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Wang L, Luo Y, Liu T, Deng M, Huang X. Prostate imaging-reporting and data system version 2 in combination with clinical parameters for prostate cancer detection: a single center experience. Int Urol Nephrol 2023:10.1007/s11255-023-03631-z. [PMID: 37171702 DOI: 10.1007/s11255-023-03631-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE The diagnostic performance of the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) has been challenged due to its lower diagnostic accuracy and higher false-positive rates for prostate cancer detection. This study aimed to analyze the diagnostic performance of PI-RADS v2 in combination with clinical parameters in patients with suspected prostate cancer. MATERIAL AND METHODS A total of 424 men with suspicion of prostate cancer were retrospectively analyzed. Logistic regression analyses were performed to identify predictors of clinically significant prostate cancer defined as a Gleason score of 3 + 4 or greater. The prediction performance was compared with prostate specific antigen (PSA), free/total PSA ratio (f/t PSA), PSA density (PSAD), PI-RADS v2 alone, and PI-RADS v2 plus PSAD using receiver operating characteristics (ROCs). RESULTS In total, 231 out of 424 cases (54.48%) were pathologically diagnosed as prostate cancer. The percentage of clinically significant prostate cancer was higher in patients with PI-RADS v2 score of 4 or greater compared to PI-RADS v2 score of less than 4 (90.86% vs. 55.88%, P < 0.001). Age, PSA level, f/t PSA, PSAD, and PI-RADS v2 were significant independent predictors of clinically significant prostate cancer. The ROC area under the curve of PI-RADS v2 plus PSAD (0.952) was larger compared with PSA (0.845), f/t PSA (0.719), PSAD (0.920), and PI-RADS v2 alone (0.885). CONCLUSION PI-RADS v2 in combination with PSAD may help detect clinically significant prostate cancer and provide benefit in making the decision to biopsy men at suspicion of prostate cancer.
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Affiliation(s)
- Lei Wang
- Department of Radiation Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Luo
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Tongzu Liu
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Ming Deng
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xing Huang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China.
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.
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Guimarães T, Gil M, Medeiros M, Andrade V, Guerra J, Pinheiro H, Fernandes F, Pina J, Lopes Dias J, Campos Pinheiro L. Magnetic resonance imaging target fusion biopsy vs. transrectal ultrasound-guided biopsy - A comparative study of ISUP score upgrading risk in the final radical prostatectomy specimen. Arch Ital Urol Androl 2022; 94:278-284. [DOI: 10.4081/aiua.2022.3.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/20/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives: The aim of this study was to com-pare the risk of International Society of Urological Pathology (ISUP) score upgrading between magnetic resonance imaging targeted fusion biopsy (MRI-TB) and tran-srectal ultrasound-guided biopsy (TRUS-B) in the final radical prostatectomy (RP) specimen pathological report.Materials and methods: This retrospective single center study included 51 patients with prostate cancer (PCa) diagnosed with MRI-TB and 83 patients diagnosed with TRUS-B between October/2019 and July/2021. We compared the rates of ISUP score upgrading between both groups after robotic-assisted radi-cal prostatectomy (RARP) and the specific transition of each ISUP score based on biopsy modality. The rate of ISUP score concordance and downgrading were also assessed. To define the intra and interobserver concordance for each ISUP score in biopsy and RP specimen for each biopsy modality, the Cohen’s Kappa coefficient was calculated. ISUP scores and biopsy modal-ity were selected for multivariate analysis and a logistic regres-sion model was built to provide independent risk factors of ISUP score upgrading.Results: The difference of the rate of upgrading between MRI-TB group and TRUS-B group was statistically significant (p = 0.007) with 42.2% of patients of TRUS-B group experiencing an upgrade in their ISUP score while only 19.6% in MRI-TB group. Concordance and downgrading rates did not statistically differ between the two groups. Strength of concordance using Cohen’s Kappa coefficient was fair in both groups but higher in MRI-TB group (TRUS-B group k = 0.230; p < 0.001; concordance: 47%vs. MRI/TB group k = 0.438; p < 0.001; concordance: 62.7%). Biopsy modality and ISUP 1 on biopsy were independent predic-tors of ISUP upgrading after RP.Conclusions: MRI-TB is highly accurate with lower risk of PCa upgrading after RP than TRUS-B. Patients with ISUP 1 on biopsy have greater susceptibility to upgrading their ISUP score.
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3
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Frozen section utilization to omit systematic biopsy in diagnosing high risk prostate cancer. Sci Rep 2022; 12:14461. [PMID: 36002475 PMCID: PMC9402539 DOI: 10.1038/s41598-022-18186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022] Open
Abstract
The current guidelines for targeted prostate biopsy recommend an additional systematic biopsy regardless of clinical risk assessment.
To evaluate frozen section biopsy utilization in targeted prostate biopsy to omit systematic biopsies in cases of positive frozen section results of patients with clinical features suggestive of high-risk prostate cancer. In this prospective, single-center study, we enrolled patients with a Prostate Imaging-Reporting and Data System (PI-RADS) 5 lesion on magnetic resonance imaging (MRI) with clinical evidence suggestive of high-risk prostate cancer (either an extracapsular extension or prostate-specific antigen level > 20 ng/ml). All patients underwent 2–4 core targeted biopsies utilizing frozen section biopsy with immediate results, allowing patients with a positive result to omit a systematic biopsy. In case of a negative result, additional systematic biopsies were performed. The primary endpoint was the detection rate of targeted biopsy. Patient demographics, clinical variables were analyzed using SPSS version 20. Sixty-six patients were enrolled in this study. Among them, 63 patients were diagnosed with cancer without the need for an additional systematic biopsy. Three patients were non-diagnostic with target biopsy alone. Hence an additional systematic biopsy was performed. Two of these patients were diagnosed with prostate cancer and one tested negative for cancer. In this report we looked into the necessity of taking a routine systematic biopsy in patients with high risk features of prostate cancer. We found that utilizing frozen section biopsy for targeted biopsy reduces unneccessary systematic biopsy in 97% of cases and still provides a means for systematic biopsy when targeted biopsy alone fails to make the diagnosis.
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Movassaghi M, Ahmed F, Patel H, Luk L, Hyams E, Wenske S, Shaish H. Association of Patient and Imaging-Related Factors with False Negative MRI-Targeted Prostate Biopsies of Suspicious PI-RADS 4 and 5 Lesions. Urology 2022; 167:165-170. [DOI: 10.1016/j.urology.2022.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
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5
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Narain TA, Sooriakumaran P. Beyond Prostate Specific Antigen: New Prostate Cancer Screening Options. World J Mens Health 2022; 40:66-73. [PMID: 34983086 PMCID: PMC8761236 DOI: 10.5534/wjmh.210076] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 11/15/2022] Open
Abstract
Prostate specific antigen (PSA) is one of the best-known biomarkers for screening, diagnosis and follow-up of patients for prostate cancer. Owing to several inherent limitations with PSA, various newer blood and urinary based biomarkers have been evaluated in pursuit of better detection and risk stratification of prostate cancer cases. A combination of these different markers, in adjunct with clinical risk factors, and recent advances in imaging promises to offer better diagnostic performance with clearer risk stratification guiding therapeutics. We carried out an extensive literature search for the different biomarkers available for screening and diagnosis of prostate cancer, compared their performance with serum PSA to allow clinicians to draw meaningful conclusions to offer their patients a more personalized medical care.
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Affiliation(s)
- Tushar Aditya Narain
- Department of Uro-Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Prasanna Sooriakumaran
- Department of Uro-Oncology, University College London Hospitals NHS Foundation Trust, London, UK.,Urology Service, Cleveland Clinic London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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Haider MA, Brown J, Yao X, Chin J, Perlis N, Schieda N, Loblaw A. Multiparametric Magnetic Resonance Imaging in the Diagnosis of Clinically Significant Prostate Cancer: an Updated Systematic Review. Clin Oncol (R Coll Radiol) 2021; 33:e599-e612. [PMID: 34400038 DOI: 10.1016/j.clon.2021.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/05/2021] [Accepted: 07/27/2021] [Indexed: 12/20/2022]
Abstract
There has been growing utilisation of multiparametric magnetic resonance imaging (MPMRI) as a non-invasive tool to diagnose and localise clinically significant prostate cancer (CSPCa). This updated systematic review examines the use of MPMRI in patients with an elevated risk of CSPCa who have had a prior negative transrectal ultrasound systematic biopsy (TRUS-SB) and who were biopsy naïve. MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews were searched for existing systematic reviews published up to September 2020. The literature search of the electronic databases combined disease-specific terms (prostate cancer, prostate carcinoma, etc.) and treatment-specific terms (magnetic resonance, etc.). Studies were included if they were randomised controlled trials (RCTs) comparing MPMRI to template transperineal mapping biopsy (TPMB) or to TRUS-SB. Thirty-six RCTs were eligible. For biopsy-naïve men, accuracy of diagnosis of CSPCa showed sensitivities from 87 to 96% and specificities ranging from 29 to 45%. Meta-analyses for CSPCa showed increased detection favouring MPMRI-targeted biopsy over TRUS-SB by 3% (95% confidence interval 0-7%, P = 0.03) and decreased detection of clinically insignificant prostate cancer (CISPCa) favouring MPMRI by 8% (95% confidence interval -11 to 5%, P < 0.00001). Accuracy of MPMRI for men with prior negative biopsy showed sensitivities of 78-100% and specificities of 30-100%. Meta-analyses comparing MPMRI to TRUS-SB showed increased detection of 5% (95% confidence interval 3-7%, P < 0.0001) with a reduction of CISPCa detection of 7% (95% confidence interval 4-9%, P < 0.00001). The growing acceptance of MPMRI utilisation internationally and the recent publication of several RCTs regarding MPMRI in reducing CISPCa detection rates, particularly in biopsy-naïve men, without loss of sensitivity for CSPCa necessitates the synthesis of updated evidence examining MPMRI in the diagnosis of CSPCa.
