Second-opinion reads in prostate MRI: added value of subspecialty interpretation and review at multidisciplinary rounds

Negative biopsy histology in men with PI-RADS score 5: is it useful PSMA PET/CT evaluation?

INTRODUCTION

To evaluate the accuracy of PSMA PET/CT in men with mpMRI PI-RADS score 5 negative biopsy histology.

MATERIALS AND METHODS

From January 2011 to January 2023, 180 men with PI-RADS score 5 underwent systematic plus mpMRI/TRUS biopsy; 25/180 (13.9%) patients had absence of cancer and six months from biopsy were submitted to: digital rectal examination, PSA and PSA density exams, mpMRI and 68GaPSMA PET/CT evaluation (standardized uptake value "SUVmax" was reported).

RESULTS

In 24/25 (96%) patients PSA and PSA density significantly decreased, moreover, the PI-RADS score was downgraded resulting < 3; in addition, median SUVmax was 7.5. Only 1/25 (4%) man had an increased PSA value (from 10.5 to 31 ng/ml) with a confirmed PI-RADS score 5, SUVmax of 32 and repeated prostate biopsy demonstrating a Gleason score 9/ISUP Grade Group 5 PCa.

CONCLUSIONS

The strict follow up of men with PI-RADS score 5 and negative histology reduce the risk of missing csPCa especially if PSMA PET/CT evaluation is in agreement with downgrading of mpMRI (PI-RADS score < 3).

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.

Impact of prostate MRI central review over the diagnostic performance of MRI-targeted biopsy: should we routinely ask for an expert second opinion?

PURPOSE

There is substantial variability in multiparametric MRI (mpMRI) protocols and inter-readers' agreement. We tested the effect of a central mpMRI review on the detection of clinically significant PCa (csPCa) in a tertiary referral center.

METHODS

We retrospectively analyzed a cohort of 364 consecutive men with a positive externally performed mpMRI (PI-RADS ≥ 3) who underwent a targeted biopsy (TBx) plus a systematic biopsy at a single tertiary referral center (2018-2020). Of those mpMRIs, 32% (n = 116) were centrally reviewed. We compared the detection of csPCa between the non-central-reviewed vs reviewed group. Multivariable logistic regression models (MVA) tested the relationship between mpMRI central review and the detection of csPCa at TBx.

RESULTS

The detection of csPCa at TBx in non-central-reviewed vs central-reviewed group was 41 vs 63%, respectively (p = 0.001). The distribution of PI-RADS 2, 3, 4, and 5 at initial assessment vs after mpMRI central review was 0, 37, 47, and 16% vs 39, 9, 35, and 16%, respectively (p < 0.004). Of 43 patients with initial PI-RADS 3 score, respectively 67, 21, and 12, and 0% had a revised PI-RADS score of ≤ 2, 3, 4, and 5. At MVA, mpMRI central review (OR: 1.65, CI 0.85-0.98) was significantly associated with higher csPCa detection at TBx.

CONCLUSIONS

We demonstrated that a central review of external mpMRIs may decrease the overcall of equivocal lesions, namely PI-RADS 3, and should be considered to maximize the clinical benefit of TBx in terms of increasing the detection of csPCa and eventually decreasing the rate of unnecessary biopsies.

A semi-automated software program to assess the impact of second reads in prostate MRI for equivocal lesions: results from a UK tertiary referral centre

PURPOSE

To investigate the utility of a prostate magnetic resonance imaging (MRI) second read using a semi-automated software program in the one-stop clinic, where patients undergo multiparametric MRI, review and biopsy planning in one visit. We looked at concordance between readers for patients with equivocal scans and the possibility for biopsy deferral in this group.

METHODS

We present data from 664 consecutive patients. Scans were reported by seven different expert genitourinary radiologists using dedicated software (MIM®) and a Likert scale. All scans were rescored by another expert genitourinary radiologist using a customised workflow for second reads that includes annotated biopsy contours for accurate visual targeting. The number of scans in which a biopsy could have been deferred using biopsy results and prostate specific antigen density was assessed. Gleason score ≥ 3 + 4 was considered clinically significant disease. Concordance between first and second reads for equivocal scans (Likert 3) was evaluated.

RESULTS

A total of 209/664 (31%) patients scored Likert 3 on first read, 128 of which (61%) were concordant after second read. 103/209 (49%) of patients with Likert 3 scans were biopsied, with clinically significant disease in 31 (30%) cases. Considering Likert 3 scans that were both downgraded and biopsied using the workflow-generated biopsy contours, 25/103 (24%) biopsies could have been deferred.

CONCLUSIONS

Implementing a semi-automated workflow for accurate lesion contouring and targeting biopsies is helpful during the one-stop clinic. We observed a reduction of indeterminate scans after second reading and almost a quarter of biopsies could have been deferred, reducing the potential biopsy-related side effects.

