Teaching Urologists "How to Read Multi-Parametric Prostate MRIs Using PIRADSv2": Results of an iBook Pilot Study

The role of urology and radiology in prostate biopsy: current trends and future perspectives

PURPOSE

Prostate biopsy is central to the accurate histological diagnosis of prostate cancer. In current practice, the biopsy procedure can be performed using a transrectal or transperineal route with different technologies available for targeting of lesions within the prostate. Historically, the biopsy procedure was performed solely by urologists, but with the advent of image-guided techniques, the involvement of radiologists in prostate biopsy has become more common. Herein, we discuss the pros, cons and future considerations regarding their ongoing role.

METHODS

A narrative review regarding the current evidence was completed. PubMed and Cochrane central register of controlled trials were search until January 2024. All study types were of consideration if published after 2000 and an English language translation was available.

RESULTS

There are no published studies that directly compare outcomes of prostate biopsy when performed by a urologist or radiologist. In all published studies regarding the learning curve for prostate biopsy, the procedure was performed by urologists. These studies suggest that the learning curve for prostate biopsy is between 10 and 50 cases to reach proficiency in terms of prostate cancer detection and complications. It is recognised that many urologists are poorly able to accurately interpret multi parametric (mp)-MRI of the prostate. Collaboration between the specialities is of importance with urology offering the advantage of being involved in prior and future care of the patient while radiology has the advantage of being able to expertly interpret preprocedure MRI.

CONCLUSION

There is no evidence to suggest that prostate biopsy should be solely performed by a specific specialty. The most important factor remains knowledge of the relevant anatomy and sufficient volume of cases to develop and maintain skills.

Understanding tumor localization in multiparametric MRI of the prostate-effectiveness of 3D printed models

Introduction

Understanding tumor localization in multiparametric MRI (mpMRI) of the prostate is challenging for urologists but of great importance in mpMRI-fused prostate biopsy or radical prostatectomy. The aim was to evaluate the effectiveness of 3D printed models of the prostate to help urologists to locate tumors.

Methods and Participants

20 urologists from University Medical Center Mainz (Germany) were asked to plot the location of a cancer suspicious lesion (PI-RADS ≥ 4) on a total of 30 mpMRI on a prostate sector diagram. The following 3 groups (as matched triplets) were divided into: mpMRI only, mpMRI with radiological report and mpMRI with 3D printed model (scaled 1:1). Statistical analysis was performed using one-way and two-way ANOVA (with bonferroni post-test).

Results

Overall, localization of the suspicious lesion was superior with the radiological report (median of max. 10 [IQR]: MRI 2 [IQR 1;5], MRI + report: 8 [6.3;9], MRI + 3D model 3 [1.3;5.8]; p < 0.001). Residents with <1 year of experience had a significantly higher detection rate using a 3D printed model [5 (5;5.8)] compared to mpMRI alone [1.5 (1;3.5)] (p < 0.05). Regarding the estimation of index lesion extension, the 3D model showed a significant benefit (mean percentage difference [95% CI]: MRI alone 234% [17.1;451.5], MRI + report 114% [78.5;149.6], MRI + 3D model 17% [-7.4;41.3] (p < 0.01).

Conclusion

Urologists still need the written radiological report for a sufficient understanding of tumor localization. The effectiveness of the 3D printed model regarding tumor localization is particularly evident in young residents (<1 year) and leads to a better overall assessment of the tumor extension.

Are Urologists Ready for Interpretation of Multiparametric MRI Findings? A Prospective Multicentric Evaluation

Aim: To assess urologists’ proficiency in the interpretation of multiparametric magnetic resonance imaging (mpMRI). Materials and Methods: Twelve mpMRIs were shown to 73 urologists from seven Italian institutions. Responders were asked to identify the site of the suspicious nodule (SN) but not to assign a PIRADS score. We set an a priori cut-off of 75% correct identification of SN as a threshold for proficiency in mpMRI reading. Data were analyzed according to urologists’ hierarchy (UH; resident vs. consultant) and previous experience in fusion prostate biopsies (E-fPB, defined as <125 vs. ≥125). Additionally, we tested for differences between non-proficient vs. proficient mpMRI readers. Multivariable logistic regression analyses (MVLRA) tested potential predictors of proficiency in mpMRI reading. Results: The median (IQR) number of correct identifications was 8 (6−8). Anterior nodules (number 3, 4 and 6) represented the most likely prone to misinterpretation. Overall, 34 (47%) participants achieved the 75% cut-off. When comparing consultants vs. residents, we found no differences in terms of E-fPB (p = 0.9) or in correct identification rates (p = 0.6). We recorded higher identification rates in urologists with E-fBP vs. their no E-fBP counterparts (75% vs. 67%, p = 0.004). At MVLRA, only E- fPB reached the status of independent predictor of proficiency in mpMRI reading (OR: 3.4, 95% CI 1.2−9.9, p = 0.02) after adjusting for UH and type of institution. Conclusions: Despite urologists becoming more familiar with interpretation of mpMRI, their results are still far from proficient. E-fPB enhances the proficiency in mpMRI interpretation.