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Affiliation(s)
- M A Haider
- Sinai Health System and University of Toronto, Joint Department of Medical Imaging, Toronto, ON, Canada
| | - J Brown
- Program in Evidence-based Care, Ontario Health (Cancer Care Ontario), McMaster University, Hamilton, ON, Canada
| | - X Yao
- Program in Evidence-based Care, Ontario Health (Cancer Care Ontario), McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - J Chin
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - N Perlis
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - N Schieda
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - A Loblaw
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Liu Y, Dong L, Xiang L, Zhou B, Wang H, Zhang Y, Xu G, Wu J, Wang S, Zhang Y, Xu H. Does PSA level affect the choice of prostate puncture methods among MRI-ultrasound fusion targeted biopsy, transrectal ultrasound systematic biopsy or the combination of both? Br J Radiol 2021; 94:20210312. [PMID: 34133228 PMCID: PMC8248205 DOI: 10.1259/bjr.20210312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To explore whether prostate-specific antigen (PSA) affects the choice of prostate puncture methods by comparing MRI-ultrasound fusion targeted biopsy (MRI-TBx) with transrectal ultrasound systematic biopsy (TRUS-SBx) in the detection of prostate cancer (PCa), clinically significant prostate cancer (csPCa) and non-clinically significant prostate cancer (nsPCa) in different PSA groups (<10.0,10.0-20.0 and>20.0 ng ml-1). METHODS A total of 190 patients with 215 lesions who underwent both MRI-TBx and TRUS-SBx were included in this retrospective study. PSA was measured pre-operatively and stratified to three levels. The detection rates of PCa, csPCa and nsPCa through different methods (MRI-TBx, TRUS-SBx, or MRI-TBx +TRUS SBx) were compared with stratification by PSA. RESULTS Among the 190 patients, the histopathological results revealed PCa in 126 cases, including 119 csPCa. In PSA <10.0 ng ml-1 group, although the detection rates of PCa and csPCa by MRI-TBx were higher than those of TRUS-SBx, no significant differences were observed (p = 0.741; p = 0.400). In PSA 10.0-20.0 ng ml-1 group, difference between the detection rate of csPCa with TRUS-SBx and the combined method was statistically significant (p = 0.044). As for PSA >20.0 ng ml-1, MRI-TBx had a higher csPCa rate than TRUS-SBx with no statistical significance noted (p = 0.600). CONCLUSION MRI-TBx combined with TRUS-SBx could be suitable as a standard detection approach for csPCa in patients with PSA 10.0-20.0 ng ml-1. As for PSA >20.0 and <10.0 ng ml-1, both MRI-TBx and TRUS-SBx might provide effective solutions for tumor detection. ADVANCES IN KNOWLEDGE This study gives an account of choosing appropriate prostate puncture methods through PSA level.
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Affiliation(s)
- Yunyun Liu
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Lin Dong
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Lihua Xiang
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Boyang Zhou
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Hanxiang Wang
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Ying Zhang
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Guang Xu
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Jian Wu
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Shuai Wang
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Yifeng Zhang
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
| | - Huixiong Xu
- Department of Medical Ultrasound, Shanghai Tenth People’s Hospital; Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, Tongji University School of Medicine; Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China
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Gavin DJ, Kam J, Krelle M, Louie-Johnsun M, Sutherland T, Koschel S, Jenkins M, Yuminaga Y, Kim R, Aluwihare K, Skinner S, Brennan J, Wong LM. Quantifying the Effect of Location Matching on Accuracy of Multiparametric Magnetic Resonance Imaging Prior to Prostate Biopsy-A Multicentre Study. EUR UROL SUPPL 2020; 20:28-36. [PMID: 34337456 PMCID: PMC8317842 DOI: 10.1016/j.euros.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 12/31/2022] Open
Abstract
Background Multiparametric magnetic resonance imaging (mpMRI) has shown promise to improve detection of prostate cancer over conventional methods. However, most studies do not describe whether the location of mpMRI lesions match that of cancer found at biopsy, which may lead to an overestimation of accuracy. Objective To quantitate the effect of mapping locations of mpMRI lesions to locations of positive biopsy cores on the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of mpMRI. Design setting and participant We retrospectively identified patients having mpMRI of the prostate preceding prostate biopsy at three centres from 2013 to 2016. Men with targetable lesions on imaging underwent directed biopsy in addition to systematic biopsy. We correlated locations of positive mpMRI lesions with those of positive biopsy cores, defining a match when both were in the same sector of the prostate. We defined positive mpMRI as Prostate Imaging Reporting and Data System (PI-RADS) score ≥4 and significant cancer at biopsy as grade group ≥2. Outcome measurements and statistical analysis Sensitivity, specificity, PPV, and NPV were calculated with and without location matching. Results and limitations Of 446 patients, 247 (55.4%) had positive mpMRI and 232 (52.0%) had significant cancer at biopsy. Sensitivity and NPV for detecting significant cancer with location matching (both 63.4%) were decreased compared with those without location matching (77.6% and 73.9%, respectively). Of the 85 significant cancers not detected by mpMRI, most were of grade group 2 (64.7%, 55/85). Conclusions We report a 10-15% decrease in sensitivity and NPV when location matching was used to detect significant prostate cancer by mpMRI. False negative mpMRI remains an issue, highlighting the continued need for biopsy and for improving the standards around imaging quality and reporting. Patient summary The true accuracy of multiparametric magnetic resonance imaging (mpMRI) must be determined to interpret results and better counsel patients. We mapped the location of positive mpMRI lesions to where cancer was found at biopsy and found, when compared with matching to cancer anywhere in the prostate, that the accuracy of mpMRI decreased by 10-15%.
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Affiliation(s)
- Dominic James Gavin
- Eastern Hill Academic Centre, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Jonathan Kam
- Gosford District Hospital and Gosford Private Hospital, Gosford, Australia.,University of Newcastle, Newcastle, Australia
| | - Matthew Krelle
- Eastern Hill Academic Centre, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Mark Louie-Johnsun
- Gosford District Hospital and Gosford Private Hospital, Gosford, Australia.,University of Newcastle, Newcastle, Australia
| | - Tom Sutherland
- Department of Radiology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Samantha Koschel
- Department of Urology, Bendigo Health, Bendigo, Victoria, Australia.,Department of Urology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Mark Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia
| | - Yuigi Yuminaga
- Gosford District Hospital and Gosford Private Hospital, Gosford, Australia
| | - Raymond Kim
- Gosford District Hospital and Gosford Private Hospital, Gosford, Australia
| | | | - Sarah Skinner
- Department of Radiology, Bendigo Health, Bendigo, Victoria, Australia
| | - Janelle Brennan
- Department of Urology, Bendigo Health, Bendigo, Victoria, Australia.,Department of Urology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Lih-Ming Wong
- Department of Urology, St Vincent's Hospital Melbourne, Victoria, Australia
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Sarkar D, Nandi D, Gangoli S, Hicks J, Carter P. The decision of targeted, systematic or combined biopsy in a biopsy naïve patient for the diagnosis of prostate cancer, can be made on the basis of multiparametric magnetic resonance imaging. JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415819889552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: The current trend to implement multiparametric magnetic resonance imaging (mpMRI)-guided targeted biopsy (TB) as primary biopsy for the diagnosis of suspected prostate cancer and to avoid systematic biopsy (SB) is growing. However, concern remains regarding missing clinically significant (Cs) cancer on the normal mpMRI areas of the prostate. Therefore, we compared the normal and abnormal areas from mpMRI at the same prostate biopsy, using simultaneous SB and TB technique. Methods: A prospective, comparative effectiveness study included 134 patients initially referred for primary biopsy (from October 2017 to June 2018); 100 men were selected, mean age 68 years, with a median level of prostate specific antigen of 7.6, with average prostate volume of 52 cm3 (T3 disease and prostate imaging reporting and data system (PI-RADS) score < 3 were excluded). All underwent six cores TB (median), from an average of two lesions on mpMRI and also eight cores SB (median) from normal mpMRI areas of the prostate after informed consent. Results: The combined (SB + TB) biopsy cancer detection rate was 67%, 51% having Cs disease. For Cs cancer, 35 patients were detected by both techniques. TB missed four Cs cancer (95% confidence interval (CI), p < 0.0001). Fewer men in the TB group than in the SB group were found to have clinically insignificant (Ci) cancer (95% CI, p < 0.0001). No Cs cancer diagnosis was missed on TB from PI-RADS 5 lesion. Overall, 4% Cs cancers were missed on TB and avoided over diagnosis of 9% Ci cancer. Conclusions: Cognitive TB didn’t miss any Cs cancer from PI-RADS 5 lesion found on mpMRI. Only doing Cognitive TB on PI-RADS 5 lesion would save time, reduce workload and will be cost effective both for Urology and Pathology. PI-RADS 3 and 4 lesions on mpMRI will benefit from adding systematic samples. Level of evidence: 4 Oxford Centre for Evidence-Based Medicine (CEBM).