Addressing Challenges and Controversies in the Management of Prostate Cancer with Multidisciplinary Teams

The diagnostic and treatment landscapes of prostate cancer are rapidly evolving. This has led to several challenges and controversies regarding optimal management of the disease that outpace guidelines and clinical data. Multidisciplinary teams (MDTs) can be used to engage the array of specialists that collaborate to treat complex malignancies such as prostate cancer. While the rationale for the use of MDTs in prostate cancer is well known, ways to optimally use MDTs to address the challenges and controversies associated with prostate cancer management are less well understood. One area of MDT care that remains undefined is how MDTs can most effectively provide guidance on clinical decision-making in situations in which information from novel diagnostic testing (genetic testing, molecular imaging) is substantially different from the established clinical risk factors. In this review, we provide a clinical perspective on ways that MDTs can be used to address this and other challenges and controversies across the prostate cancer disease continuum, from diagnosis to end-of-life considerations. Beyond clinical scenarios, we also review ways in which MDTs can mitigate disparities of care in prostate cancer. Overall, MDTs play a central role in helping to address the daily vexing issues faced by clinicians related to diagnosis, risk stratification, and treatment. Given the accelerating advances in precision medicine and targeted therapy, and the new questions and controversies these will bring, the value of MDTs for prostate cancer management will only increase in the future.

Structured approach to resolving discordance between PI-RADS v2.1 score and targeted prostate biopsy results: an opportunity for quality improvement

BACKGROUND

Prostate multiparametric magnetic resonance imaging (mpMRI) can identify lesions within the prostate with characteristics identified in Prostate Imaging Reporting and Data System (PI-RADS) v2.1 associated with clinically significant prostate cancer (csPCa) or Gleason grade group (GGG) ≥ 2 at biopsy.

OBJECTIVE

To assess concordance (PI-RADS 5 lesions with csPCa) of PI-RADS v2/2.1 with targeted, fusion biopsy results and to examine causes of discordance (PI-RADS 5 lesions without csPCa) with aim to provide a structured approach to resolving discordances and develop quality improvement (QI) protocols.

METHODS

A retrospective study of 392 patients who underwent mpMRI at 3 Tesla followed by fusion biopsy. PI-RADS v2/2.1 scores were assigned to lesions identified on mpMRI and compared to biopsy results expressed as GGG. Positive predictive value (PPV) of PI-RADS v2/2.1 was calculated for all prostate cancer and csPCa. Discordant cases were re-reviewed by a radiologist with expertise in prostate mpMRI to determine reason for discordance.

RESULTS

A total of 521 lesions were identified on mpMRI. 121/521 (23.2%), 310/524 (59.5%), and 90/521 (17.3%) were PI-RADS 5, 4, and 3, respectively. PPV of PI-RADS 5, 4, and 3 for all PCa and csPCa was 0.80, 0.55, 0.24 and 0.63, 0.33, and 0.09, respectively. 45 cases of discordant biopsy results for PI-RADS 5 lesions were found with 27 deemed "true" discordances or "unresolved" discordances where imaging re-review confirmed PI-RADS appropriateness, while 18 were deemed "false" or resolved discordances due to downgrading of PI-RADS scores based on imaging re-review. Adjusting for resolved discordances on re-review, the PPV of PI-RADS 5 lesions for csPCa was deemed to be 0.74 and upon adjusting for presence of csPCa found in cases of unresolved discordance, PPV rose to 0.83 for PI-RADS 5 lesions.

CONCLUSION

Although PIRADS 5 lesions are considered high risk for csPCa, the PPV is not 100% and a diagnostic dilemma occurs when targeted biopsy returns discordant. While PI-RADS score is downgraded in some cases upon imaging re-review, a number of "false" or "unresolved" discordances were identified in which MRI re-review confirmed initial PI-RADS score and subsequent pathology confirmed presence of csPCa in these lesions.

CLINICAL IMPACT

We propose a structured approach to resolving discordant biopsy results using multi-disciplinary re-review of imaging and archived biopsy strikes as a quality improvement pathway. Further work is needed to determine the value of re-biopsy in cases of unresolved discordance and to develop robust QI systems for prostate MRI.

Quality Assurance of a Cross-Border and Sub-Specialized Teleradiology Service

Background: The current literature discusses aspects of quality assurance (QA) and sub-specialization. However, the challenges of these topics in a teleradiology network have been less explored. In a project report, we aimed to review the development and enforcement of sub-specialized radiology at Telemedicine Clinic (TMC), one of the largest teleradiology providers in Europe, and to describe each step of its QA. Evaluation: The company-specific background was provided by the co-authors—current and former staff members of TMC. Detailed descriptions of the structures of sub-specialization and QA at TMC are provided. Exemplary quantitative evaluation of caseloads and disagreement rates of secondary reviews are illustrated. Description of Sub-specialization and Quality Assurance at TMC: Sub-specialization at TMC is divided into musculoskeletal radiology, neuroradiology, head and neck, a body, and an emergency section operating at local daytime in Europe and Australia. Quality assurance is based on a strict selection process of radiologists, specific reporting guidelines, feedback through the secondary reading of 100% of all radiology reports for new starters, and a minimum of 5% of radiology reports on a continuous basis for all other radiologists, knowledge sharing activities and ongoing training. The level of sub-specialization of each radiologist is monitored continuously on an individual basis in detail. After prospective secondary readings, the mean disagreement rate at TMC indicating at least possibly clinically relevant findings was 4% in 2021. Conclusion: With continuing and current developments in radiology in mind, the essential features of sub-specialization and innovative QA are relevant for further expansion of teleradiology services and for most radiology departments worldwide to respond to the increasing demand for value-based radiology.