis of case-mix correction for PSA, age, year of diagnosis, number of biopsies and positive cores. Results: A total of 38,321 reports of 35,258 patients were included. Grade 1 ranged between 19.7% and 44.3% per laboratory (national mean = 34.1%). Out of 40 laboratories, 22 (55%) reported a significantly deviant OR, ranging from 0.48 (95% confidence interval (CI) 0.39–0.59) to 1.54 (CI 1.22–1.93). Case-mix correction was performed for 10,294 reports, altering the status of 3/21 (14%) laboratories, but increasing the observed variation (20.8% vs. 17.7%). Within 15/21 (71%) of laboratories, significant inter-pathologist variation existed. Conclusion: Substantial variation in prostate cancer grading was observed between and within Dutch pathology laboratories. Case-mix correction did not explain the variation. Better standardization of prostate cancer grading is warranted to optimize and harmonize treatment.

Transrectal ultrasound-guided prostate needle biopsy remains a safe method in confirming a prostate cancer diagnosis: a multicentre Australian analysis of infection rates

PURPOSE

Worldwide, transrectal ultrasound-guided prostate needle remains the most common method of diagnosing prostate cancer. Due to high infective complications reported, some have suggested it is now time to abandon this technique in preference of a trans-perineal approach. The aim of this study was to report on the infection rates following transrectal ultrasound-guided prostate needle biopsy in multiple Australian centres.

MATERIALS AND METHODS

Data were collected from seven Australian centres across four states and territories that undertake transrectal ultrasound-guided prostate needle biopsies for the diagnosis of prostate cancer, including major metropolitan and regional centres. In four centres, the data were collected prospectively. Rates of readmissions due to infection, urosepsis resulting in intensive care admission and mortality were recorded.

RESULTS

12,240 prostate biopsies were performed in seven Australian centres between July 1998 and December 2020. There were 105 readmissions for infective complications with rates between centres ranging from 0.19 to 2.60% and an overall rate of 0.86%. Admission to intensive care with sepsis ranged from 0 to 0.23% and overall 0.03%. There was no mortality in the 12,240 cases.

CONCLUSION

Infective complications following transrectal ultrasound-guided prostate needle biopsies are very low, occurring in less than 1% of 12,240 biopsies. Though this study included a combination of both prospective and retrospective data and did not offer a comparison with a trans-perineal approach, TRUS prostate biopsy is a safe means of obtaining a prostate cancer diagnosis. Further prospective studies directly comparing the techniques are required prior to abandoning TRUS based upon infectious complications.

The Role of Prostate Combination Biopsy Consisting of Targeted and Additional Systematic Biopsy

BACKGROUND

To identify the role of combination biopsy, which consists of both targeted and additional systematic cores, in the diagnosis of clinically significant prostate cancer (csPCa).

METHODS

We retrospectively reviewed patients with PSA levels 2.5-15 ng/mL who have a suspicious prostate lesion (with the Prostate Imaging Reporting and Data System (PI-RADS) ≥ 3) on multiparametric MRI (mpMRI) between January 2016 and December 2018. We analyzed biopsy results by PI-RADS score and biopsy methods (systematic, targeted, and combination biopsy).

RESULTS

Of the 711 total patients, an average of 4.0 ± 1.8 targeted and 8.6 ± 3.1 additional systematic biopsies were performed. The additional systematic biopsies were sampled outside the targeted biopsy area. The combination biopsies detected more csPCa (201 patients, 28.3%) than did the targeted (175 patients, 24.6%) or systematic (124 patients, 17.4%) biopsies alone (p < 0.001). In the initial biopsy samples, there was a 7% increase in the detection of csPCa than in targeted biopsy (62% to 69%). It increased by 11% in repeat biopsy (46% to 57%). There was no statistical significance in both groups (p = 0.3174).

CONCLUSIONS

Combination biopsy has the benefit of detecting csPCa in both initial and repeat biopsy when there is a suspicious lesion on mpMRI.

Prostate Health Index and Multiparametric MRI: Partners in Crime Fighting Overdiagnosis and Overtreatment in Prostate Cancer

Simple Summary

In the last decades, the widespread use of PSA as the standard tool for prostate cancer diagnosis led to a high rate of overdiagnosis and overtreatment. More recently, multiparametric magnetic resonance imaging (mpMRI) became part of the diagnostic pathway, and several next-generation PSA-based tests (PHI, PHI density, 4Kscore, STHLM3) have been proposed. The multivariable approach promises to help with a better stratification of PCa patients at initial diagnosis. In this study, we evaluated the performance of the prostate health index (PHI) and mpMRI for the prediction of positive biopsy and of high-grade PCa at radical prostatectomy (RP). Our findings suggested that PHI had a better ability than mpMRI to predict positive biopsy, whereas a comparable performance in the identification of pathological aggressive PCa was pointed out. Notably, PHI and PHI density might represent useful biomarkers to recognize high-grade PCa in patients with low or uncertain PI-RADS scores on mpMRI.