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Venderink W, Bomers JG, Overduin CG, Padhani AR, de Lauw GR, Sedelaar MJ, Barentsz JO. Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know. Part 3: Targeted Biopsy. Eur Urol 2020; 77:481-490. [DOI: 10.1016/j.eururo.2019.10.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/18/2019] [Indexed: 02/02/2023]
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Zhen L, Liu X, Yegang C, Yongjiao Y, Yawei X, Jiaqi K, Xianhao W, Yuxuan S, Rui H, Wei Z, Ningjing O. Accuracy of multiparametric magnetic resonance imaging for diagnosing prostate Cancer: a systematic review and meta-analysis. BMC Cancer 2019; 19:1244. [PMID: 31870327 PMCID: PMC6929472 DOI: 10.1186/s12885-019-6434-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 12/04/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The application of multiparametric magnetic resonance imaging (mpMRI) for diagnosis of prostate cancer has been recommended by the European Association of Urology (EAU), National Comprehensive Cancer Network (NCCN), and European Society of Urogenital Radiology (ESUR) guidelines. The purpose of this study is to systematically review the literature on assessing the accuracy of mpMRI in patients with suspicion of prostate cancer. METHOD We searched Embase, Pubmed and Cochrane online databases from January 12,000 to October 272,018 to extract articles exploring the possibilities that the pre-biopsy mpMRI can enhance the diagnosis accuracy of prostate cancer. The numbers of true- and false-negative results and true- and false-positive ones were extracted to calculate the corresponding sensitivity and specificity of mpMRI. Study quality was assessed using QUADAS-2 tool. Random effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) plot were performed for further study. RESULTS After searching, we acquired 3741 articles for reference, of which 29 studies with 8503 participants were eligible for inclusion. MpMRI maintained impressive diagnostic value, the area under the HSROC curve was 0.87 (95%CI,0.84-0.90). The sensitivity and specificity for mpMRI were 0.87 [95%CI, 0.81-0.91] and 0.68 [95%CI,0.56-0.79] respectively. The positive likelihood ratio was 2.73 [95%CI 1.90-3.90]; negative likelihood ratio was 0.19 [95% CI 0.14,-0.27]. The risk of publication bias was negligible with P = 0.96. CONCLUSION Results of the meta-analysis suggest that mpMRI is a sensitive tool to diagnose prostate cancer. However, because of the high heterogeneity existing among the included studies, further studies are needed to apply the results of this meta-analysis in clinic.
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Affiliation(s)
- Liang Zhen
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Xiaoqiang Liu
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Chen Yegang
- Department of Urology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yang Yongjiao
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Xu Yawei
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Kang Jiaqi
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Wang Xianhao
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Song Yuxuan
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Hu Rui
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Zhang Wei
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
| | - Ou Ningjing
- Department of Urology, Tianjin Medical University General Hospital, Tianjin, 300211 People’s Republic of China
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He BM, Shi ZK, Li HS, Lin HZ, Yang QS, Lu JP, Sun YH, Wang HF. A Novel Prediction Tool Based on Multiparametric Magnetic Resonance Imaging to Determine the Biopsy Strategy for Clinically Significant Prostate Cancer in Patients with PSA Levels Less than 50 ng/ml. Ann Surg Oncol 2019; 27:1284-1295. [PMID: 31848822 DOI: 10.1245/s10434-019-08111-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE To develop and internally validate nomograms to help choose the optimal biopsy strategy among no biopsy, targeted biopsy (TB) only, or TB plus systematic biopsy (SB). PATIENTS AND METHODS This retrospective study included a total of 385 patients who underwent magnetic resonance imaging (MRI)-guided TB and/or SB at our institute after undergoing multiparametric MRI (mpMRI) between 2015 and 2018. We developed models to predict clinically significant prostate cancer (csPCa) based on suspicious lesions from a TB result and based on the whole prostate gland from the results of TB plus SB or SB only. Nomograms were generated using logistic regression and evaluated using receiver-operating characteristic (ROC) curve analysis, calibration curves and decision analysis. The results were validated using ROC curve and calibration on 177 patients from 2018 to 2019 at the same institute. RESULTS In the multivariate analyses, prostate-specific antigen level, prostate volume, and the Prostate Imaging Reporting and Data System score were predictors of csPCa in both nomograms. Age was also included in the model for suspicious lesions, while obesity was included in the model for the whole gland. The area under the curve (AUC) in the ROC analyses of the prediction models was 0.755 for suspicious lesions and 0.887 for the whole gland. Both models performed well in the calibration and decision analyses. In the validation cohort, the ROC curve described the AUCs of 0.723 and 0.917 for the nomogram of suspicious lesions and nomogram of the whole gland, respectively. Also, the calibration curve detected low error rates for both models. CONCLUSION Nomograms with excellent discriminative ability were developed and validated. These nomograms can be used to select the optimal biopsy strategy for individual patients in the future.
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Affiliation(s)
- Bi-Ming He
- Department of Urology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Urology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhen-Kai Shi
- Department of Urology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Hu-Sheng Li
- Department of Urology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Heng-Zhi Lin
- Department of Urology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qing-Song Yang
- Department of Radiology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Ping Lu
- Department of Radiology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ying-Hao Sun
- Department of Urology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - Hai-Feng Wang
- Department of Urology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China. .,Department of Urology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China.
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13
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Marzouk K, Ehdaie B, Vertosick E, Zappala S, Vickers A. Developing an effective strategy to improve the detection of significant prostate cancer by combining the 4Kscore and multiparametric MRI. Urol Oncol 2019; 37:672-677. [PMID: 31378585 PMCID: PMC6733611 DOI: 10.1016/j.urolonc.2019.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Recent years have seen the development of biomarkers and imaging technologies designed to improve the specificity of PSA. Widespread implementation of imaging technologies, such as mp-MRI raises considerable logistical challenges. Our objective was to evaluate a biopsy strategy that utilizes selective mp-MRI as a follow-up test to biomarkers to improve the detection of significant prostate cancer. METHODS AND MATERIALS We developed a conceptual approach based on the risk calculated from the 4Kscore using results from the US prospective validation study, multiplied by the likelihood ratio of mp-MRI from the PROMIS trial. The primary outcome was Gleason grade ≥ 7 (grade group ≥ 2) cancer on biopsy. Using decision curve analysis, the net benefit was determined for our model and compared with the use of the 4Kscore and mp-MRI independently at various thresholds for biopsy. RESULTS For a cut-point of 7.5% risk of high-grade disease, patients with <5% risk from a blood marker would not have risk of significant prostate cancer sufficiently increased by a positive mp-MRI to warrant biopsy; comparably, patients with a risk >23% would not have risk sufficiently reduced by a negative imaging study to forgo biopsy. From the 4Kscore validation study, 46% of men considered for biopsy in the US have risks 5% to 23%. Net benefit was highest for the combined strategy, followed by 4Kscore alone. CONCLUSIONS Selective mp-MRI in men with intermediate scores on a secondary blood test results in a biopsy strategy that is more scalable than mp-MRI for all men with elevated PSA. Prospective validation is required to demonstrate if the predicted properties of combined blood and imaging testing are empirically confirmed.
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Affiliation(s)
- Karim Marzouk
- Urology Service, Department of Surgery, Windsor Regional Hospital, University of Western Ontario, Windsor, Ontario, Canada
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emily Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
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14
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Patel P, Wang S, Siddiqui MM. The Use of Multiparametric Magnetic Resonance Imaging (mpMRI) in the Detection, Evaluation, and Surveillance of Clinically Significant Prostate Cancer (csPCa). Curr Urol Rep 2019; 20:60. [PMID: 31478113 DOI: 10.1007/s11934-019-0926-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW With the long-standing controversy surrounding the use of prostate-specific antigen (PSA) for the detection, evaluation, and surveillance of prostate cancer, there is a need for a minimally invasive technique to identify and risk-stratify these patients. Additionally, in an effort to reduce the number of unnecessary biopsies and identify clinically significant prostate cancer (csPCa), there has been a shift in practice towards the use of multiparametric magnetic resonance imaging (mpMRI) in conjunction with decision-making regarding prostate cancer diagnosis and management. In the current review, we summarize the data regarding the use of mpMRI in the detection, evaluation, and surveillance of csPCa. RECENT FINDINGS Recent prospective clinical trials have determined that a pre-biopsy mpMRI may rule out insignificant prostate cancers, thereby reducing the number of patients who require a biopsy. The anatomic information gathered from these pre-biopsy mpMRI performed during MRI fusion biopsy in csPCa increases the accuracy of pathologic staging in terms of Gleason scores. In regard to active surveillance, prospective trials suggest little to no clinical utility for mpMRI and fusion biopsy in the surveillance of prostate cancer despite conflicting findings from retrospective studies. Recent trials suggest that mpMRI can play an important role in the detection and evaluation of csPCa. The ideal role for mpMRI in active surveillance remains limited.
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Affiliation(s)
- Parth Patel
- Division of Urology, Department of Surgery, University of Maryland Medical Center, 29 S Greene St Suite 500, Baltimore, MD, 21201, USA
| | - Shu Wang
- Division of Urology, Department of Surgery, University of Maryland Medical Center, 29 S Greene St Suite 500, Baltimore, MD, 21201, USA
| | - Mohummad Minhaj Siddiqui
- Division of Urology, Department of Surgery, University of Maryland Medical Center, 29 S Greene St Suite 500, Baltimore, MD, 21201, USA.