Development and Application of an Interactive Neuropathology iBook as a Complementary Learning Tool for Veterinary Medicine Students

Neuropathology is a challenging subject for most medical students. Delivering a gamified learning tool on this topic may motivate students and increase knowledge in the discipline. We report the development of such a tool in iBook format for the systemic pathology course delivered at Ross University School of Veterinary Medicine. Composed of 10 chapters (cases), this Neuropathology iBook (NP-iB) reviews basic clinical manifestations, neuropathology, and pathogenesis of common non-neoplastic conditions that cause brain disease in domestic animals. The goal of each chapter is to reach a diagnosis by interactively answering specific questions after reviewing relevant medical history, clinical pathology, and autopsy findings. Our hypothesis: the NP-iB improves students' ability to recognize these diseases, reflected in higher test scores. Using a post-test only control group design, data were gathered from all students enrolled in the course in two different semesters, fall 2017 and spring 2018 (n = 300). NP-iB users (n = 51, 17%) and usage time were identified by answers to multiple-choice questions embedded in the course assessments. Ninety percent of users had a positive perception although no statistically significant differences were found in median test scores between users and non-users. Statistically significant test score differences were found across how much time students used the NP-iB (p = .005); the lowest test score median values were found for neuropathology questions not related to the NP-iB, in students who used it for more than 3 hours. Unexpectedly, a low number of students preferred this digital learning tool, and its use did not improve their learning outcomes.

Analyzing the learning curves of a novice and an experienced urologist for transrectal magnetic resonance imaging-ultrasound fusion prostate biopsy

Background

The aim of the current study was to evaluate and compare the learning curves of transrectal magnetic resonance imaging-ultrasound fusion biopsy for two urologists with different backgrounds (Operator 1: experienced, self-trained and Operator 2: novice, trained by a mentor/MRI reading courses).

Methods

A cohort of 400 patients who underwent fusion prostate biopsy in our department was analyzed. The learning curves were assessed in terms of overall and clinically significant prostate cancer (PCa) detection rates, percentage of positive biopsy cores/targeted and the percentage of PCa tissue on positive targeted cores.

Results

Increasing trends were observed for both urologists in terms of all biopsy outcomes during the study time. For the novice urologist, a significant increase was observed for overall PCa detection rate, but not for clinically significant disease (25.44%, P=0.04/15%, P=0.145). Operator 1 showed an increasing diagnosis yield of clinically significant disease up to 104 cases. Similar cancer detection rates were observed when comparing the first and last biopsies performed by both operators. Multivariate analysis adjusted for age, PSA, prostate volume, lesion diameter and PIRADS score showed an increase of PCa detection with 51% for every 52 biopsies performed (P=0.022).

Conclusions

When starting with magnetic resonance imaging-ultrasound fusion prostate biopsy, mentoring and prostate magnetic resonance imaging reading training allow a novice urologist to demonstrate a good initial PCa detection rate. After about 52 cases, he reached a stable PCa and clinically significant PCa detection rate, that was similar to that of an experienced urologist.

MRI-targeted prostate biopsy: the next step forward!

Aim

For decades, the gold standard technique for diagnosing prostate cancer was the 10 to 12 core systematic transrectal or transperineal biopsy, under ultrasound guidance. Over the past years, an increased rate of false negative results and detection of clinically insignificant prostate cancer has been noted, resulting into overdiagnosis and overtreatment. The purpose of the current study was to evaluate the changes in diagnosis and management of prostate cancer brought by MRI-targeted prostate biopsy.

Methods

A critical review of literature was carried out using the Medline database through a PubMed search, 37 studies meeting the inclusion criteria: prospective studies published in the past 8 years with at least 100 patients per study, which used multiparametric magnetic resonance imaging as guidance for targeted biopsies.

Results

In-Bore MRI targeted biopsy and Fusion targeted biopsy outperform standard systematic biopsy both in terms of overall and clinically significant prostate cancer detection, and ensure a lower detection rate of insignificant prostate cancer, with fewer cores needed. In-Bore MRI targeted biopsy performs better than Fusion biopsy especially in cases of apical lesions.

Conclusion

Targeted biopsy is an emerging and developing technique which offers the needed improvements in diagnosing clinically significant prostate cancer and lowers the incidence of insignificant ones, providing a more accurate selection of the patients for active surveillance and focal therapies.

Detection of individual prostate cancer via multiparametric magnetic resonance imaging in own material - initial experience

Purpose

Multiparametric magnetic resonance imaging (mpMRI) is an evolving non-invasive imaging modality that increases the accurate localization of prostate cancer (PCa) at the time of MRI targeted biopsy, enhancing clinical risk assessment, and improving the ability to appropriately counsel patients regarding therapy.

Material and methods

A total of forty patients with prostate-specific antigen (PSA), mpMRI and Gleason score (based on MRI template-guided cognitive biopsy) results were analyzed in this study, with eight patients (20%) diagnosed with PCa. The mpMRI was performed to facilitate the decision to perform prostate biopsy. Spearman’s coefficient analysis was used to evaluate the relationships between characteristics. Diagnostic performance was assessed measuring the area under the curve (AUC) of the receiver operating characteristic (ROC) analysis. Diagnostic accuracy, sensitivity, and specificity were determined using the best cut-off on each ROC.

Results

Out of all the study group, 55% of patients were subjected to primary biopsy and 45% were directed to repeated TRUS-Bx with the suspicion of prostate cancer. Forty suspected lesions on MRI images were identified with 5% of PI-RADS 1, 17.5% of PI-RADS 2, 32.5% of PI-RADS 3, 27.5% of PI-RADS 4 (27.5%) and 17.5% of PI-RADS 5. The highest correlation was observed for mpMRI results and Gleason score with Spearman’s coefficient equal to 0.41 (95% CI: 0.104-0.646). ROC analysis revealed that mpMRI discriminates between directing the patients for prostate biopsy or active surveillance with AUC = 0.771 (0.117, 95% CI: 0.542-1.001).

Conclusions

Introducing pre-biopsy mpMRI into our contemporary PCa diagnosis pathway increased the diagnostic yield of transrectal biopsy by increasing the prostate cancer detection. This enabled the introduction of clinically significant prostate cancer (csPCa) treatment. mpMRI application also allowed biopsy to be avoided among patients with no csPCa.