Abstract

Widespread use of PSA as the standard tool for prostate cancer (PCa) diagnosis led to a high rate of overdiagnosis and overtreatment. In this study, we evaluated the performance of the prostate health index (PHI) and multiparametric magnetic resonance imaging (mpMRI) for the prediction of positive biopsy and of high-grade PCa at radical prostatectomy (RP). To this end, we prospectively enrolled 196 biopsy-naïve patients who underwent mpMRI. A subgroup of 116 subjects with biopsy-proven PCa underwent surgery. We found that PHI significantly outperformed both PI-RADS score (difference in AUC: 0.14; p < 0.001) and PHI density (difference in AUC: 0.08; p = 0.002) in the ability to predict positive biopsy with a cut-off value of 42.7 as the best threshold. Conversely, comparing the performance in the identification of clinically significant prostate cancer (csPCa) at RP, we found that PHI ≥ 61.68 and PI-RADS score ≥ 4 were able to identify csPCa (Gleason score ≥ 7 (3 + 4)) both alone and added to a base model including age, PSA, fPSA-to-tPSA ratio and prostate volume. In conclusion, PHI had a better ability than PI-RADS score to predict positive biopsy, whereas it had a comparable performance in the identification of pathological csPCa.

Comparison of Accuracies between Real-Time Nonrigid and Rigid Registration in the MRI-US Fusion Biopsy of the Prostate

Magnetic resonance imaging (MRI) is increasingly important in the detection and localization of prostate cancer. Regarding suspicious lesions on MRI, a targeted biopsy using MRI fused with ultrasound (US) is widely used. To achieve a successful targeted biopsy, a precise registration between MRI and US is essential. The purpose of our study was to show any decrease in errors using a real-time nonrigid registration technique for prostate biopsy. Nineteen patients with suspected prostate cancer were prospectively enrolled in this study. Registration accuracy was calculated by the measuring distance of corresponding points by rigid and nonrigid registration between MRI and US, and compared for rigid and nonrigid registration methods. Overall cancer detection rates were also evaluated by patient and by core. Prostate volume was measured automatically from MRI and manually from US, and compared to each other. Mean distances between the corresponding points in MRI and US were 5.32 ± 2.61 mm for rigid registration and 2.11 ± 1.37 mm for nonrigid registration (p < 0.05). Cancer was diagnosed in 11 of 19 patients (57.9%), and in 67 of 266 biopsy cores (25.2%). There was no significant difference in prostate-volume measurement between the automatic and manual methods (p = 0.89). In conclusion, nonrigid registration reduces targeting errors.

Correlation of MRI-Lesion Targeted Biopsy vs. Systematic Biopsy Gleason Score with Final Pathological Gleason Score after Radical Prostatectomy

Background: The impact of MRI-lesion targeted (TB) and systematic biopsy (SB) Gleason score (GS) as a predictor for final pathological GS still remains unclear. Methods: All patients with TB + SB, and subsequent radical prostatectomy (RP) between 01/2014-12/2020 were analyzed. Rank correlation coefficient predicted concordance with pathological GS for patients’ TB and SB GS, as well as for the combined effect of SB + TB. Results: Of 159 eligible patients, 77% were biopsy naïve. For SB taken in addition to TB, a Spearman’s correlation of +0.33 was observed regarding final GS. Rates of concordance, upgrading, and downgrading were 37.1, 37.1 and 25.8%, respectively. For TB, a +0.52 correlation was computed regarding final GS. Rates of concordance, upgrading and downgrading for TB biopsy GS were 45.9, 33.3, and 20.8%, respectively. For the combination of SB + TB, a correlation of +0.59 was observed. Rates of concordance, upgrading and downgrading were 49.7, 15.1 and 35.2%, respectively. The combined effect of SB + TB resulted in a lower upgrading rate, relative to TB and SB (both p < 0.001), but a higher downgrading rate, relative to TB (p < 0.01). Conclusions: GS obtained from TB provided higher concordance and lower upgrading and downgrading rates, relative to SB GS with regard to final pathology. The combined effect of SB + TB led to the highest concordance rate and the lowest upgrading rate.