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15
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Venderink W, van Luijtelaar A, van der Leest M, Barentsz JO, Jenniskens SF, Sedelaar MJ, Hulsbergen-van de Kaa C, Overduin CG, Fütterer JJ. Multiparametric magnetic resonance imaging and follow-up to avoid prostate biopsy in 4259 men. BJU Int 2019; 124:775-784. [DOI: 10.1111/bju.14853] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Wulphert Venderink
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Annemarijke van Luijtelaar
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Marloes van der Leest
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Jelle O. Barentsz
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Sjoerd F.M. Jenniskens
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | | | | | - Christiaan G. Overduin
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Jurgen J. Fütterer
- Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen the Netherlands
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16
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van Luijtelaar A, Bomers J, Fütterer J. A comparison of magnetic resonance imaging techniques used to secure biopsies in prostate cancer patients. Expert Rev Anticancer Ther 2019; 19:705-716. [PMID: 31277551 DOI: 10.1080/14737140.2019.1641086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Prostate cancer (PCa) is the most common diagnosed malignancy among the male population in the United States. The incidence is increasing with an estimated amount of 175.000 cases in 2019. Areas covered: Primarily, PCa is generally detected by an elevated or rising serum prostate-specific antigen (PSA) and digital rectal examination (DRE) followed by pathological examination. Histopathology ultimately confirms the presence of PCa and determines a Gleason score. However, PSA and DRE have low specificity and sensitivity, respectively. Subsequently, accurate assessment of the aggressiveness of PCa is essential to prevent overdiagnosis and thus overtreatment of low-risk or indolent cancers. By visualizing PCa suspicious lesions and sampling them during the targeted biopsy, it is likely that the diagnostic accuracy of significant PCa improves. This article reviews the current imaging techniques used to secure biopsies in patients with a suspicion of PCa. The advantages and limitations of each technique are described. Expert opinion: Multiparametric magnetic resonance imaging (mpMRI) and subsequent-targeted biopsy have improved the diagnostic accuracy of PCa detection in men with an elevated or rising serum PSA. Prostate lesions visible on mpMRI are easily targeted during either in-bore MRI-guided biopsy, cognitive fusion biopsy or MRI-TRUS fusion biopsy.
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Affiliation(s)
- Annemarijke van Luijtelaar
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Joyce Bomers
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Jurgen Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center , Nijmegen , The Netherlands
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17
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Richenberg J, Løgager V, Panebianco V, Rouviere O, Villeirs G, Schoots IG. The primacy of multiparametric MRI in men with suspected prostate cancer. Eur Radiol 2019; 29:6940-6952. [PMID: 31172275 PMCID: PMC6828624 DOI: 10.1007/s00330-019-06166-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 12/14/2022]
Abstract
Background Multiparametric MRI (mpMRI) became recognised in investigating those with suspected prostate cancer between 2010 and 2012; in the USA, the preventative task force moratorium on PSA screening was a strong catalyst. In a few short years, it has been adopted into daily urological and oncological practice. The pace of clinical uptake, born along by countless papers proclaiming high accuracy in detecting clinically significant prostate cancer, has sparked much debate about the timing of mpMRI within the traditional biopsy-driven clinical pathways. There are strongly held opposing views on using mpMRI as a triage test regarding the need for biopsy and/or guiding the biopsy pattern. Objective To review the evidence base and present a position paper on the role of mpMRI in the diagnosis and management of prostate cancer. Methods A subgroup of experts from the ESUR Prostate MRI Working Group conducted literature review and face to face and electronic exchanges to draw up a position statement. Results This paper considers diagnostic strategies for clinically significant prostate cancer; current national and international guidance; the impact of pre-biopsy mpMRI in detection of clinically significant and clinically insignificant neoplasms; the impact of pre-biopsy mpMRI on biopsy strategies and targeting; the notion of mpMRI within a wider risk evaluation on a patient by patient basis; the problems that beset mpMRI including inter-observer variability. Conclusions The paper concludes with a set of suggestions for using mpMRI to influence who to biopsy and who not to biopsy at diagnosis. Key Points • Adopt mpMRI as the first, and primary, investigation in the workup of men with suspected prostate cancer. • PI-RADS assessment categories 1 and 2 have a high negative predictive value in excluding significant disease, and systematic biopsy may be postponed, especially in men with low-risk of disease following additional risk stratification. • PI-RADS assessment category lesions 4 and 5 should be targeted; PI-RADS assessment category lesion 3 may be biopsied as a target, as part of systematic biopsies or may be observed depending on risk stratification. Electronic supplementary material The online version of this article (10.1007/s00330-019-06166-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonathan Richenberg
- Department of Imaging, Brighton & Sussex University Hospitals NHS Trust and Brighton and Sussex Medical School, Brighton, BN2 5BE, UK.
| | - Vibeke Løgager
- Department of Radiology, Herlev University Hospital Copenhagen University, Herlev, Denmark
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza, University of Rome, Rome, Italy
| | - Olivier Rouviere
- Hospices civils de Lyon, Department of Urinary and Vascular Radiology, hôpital Édouard-Herriot, 69437, Lyon, France.,Faculté de médecine Lyon Est, Université Lyon 1, 69003, Lyon, France
| | - Geert Villeirs
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
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18
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Xiang LH, Fang Y, Wan J, Xu G, Yao MH, Ding SS, Liu H, Wu R. Shear-wave elastography: role in clinically significant prostate cancer with false-negative magnetic resonance imaging. Eur Radiol 2019; 29:6682-6689. [DOI: 10.1007/s00330-019-06274-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/15/2019] [Accepted: 05/13/2019] [Indexed: 12/17/2022]
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19
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Patel B, Sriprasad S, Cadeddu J, Thind A, Rane A. Obstacles in prostate cancer screening: Current issues and future solutions. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818815395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prostate cancer is the most common cancer in men and is associated with unacceptably high mortality rates, yet an accurate and acceptable screening programme that detects clinically significant prostate cancer remains elusive. Although there is good evidence that prostate-specific antigen (PSA)-based screening lowers prostate cancer-specific mortality, especially when conducted at high intensity, the harm caused by overinvestigation, overdiagnosis and overtreatment of clinically insignificant cases arguably outweighs these benefits. Several attempts have therefore been made to improve screening, enhancing the diagnostic value of PSA and identifying novel modalities for screening. Here, we provide a comprehensive review of the benefits and harms, and analyse which of these novel screening methods show most promise. Level of evidence: 5, expert opinion
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Affiliation(s)
| | | | | | - Arron Thind
- Department of Medicine, Croydon University Hospital, UK
| | - Abhay Rane
- Department of Urology, East Surrey Hospital, UK
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20
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Sönmez G, Tombul ŞT, İmamoğlu H, Akgün H, Demirtaş A, Tatlışen A. Multiparametric MRI fusion-guided prostate biopsy in biopsy naive patients: Preliminary results from 80 patients. Turk J Urol 2019; 45:196-201. [PMID: 30817279 DOI: 10.5152/tud.2019.03710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/22/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this prospective study was to evaluate the early results of transrectal prostate biopsies performed under the guidance of multiparametric prostate magnetic resonance imaging (mpMRI) in biopsy naive patients. MATERIAL AND METHODS Biopsy naive patients who had prostate-specific antigen level 4-10 ng/mL and/or abnormal digital rectal examination findings and provided informed consent were examined using mpMRI. The study included 80 patients with an MRI-defined lesion with a Prostate Imaging and Reporting and Data System (PIRADS) score of ≥3. All mpMRIs were reported by the same uro-radiologist according to PIRADS version 2. An MRI-targeted biopsy was performed by an ultrasonography system with rigid fusion registration software. The first two to five core biopsies per MRI-defined lesions were obtained, and then a standard random 12-core biopsy was performed. Transrectal biopsies were performed under local anesthesia or sedoanalgesia. RESULTS Of the 80 patients, 29 (36.3%) were found to have cancer using the conventional 12-core biopsy, but only 20 (25%) were found to have prostate cancer using the MRI-targeted prostate biopsy. Combining the two biopsy methods (conventional+MRI-targeted), cancer detection rate increased to 43.8% (35/80 patients). The cancer detection rate using the combined method was statistically higher than that using the conventional biopsy method (p=0.03). Using the conventional biopsy method, 960 core biopsies were collected from 80 patients. Of the 960 core biopsies, 111 (11.6%) were found to be cancer. Further, 101 suspected lesions were detected using mpMRI in 80 patients. In addition, 397 core biopsies were obtained from these lesions. Of the 397 core biopsies, 62 (15.6%) were reported as prostate cancer. The core positivity rate of MR-targeted biopsy was statistically higher than that of conventional biopsy (p=0.04). CONCLUSION The preliminary results of MRI-targeted prostate biopsy combined with conventional biopsy suggested that the combined biopsy method was crucial in prostate cancer diagnosis especially in patients with prostate cancer suspicion and no biopsy history. However, larger sample prospective studies are needed to validate the effectiveness of MRI-targeted biopsy and combined biopsy methods.
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Affiliation(s)
- Gökhan Sönmez
- Clinic of Urology, Kayseri City Hospital, Kayseri, Turkey
| | - Şevket Tolga Tombul
- Department of Urology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Hakan İmamoğlu
- Department of Radiology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Hülya Akgün
- Department of Pathology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Abdullah Demirtaş
- Department of Urology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Atila Tatlışen
- Department of Urology, Erciyes University School of Medicine, Kayseri, Turkey
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21
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Bass EJ, Freeman A, Jameson C, Punwani S, Moore CM, Arya M, Emberton M, Ahmed HU. Prostate cancer diagnostic pathway: Is a one-stop cognitive MRI targeted biopsy service a realistic goal in everyday practice? A pilot cohort in a tertiary referral centre in the UK. BMJ Open 2018; 8:e024941. [PMID: 30361408 PMCID: PMC6224764 DOI: 10.1136/bmjopen-2018-024941] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/24/2018] [Accepted: 09/20/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility of a novel multiparametric MRI (mpMRI) and cognitive fusion transperineal targeted biopsy (MRTB) led prostate cancer (PCa) diagnostic service with regard to cancer detection and reducing time to diagnosis and treatment. DESIGN Consecutive men being investigated for possible PCa under the UK 2-week wait guidelines. SETTING Tertiary referral centre for PCa in the UK. PARTICIPANTS Men referred with a raised prostate-specific antigen (PSA) or abnormal digital rectal examination between February 2015 and March 2016 under the UK 2-week rule guideline. INTERVENTIONS An mpMRI was performed prior to patients attending clinic, on the same day. If required, MRTB was offered. Results were available within 48 hours and discussed at a specialist multidisciplinary team meeting. Patients returned for counselling within 7 days PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome measures in this regard included the time to diagnosis and treatment of patients referred with a suspicion of PCa. Quality control outcome measures included clinically significant and total cancer detection rates. RESULTS 112 men were referred to the service. 111 (99.1%) underwent mpMRI. Median PSA was 9.4 ng/mL (IQR 5.6-21.0). 87 patients had a target on mpMRI with 25 scoring Likert 3/5 for likelihood of disease, 26 4/5 and 36 5/5.57 (51%) patients received a local anaesthetic, Magnetic resonance imaging targeted biopsy (MRTB). Cancer was detected in 45 (79%). 43 (96%) had University College London definition 2 disease or greater. The times to diagnosis and treatment were a median of 8 and 20 days, respectively. CONCLUSIONS This approach greatly reduces the time to diagnosis and treatment. Detection rates of significant cancer are high. Similar services may be valuable to patients with a potential diagnosis of PCa.
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Affiliation(s)
- Edward James Bass
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Charles Jameson
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
- Division of Medicine, Centre for Medical Imaging, University College London, London, UK
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Manit Arya
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Hashim Uddin Ahmed
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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Sathianathen NJ, Warlick CA. The Use of Magnetic Resonance Imaging in the Prostate Cancer Primary Diagnostic Pathway: Is It Ready for Primetime? World J Mens Health 2018; 36:223-229. [PMID: 30168298 DOI: 10.5534/wjmh.2018.180025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/27/2018] [Accepted: 05/31/2018] [Indexed: 12/16/2022] Open
Abstract
Multiparametric magnetic resonance imaging (mpMRI) has been increasingly utilized in the prostate cancer diagnostic landscape over the last five years. The majority of the literature has focused on its use in men with a previous negative biopsy. However, over time, clinicians have begun using mpMRI in the work-up of men being considered for primary biopsy and subsequently data characterizing its diagnostic performance in this setting is emerging. This review comprehensively assesses the utility of mpMRI in the primary biopsy setting.
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Sathianathen NJ, Warlick CA. The Use of Magnetic Resonance Imaging in the Prostate Cancer Primary Diagnostic Pathway: Is It Ready for Primetime? World J Mens Health 2018. [PMID: 30168298 PMCID: PMC6119840 DOI: 10.5534/wjmh.180025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Multiparametric magnetic resonance imaging (mpMRI) has been increasingly utilized in the prostate cancer diagnostic landscape over the last five years. The majority of the literature has focused on its use in men with a previous negative biopsy. However, over time, clinicians have begun using mpMRI in the work-up of men being considered for primary biopsy and subsequently data characterizing its diagnostic performance in this setting is emerging. This review comprehensively assesses the utility of mpMRI in the primary biopsy setting.
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24
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A Single Center Evaluation of the Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging against Transperineal Prostate Mapping Biopsy: An Analysis of Men with Benign Histology and Insignificant Cancer following Transrectal Ultrasound Biopsy. J Urol 2018; 200:302-308. [DOI: 10.1016/j.juro.2018.02.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 11/23/2022]
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25
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Otti VC, Miller C, Powell RJ, Thomas RM, McGrath JS. The diagnostic accuracy of multiparametric magnetic resonance imaging before biopsy in the detection of prostate cancer. BJU Int 2018; 123:82-90. [PMID: 29804315 DOI: 10.1111/bju.14420] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the extent to which clinically significant prostate cancer (csPCa) can be detected in a routine National Health Service setting in men with no previous biopsy, when multiparametric magnetic resonance imaging (mpMRI) is introduced into the diagnostic pathway. PATIENTS AND METHODS In all, 1 090 mpMRIs were performed between July 2013 and April 2016 in biopsy-naïve men with an abnormal prostate-specific antigen level and/or digital rectal examination. Data were collected from patient records at the Royal Devon and Exeter NHS Foundation Trust. mpMRI Prostate Imaging Reporting and Data System (PI-RADS) scores were compared to transperineal or transrectal ultrasonography (TRUS)-guided biopsy findings as the reference standard. csPCa was defined as Gleason score of ≥3+4. The diagnostic accuracy of mpMRI was also assessed. RESULTS The mpMRI was interpretable in 1 023 men and 792 underwent biopsy, of which 106 were transperineal. The median number of cores taken in transperineal and TRUS-guided biopsy were 10 and 6, respectively. The detection rate of csPCa was 37%; csPCa rose from 15% of PI-RADS 1 and 2 to 86% of PI-RADS 5. The sensitivity, negative predictive value, specificity, and positive predictive value were 82%, 85%, 59% and 54%, respectively. The study is limited by its retrospective nature and lack of reporting of follow-up for 'missed cancers'. Men with low mpMRI PI-RADS were also less likely to undergo biopsy. Whilst this selection bias may overestimate the detection rate of csPCa, this reflects the shared decisions patients and clinicians make in day-to-day practice outside of research centres. CONCLUSION In a routine clinical setting, the higher the mpMRI PI-RADS, the greater the detection rate of csPCa in biopsy-naïve men. A normal mpMRI does not exclude csPCa; however, mpMRI may have utility in informing shared-decision making on whether to proceed to biopsy and subsequent treatment.
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Affiliation(s)
- Vanessa C Otti
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,University of Exeter Medical School, Exeter, UK
| | | | - Roy J Powell
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,University of Exeter Medical School, Exeter, UK
| | | | - John S McGrath
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,University of Exeter Medical School, Exeter, UK
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26
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Kirlik G, Gullapalli R, D'Souza W, Md Daud Iqbal G, Naslund M, Wong J, Papadimitriou JC, Papadimitrou J, Roys S, Mistry N, Zhang H. A Supervised Learning Tool for Prostate Cancer Foci Detection and Aggressiveness Identification using Multiparametric magnetic resonance imaging/magnetic resonance spectroscopy imaging. Cancer Inform 2018; 17:1176935118786260. [PMID: 30013306 PMCID: PMC6043929 DOI: 10.1177/1176935118786260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/24/2018] [Indexed: 12/13/2022] Open
Abstract
Prostate cancer is the most frequently diagnosed cancer in men in the United States. The current main methods for diagnosing prostate cancer include prostate-specific antigen test and transrectal biopsy. Prostate-specific antigen screening has been criticized for overdiagnosis and unnecessary treatment, and transrectal biopsy is an invasive procedure with low sensitivity for diagnosis. We provided a quantitative tool using supervised learning with multiparametric imaging to be able to accurately detect cancer foci and its aggressiveness. A total of 223 specimens from patients who received magnetic resonance imaging (MRI) and magnetic resonance spectroscopy imaging prior to the surgery were studied. Multiparametric imaging included extracting T2-map, apparent diffusion coefficient (ADC) using diffusion-weighted MRI, Ktrans using dynamic contrast-enhanced MRI, and 3-dimensional-MR spectroscopy. A pathologist reviewed all 223 specimens and marked cancerous regions on each and graded them with Gleason scores, which served as the ground truth to validate our prediction model. In cancer aggressiveness prediction, the average area under the receiver operating characteristic curve (AUC) value was 0.73 with 95% confidence interval (0.72-0.74) and the average sensitivity and specificity were 0.72 (0.71-0.73) and 0.73 (0.71-0.75), respectively. For the cancer detection model, the average AUC value was 0.68 (0.66-0.70) and the average sensitivity and specificity were 0.73 (0.70-0.77) and 0.62 (0.60-0.68), respectively. Our method included capability to handle class imbalance using adaptive boosting with random undersampling. In addition, our method was noninvasive and allowed for nonsubjective disease characterization, which provided physician information to make personalized treatment decision.
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Affiliation(s)
- Gokhan Kirlik
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rao Gullapalli
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Warren D'Souza
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gazi Md Daud Iqbal
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Naslund
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jade Wong
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - John Papadimitrou
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steve Roys
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Hao Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Venderink W, Jenniskens SF, Michiel Sedelaar JP, Tamada T, Fütterer JJ. Yield of Repeat Targeted Direct in-Bore Magnetic Resonance-Guided Prostate Biopsy (MRGB) of the Same Lesions in Men Having a Prior Negative Targeted MRGB. Korean J Radiol 2018; 19:733-741. [PMID: 29962879 PMCID: PMC6005956 DOI: 10.3348/kjr.2018.19.4.733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/15/2018] [Indexed: 11/25/2022] Open
Abstract
Objective This study's purposes were to determine the yield of repeat direct in-bore magnetic resonance-guided prostate biopsy (MRGB) (MRGB-2) after the first one was found to be negative (MRGB-1), to correlate with clinical parameters, and to present the subgroup analyses of patients with positive repeat biopsies, despite having a negative initial biopsies. Materials and Methods We retrospectively included patients with MRGB-2 after a negative MRGB-1 both between January 2006 and August 2016. This study included 62 patients (median age, 63 years; interquartile range [IQR], 58–66 years) with 75 sampled lesions during MRGB-2 left for analysis, and 63 lesions were resampled and 12 new lesions were sampled. Included patients had a prostate specific antigen (PSA) at MRGB-1 of 13 ng/mL (IQR, 5.8–20.0) and a PSA at MRGB-2 of 15 ng/mL (IQR, 9.0–22.5). All anonymized magnetic resonance imaging (MRI) data were retrospectively reassessed according to Prostate Imaging-Reporting and Data System version 2 by two radiologists. Images of MRGB were compared to determine whether the same prostate lesion was biopsied during MRGB-1 and MRGB-2. Descriptive statistics were utilized to determine the yield of clinically significant prostate cancer (csPCa) at MRGB-2. Gleason score of ≥ 3 + 4 was considered csPCa. Results In 16/75 (21%) lesions csPCa was detected during MRGB-2. Of 63 resampled lesions, 13 (21%) harbored csPCa at MRGB-2. In two patients, csPCa was detected on repeat biopsy, while the volume of the lesion decreased between MRGB-1 and MRGB-2. Conclusion Patients could benefit from repeat biopsy after negative initial MRGB, especially in the case of increasing PSA values and persisting PCa suspicion in MRI. Further research is needed to establish predictors for positive repeat targeted biopsies.
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Affiliation(s)
- Wulphert Venderink
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen 6500, the Netherlands
| | - Sjoerd Fm Jenniskens
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen 6500, the Netherlands
| | - J P Michiel Sedelaar
- Department of Urology, Radboud University Medical Center, Nijmegen 6500, the Netherlands
| | - Tsutomu Tamada
- Department of Radiology, Kawasaki Medical School, Kurashiki city, Okayama 701-0192, Japan
| | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen 6500, the Netherlands
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Miller ET, Salmasi A, Reiter RE. Anatomic and Molecular Imaging in Prostate Cancer. Cold Spring Harb Perspect Med 2018; 8:cshperspect.a030619. [PMID: 28710256 DOI: 10.1101/cshperspect.a030619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Prostate cancer is characterized by a complex set of heterogeneous disease states. This review aims to describe how imaging has been studied within each specific state. As physicians transition into an era of precision medicine, multiparametric magnetic resonance imaging (mpMRI) is proving to be a powerful tool leading the way for a paradigm shift in the diagnosis and management of localized prostate cancer. With further research and development, molecular imaging modalities will likely change the way we approach recurrent and metastatic disease. Given the range of possible oncological progression patterns, a thorough understanding of the underlying carcinogenesis, as it relates to imaging, is a requisite if we are to appropriately manage prostate cancer in future decades.
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Affiliation(s)
- Eric T Miller
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Amirali Salmasi
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095
| | - Robert E Reiter
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095.,Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at UCLA, Los Angeles, California 90095
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29
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Improving the Diagnosis of Clinically Significant Prostate Cancer with Magnetic Resonance Imaging. J Belg Soc Radiol 2018. [PMCID: PMC6095051 DOI: 10.5334/jbsr.1438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Dwivedi DK, Kumar R, Dwivedi AK, Bora GS, Thulkar S, Sharma S, Gupta SD, Jagannathan NR. Prebiopsy multiparametric MRI-based risk score for predicting prostate cancer in biopsy-naive men with prostate-specific antigen between 4-10 ng/mL. J Magn Reson Imaging 2017; 47:1227-1236. [PMID: 28872226 DOI: 10.1002/jmri.25850] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/24/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Risk calculators have traditionally utilized serum prostate-specific antigen (PSA) values in addition to clinical variables to predict the likelihood of prostate cancer (PCa). PURPOSE To develop a prebiopsy multiparametric MRI (mpMRI)-based risk score (RS) and a statistical equation for predicting the risk of PCa in biopsy-naive men with serum PSA between 4-10 ng/mL that may help reduce unnecessary biopsies. STUDY TYPE Prospective cross-sectional study. SUBJECTS In all, 137 consecutive men with PSA between 4-10 ng/mL underwent prebiopsy mpMRI (diffusion-weighted [DW]-MRI and MR spectroscopic imaging [MRSI]) during 2009-2015 were recruited for this study. FIELD STRENGTH/SEQUENCE 1.5T (Avanto, Siemens Health Care, Erlangen, Germany); T1 -weighted, T2 -weighted, DW-MRI, and MRSI sequences were used. ASSESSMENT All eligible patients underwent mpMRI-directed, cognitive-fusion transrectal ultrasound (TRUS)-guided biopsies. STATISTICAL TESTS An equation model and an RS were developed using receiver operating characteristic (ROC) curve analysis and a multivariable logistic regression approach. A 10-fold crossvalidation and simulation analyses were performed to assess diagnostic performance of various combinations of mpMRI parameters. RESULTS Of 137 patients, 32 were diagnosed with PCa on biopsy. Multivariable analysis, adjusted with positive pathology, showed apparent diffusion coefficient (ADC), metabolite ratio, and PSA as significant predictors of PCa (P < 0.05). A statistical equation was derived using these predictors. A simple 6-point mpMRI-based RS was derived for calculating the risk of PCa and it showed that it is highly predictive for PCa (odds ratio = 3.74, 95% confidence interval [CI]: 2.24-6.27, area under the curve [AUC] = 0.87). Both models (equation and RS) yielded high predictive performance (AUC ≥0.85) on validation analysis. DATA CONCLUSION A statistical equation and a simple 6-point mpMRI-based RS can be used as a point-of-care tool to potentially help limit the number of negative biopsies in men with PSA between 4 and 10 ng/mL. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1227-1236.
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Affiliation(s)
- Durgesh Kumar Dwivedi
- Department of NMR & MRI Facility, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeev Kumar
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Kumar Dwivedi
- Division of Biostatistics and Epidemiology, Department of Biomedical Sciences, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Girdhar S Bora
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Sharma
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
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Retrospective comparison of direct in-bore magnetic resonance imaging (MRI)-guided biopsy and fusion-guided biopsy in patients with MRI lesions which are likely or highly likely to be clinically significant prostate cancer. World J Urol 2017; 35:1849-1855. [PMID: 28871396 PMCID: PMC5693982 DOI: 10.1007/s00345-017-2085-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 08/28/2017] [Indexed: 12/15/2022] Open
Abstract
Purpose To compare clinically significant prostate cancer (csPCa) detection rates between magnetic resonance imaging (MRI)–transrectal ultrasound (TRUS) fusion-guided prostate biopsy (FGB) and direct in-bore MRI-guided biopsy (MRGB). Methods We performed a comparison of csPCa detection rates between FGB and MRGB. Included patients had (1) at least one prior negative TRUS biopsy; (2) a Prostate Imaging Reporting and Data System (PI-RADS) 4 or 5 lesion and (3) a lesion size of ≥8 mm measured in at least one direction. We considered a Gleason score ≥7 being csPCa. Descriptive statistics with 95% confidence intervals (CI) were used to determine any differences. Results We included 51 patients with FGB (59 PI-RADS 4 and 41% PI-RADS 5) and 227 patients with MRGB (34 PI-RADS 4 and 66% PI-RADS 5). Included patients had a median age of 69 years (IQR, 65–72) and a median PSA level of 11.0 ng/ml (IQR, 7.4–15.1) and a median age of 67 years (IQR, 61–70), the median PSA 12.8 ng/ml (IQR, 9.1–19.0) within the FGB and the MRGB group, respectively. Detection rates of csPCA did not differ significantly between FGB and MRGB, 49 vs. 61%, respectively. Conclusion We did not detect significant differences between FGB and MRGB in the detection of csPCa. The differences in detection ratios between both biopsy techniques are narrow with an increasing lesion size. This study warrants further studies to optimize selection of best biopsy modality.
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Bass EJ, Donaldson IA, Freeman A, Jameson C, Punwani S, Moore C, Arya M, Emberton M, Ahmed HU. Magnetic resonance imaging targeted transperineal prostate biopsy: a local anaesthetic approach. Prostate Cancer Prostatic Dis 2017; 20:311-317. [PMID: 28485391 DOI: 10.1038/pcan.2017.13] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/29/2017] [Accepted: 02/22/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite high rates of disease misclassification and sepsis, the use of transrectal biopsy remains commonplace. Transperineal mapping biopsies mitigate these problems but carry increased cost and patient burden. Local anaesthetic, multiparametric magnetic resonance imaging (MRI)-targeted transperineal biopsy may offer an alternative. Here, we aim to determine the feasibility, tolerability and detection rates of clinically significant prostate cancer using a local anaesthetic, transperineal, MRI-targeted biopsy technique. METHODS Tertiary referral centre in which 181 consecutive men underwent local anaesthetic, transperineal MRI-targeted prostate biopsy (September 2014 to January 2016). A standardized local anaesthetic technique was used to obtain targeted biopsies using visual estimation with the number of targeted cores determined by each of a number of users. We assessed adverse events, patient visual analogue pain scores and detection rates of clinically significant cancer (defined by University College London (UCL) definitions one and two and separately by the presence of dominant and non-dominant Gleason pattern 4). We secondarily assessed detection of any cancer, rates of detection by MRI (Likert) score and by presenting PSA. Differences were assessed using Chi-squared tests (P<0.05). RESULTS One hundred eighty-one men with 243 lesions were included. There were no episodes of sepsis or re-admissions and one procedure was abandoned owing to patient discomfort. Twenty-three out of 25 (92%) men would recommend the procedure to another. Median visual analogue pain score was 1.0 (interquartile range: 0.0-2.4). A total 104/181 (57%) had UCL definition 1 disease (Gleason ⩾4+3 and/or maximum cancer length ⩾6 mm) and 129/181 (71%) had UCL definition 2 cancer (Gleason ⩾3+4 and/or maximum cancer length ⩾4 mm). Fifty-four out of 181 (30%) and 124/181 (69%) had dominant and non-dominant pattern 4 disease or greater (irrespective of cancer length). Any cancer was detected in 142/181 (78%). Significant disease was more likely in higher MRI-scoring lesions and in men with PSAs ⩾10 ng ml-1. CONCLUSIONS This approach to prostate biopsy is feasible, tolerable and can be performed in ambulatory settings.
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Affiliation(s)
- E J Bass
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - I A Donaldson
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Freeman
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
- The Prostate Unit, BUPA Cromwell Hospital, London, UK
| | - C Jameson
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
- The Prostate Unit, BUPA Cromwell Hospital, London, UK
| | - S Punwani
- Centre for Medical Imaging, University College London, London, UK
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - C Moore
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Arya
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Emberton
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - H U Ahmed
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
- The Prostate Unit, BUPA Cromwell Hospital, London, UK
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Scialpi M, Martorana E, Aisa MC, Rondoni V, D'Andrea A, Bianchi G. Score 3 prostate lesions: a gray zone for PI-RADS v2. Turk J Urol 2017; 43:237-240. [PMID: 28861291 DOI: 10.5152/tud.2017.01058] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/26/2017] [Indexed: 12/19/2022]
Abstract
Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) does not offer a precise guidance on the clinical management (biopsy or not biopsy) for PI-RADS v2 score 3 lesions. Lesion volume calculated on biparametric MRI (bpMRI) [T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI)] by introducing a cut-off of 0.5 mL, allows to distinguish the lesions assigned by the multiparametric MRI (mpMRI) to the category PI-RADS v2 score 3 in two subgroups: a) Indolent or low risk lesions with volume <0.5 mL, and b) Significant or high risk lesions with volume ≥0.5 mL. For mpMRI lesions assigned to PI-RADS v2 score 3, we suggest the following management: 1) Subgroup a (low-risk lesion): Clinical surveillance (accurate evaluation of age and clinical informations, periodic monitoring of prostate specific antigen value and repeated bpMRI 1 year later); 2) Subgroup b (high-risk lesion): Targeted biopsy. The proposed management would reduce the use of unnecessary biopsies and increase the diagostic yield of significant prostate cancer of approximately 50% and 30% respectively. These approaches encourage the radiologist to adopt MRI lesion volume to improve PI-RADS v2 and to optimize the management of PI-RADS v2 score 3 lesions.
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Affiliation(s)
- Michele Scialpi
- Department of Surgical and Biomedical Sciences, Division of Radiology 2, Perugia University, S.Maria Della Misericordia Hospital, S. Andrea Delle Fratte, Perugia, Italy
| | | | - Maria Cristina Aisa
- Department of Surgical and Biomedical Sciences, Division of Radiology 2, Perugia University, S.Maria Della Misericordia Hospital, S. Andrea Delle Fratte, Perugia, Italy
| | - Valeria Rondoni
- Department of Surgical and Biomedical Sciences, Division of Radiology 2, Perugia University, S.Maria Della Misericordia Hospital, S. Andrea Delle Fratte, Perugia, Italy
| | - Alfredo D'Andrea
- Department of Experimental Medicine, Magrassi Lanzara, Second University of Naples, Italy
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Ultrasound Elastography of the Prostate Using an Unconstrained Modulus Reconstruction Technique: A Pilot Clinical Study. Transl Oncol 2017; 10:744-751. [PMID: 28735201 PMCID: PMC5522957 DOI: 10.1016/j.tranon.2017.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/15/2017] [Accepted: 06/15/2017] [Indexed: 12/04/2022] Open
Abstract
A novel full-inversion-based technique for quantitative ultrasound elastography was investigated in a pilot clinical study on five patients for non-invasive detection and localization of prostate cancer and quantification of its extent. Conventional-frequency ultrasound images and radiofrequency (RF) data (~5 MHz) were collected during mechanical stimulation of the prostate using a transrectal ultrasound probe. Pre and post-compression RF data were used to construct the strain images. The Young's modulus (YM) images were subsequently reconstructed using the derived strain images and the stress distribution estimated iteratively using finite element (FE) analysis. Tumor regions determined based on the reconstructed YM images were compared to whole-mount histopathology images of radical prostatectomy specimens. Results indicated that tumors were significantly stiffer than the surrounding tissue, demonstrating a relative YM of 2.5 ± 0.8 compared to normal prostate tissue. The YM images had a good agreement with the histopathology images in terms of tumor location within the prostate. On average, 76% ± 28% of tumor regions detected based on the proposed method were inside respective tumor areas identified in the histopathology images. Results of a linear regression analysis demonstrated a good correlation between the disease extents estimated using the reconstructed YM images and those determined from whole-mount histopathology images (r2 = 0.71). This pilot study demonstrates that the proposed method has a good potential for detection, localization and quantification of prostate cancer. The method can potentially be used for prostate needle biopsy guidance with the aim of decreasing the number of needle biopsies. The proposed technique utilizes conventional ultrasound imaging system only while no additional hardware attachment is required for mechanical stimulation or data acquisition. Therefore, the technique may be regarded as a non-invasive, low cost and potentially widely-available clinical tool for prostate cancer diagnosis.
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35
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[Prostate gland - what would urologists like to know from radiologists?]. Radiologe 2017; 57:608-614. [PMID: 28660295 DOI: 10.1007/s00117-017-0273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A more than 100-year period, where the prostate was only seen and treated as a whole is coming to an end right now. Finally, high resolution imaging is providing deep insights and detailed information so that new therapeutic procedures can aim for the smallest targets within the gland. The long-standing wish of patients for individual noninvasive diagnostics and treatment of prostate diseases can now be fulfilled by providing new tailored concepts; however, in order to transfer the enormous amount of new information into the specific clinical patient situation, a closely knit interdisciplinary approach is required. In this setting, the traditional outpatient consultation service is overstretched in every aspect. It is now the time for new innovative constructs. The current one-sided service concept for urologists, radiologists and radiation therapists is therefore behind the times and the development of a "prostate management team" with equally cooperating partners from each specialty is the task for the future.
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Scialpi M, Rondoni V, Aisa MC, Martorana E, D’Andrea A, Malaspina CM, Orlandi A, Galassi G, Orlandi E, Scialpi P, Dragone M, Palladino D, Simeone A, Amenta M, Bianchi G. Is contrast enhancement needed for diagnostic prostate MRI? Transl Androl Urol 2017; 6:499-509. [PMID: 28725592 PMCID: PMC5503975 DOI: 10.21037/tau.2017.05.31] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 05/15/2017] [Indexed: 11/30/2022] Open
Abstract
Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) provides clinical guidelines for multiparametric magnetic resonance imaging (mpMRI) [T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI)] of prostate. However, DCE-MRI seems to show a limited contribution in prostate cancer (PCa) detection and management. In our experience, DCE-MRI, did not show significant change in diagnostic performance in addition to DWI and T2WI [biparametric MRI (bpMRI)] which represent the predominant sequences to detect suspected lesions in peripheral and transitional zone (TZ). In this article we reviewed the role of DCE-MRI also indicating the potential contribute of bpMRI approach (T2WI and DWI) and lesion volume evaluation in the diagnosis and management of suspected PCa.
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Affiliation(s)
- Michele Scialpi
- Division of Radiology 2, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | - Valeria Rondoni
- Division of Radiology 2, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | - Maria Cristina Aisa
- Division of Gynaecology, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | | | - Alfredo D’Andrea
- Department of Clinical and Experimental Internal Medicine, “F. Magrassi and A. Lanzara” University of Campania “Luigi Vanvitelli” Second University of Naples, Naples, Italy
| | - Corrado Maria Malaspina
- Division of Radiology 2, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | - Agostino Orlandi
- Division of Radiology 2, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | - Giorgio Galassi
- Division of Radiology 2, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | - Emanuele Orlandi
- Division of Radiology 2, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
| | | | - Michele Dragone
- Department of Radiology IRCC Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Diego Palladino
- Department of Radiology IRCC Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Annalisa Simeone
- Department of Radiology IRCC Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | | | - Giampaolo Bianchi
- Division of Gynaecology, Department of Surgical and Biomedical Sciences, S. Maria della Misericordia Hospital, Perugia University, Perugia, Italy
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Schouten MG, van der Leest M, Pokorny M, Hoogenboom M, Barentsz JO, Thompson LC, Fütterer JJ. Why and Where do We Miss Significant Prostate Cancer with Multi-parametric Magnetic Resonance Imaging followed by Magnetic Resonance-guided and Transrectal Ultrasound-guided Biopsy in Biopsy-naïve Men? Eur Urol 2017; 71:896-903. [PMID: 28063613 DOI: 10.1016/j.eururo.2016.12.006] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/07/2016] [Indexed: 01/28/2023]
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38
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Wallis CJD, Haider MA, Nam RK. Role of mpMRI of the prostate in screening for prostate cancer. Transl Androl Urol 2017; 6:464-471. [PMID: 28725588 PMCID: PMC5503955 DOI: 10.21037/tau.2017.04.31] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Prostate cancer screening offers the opportunity to significantly reduce morbidity and mortality from this disease. Currently, serum prostate-specific antigen (PSA) testing is the most widely used screening modality. However, PSA testing continues to have low positive and negative predictive value leading to unnecessary invasive prostate biopsy while missing patients with aggressive forms of the disease. Magnetic resonance imaging (MRI) has been gaining an increasingly large role in the management of patients with early stage prostate cancer including diagnosis in patients with abnormal PSA levels, monitoring of patients on active surveillance, and staging prior to definitive interventions. MRI-based prostate cancer risk assessment has been shown to better distinguish between clinically-significant and insignificant tumors than PSA testing alone or from nomograms. Preliminary data indicate that, among unselected patients, MRI outperforms PSA in the identification of patients with clinically significant prostate cancer. Further work is needed to examine the role of mpMRI in prostate cancer screening.
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Affiliation(s)
- Christopher J D Wallis
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Masoom A Haider
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Robert K Nam
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Distler FA, Radtke JP, Bonekamp D, Kesch C, Schlemmer HP, Wieczorek K, Kirchner M, Pahernik S, Hohenfellner M, Hadaschik BA. The Value of PSA Density in Combination with PI-RADS™ for the Accuracy of Prostate Cancer Prediction. J Urol 2017; 198:575-582. [PMID: 28373135 DOI: 10.1016/j.juro.2017.03.130] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE Multiparametric magnetic resonance imaging has an emerging role in prostate cancer diagnostics. In addition, clinical information is a reliable predictor of significant prostate cancer. We analyzed whether the negative predictive value of multiparametric magnetic resonance imaging to rule out significant prostate cancer could be improved using clinical factors, especially prostate specific antigen density. MATERIALS AND METHODS A total of 1,040 consecutive men with suspicion of prostate cancer underwent multiparametric magnetic resonance imaging first, followed by transperineal systematic and magnetic resonance imaging-transrectal ultrasound fusion guided biopsy. Logistic regression analyses were performed to test different clinical factors as predictors of significant prostate cancer and build nomograms. To simplify these nomograms for clinical use patients were stratified into 3 prostate specific antigen density groups, including group 1-less than 0.07, group 2-0.07 to 0.15 and group 3-greater than 0.15 ng/ml/ml. After stratification we calculated the negative predictive value of a PI-RADS (Prostate Imaging Reporting and Data System) Likert score of less than 3. Significant prostate cancer was defined as a Gleason score of 3 + 4 or greater. High grade prostate cancer was defined as a Gleason score of 4 + 3 or greater. RESULTS Overall 451 men were diagnosed with significant prostate cancer, including 187 with a Gleason score of 4 + 3 or greater. On ROC curve analyses the predictive power of the developed nomogram for significant prostate cancer showed a higher AUC than that of PI-RADS alone (0.79 vs 0.75, p <0.001). The negative predictive value of harboring significant prostate cancer increased in men with unsuspicious magnetic resonance imaging from 79% up to 89% when prostate specific antigen density was 0.15 ng/ml/ml or less. In the repeat biopsy setting the negative predictive value of significant prostate cancer increased from 83% to 93%. The negative predictive value to harbor high grade prostate cancer increased from 92% up to 98% in the entire cohort. CONCLUSIONS Using prostate specific antigen density combined with multiparametric magnetic resonance imaging improved the negative predictive value of PI-RADS scoring. By increasing the probability of ruling out significant prostate cancer approximately 20% of unnecessary biopsies could be avoided safely.
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Affiliation(s)
- Florian A Distler
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Jan P Radtke
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany; Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - David Bonekamp
- Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Claudia Kesch
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Kathrin Wieczorek
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Sascha Pahernik
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Boris A Hadaschik
- Department of Urology, University Hospital Heidelberg, Heidelberg, Germany
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Furuya K, Kawahara T, Narahara M, Tokita T, Fukui S, Imano M, Mitome T, Ito Y, Izumi K, Osaka K, Yokomizo Y, Hayashi N, Hasumi H, Nawata S, Kawano T, Yao M, Uemura H. Measurement of serum isoform [-2]proPSA derivatives shows superior accuracy to magnetic resonance imaging in the diagnosis of prostate cancer in patients with a total prostate-specific antigen level of 2-10 ng/ml. Scand J Urol 2017; 51:251-257. [PMID: 28351193 DOI: 10.1080/21681805.2017.1298155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE More accurate diagnostic procedures for prostate cancer are needed to avoid unnecessary biopsy due to the low specificity of prostate-specific antigen (PSA). Recent studies showed that the percentage of serum isoform [-2]proPSA (p2PSA) to free PSA (%p2PSA), the Prostate Health Index (PHI) and magnetic resonance imaging (MRI) were more accurate than PSA. The aim of this study was to test the accuracy of %p2PSA, PHI and MRI in discriminating patients with and without prostate cancer. MATERIALS AND METHODS The subjects were 50 consecutive men with a PSA level of 2.0-10.0 ng/ml, who underwent prostate biopsy from October 2012 to July 2014. These patients underwent multiparametric MRI before biopsy, and their serum samples were measured for PSA, free PSA and p2PSA. The sensitivity, specificity and accuracy of PHI, %p2PSA and MRI were compared with PSA in the diagnosis of biopsy-confirmed prostate cancer. RESULTS In a univariate analysis, %p2PSA [area under the curve (AUC): 0.811] and PHI (AUC 0.795) were more accurate than MRI (AUC: 0.583) and PSA (AUC: 0.554) for prostate cancer detection. At 60% sensitivity, the specificity of PHI (76.5%) was higher than that of MRI (52.9%). For significant cancer detection, %p2PSA (AUC: 0.745), PHI (AUC: 0.791) and MRI (AUC: 0.739) were marginally more accurate than PSA (AUC: 0.696). At 85% sensitivity, the specificity of MRI (62.1%) was higher than that of PHI (34.5%). CONCLUSION PHI and %p2PSA can be used for screening the general population and MRI can be used for detection of significant cancer in patients suspected, from screening tests, of having prostate cancer.
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Affiliation(s)
- Kazuhiro Furuya
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Takashi Kawahara
- b Department of Urology , Yokohama City University Medical Center , Yokohama , Japan
| | - Masaki Narahara
- b Department of Urology , Yokohama City University Medical Center , Yokohama , Japan
| | - Takashi Tokita
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Sachi Fukui
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Masashi Imano
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Taku Mitome
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Yusuke Ito
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Koji Izumi
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Kimito Osaka
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Yumiko Yokomizo
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Narihiko Hayashi
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Hisashi Hasumi
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Shintaro Nawata
- c Department of Radiology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Tsuyoshi Kawano
- c Department of Radiology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Masahiro Yao
- a Department of Urology , Graduate School of Medicine, Yokohama City University , Yokohama , Japan
| | - Hiroji Uemura
- b Department of Urology , Yokohama City University Medical Center , Yokohama , Japan
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Moldovan PC, Van den Broeck T, Sylvester R, Marconi L, Bellmunt J, van den Bergh RCN, Bolla M, Briers E, Cumberbatch MG, Fossati N, Gross T, Henry AM, Joniau S, van der Kwast TH, Matveev VB, van der Poel HG, De Santis M, Schoots IG, Wiegel T, Yuan CY, Cornford P, Mottet N, Lam TB, Rouvière O. What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy? A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel. Eur Urol 2017; 72:250-266. [PMID: 28336078 DOI: 10.1016/j.eururo.2017.02.026] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/16/2017] [Indexed: 11/16/2022]
Abstract
CONTEXT It remains unclear whether patients with a suspicion of prostate cancer (PCa) and negative multiparametric magnetic resonance imaging (mpMRI) can safely obviate prostate biopsy. OBJECTIVE To systematically review the literature assessing the negative predictive value (NPV) of mpMRI in patients with a suspicion of PCa. EVIDENCE ACQUISITION The Embase, Medline, and Cochrane databases were searched up to February 2016. Studies reporting prebiopsy mpMRI results using transrectal or transperineal biopsy as a reference standard were included. We further selected for meta-analysis studies with at least 10-core biopsies as the reference standard, mpMRI comprising at least T2-weighted and diffusion-weighted imaging, positive mpMRI defined as a Prostate Imaging Reporting Data System/Likert score of ≥3/5 or ≥4/5, and results reported at patient level for the detection of overall PCa or clinically significant PCa (csPCa) defined as Gleason ≥7 cancer. EVIDENCE SYNTHESIS A total of 48 studies (9613 patients) were eligible for inclusion. At patient level, the median prevalence was 50.4% (interquartile range [IQR], 36.4-57.7%) for overall cancer and 32.9% (IQR, 28.1-37.2%) for csPCa. The median mpMRI NPV was 82.4% (IQR, 69.0-92.4%) for overall cancer and 88.1% (IQR, 85.7-92.3) for csPCa. NPV significantly decreased when cancer prevalence increased, for overall cancer (r=-0.64, p<0.0001) and csPCa (r=-0.75, p=0.032). Eight studies fulfilled the inclusion criteria for meta-analysis. Seven reported results for overall PCa. When the overall PCa prevalence increased from 30% to 60%, the combined NPV estimates decreased from 88% (95% confidence interval [95% CI], 77-99%) to 67% (95% CI, 56-79%) for a cut-off score of 3/5. Only one study selected for meta-analysis reported results for Gleason ≥7 cancers, with a positive biopsy rate of 29.3%. The corresponding NPV for a cut-off score of ≥3/5 was 87.9%. CONCLUSIONS The NPV of mpMRI varied greatly depending on study design, cancer prevalence, and definitions of positive mpMRI and csPCa. As cancer prevalence was highly variable among series, risk stratification of patients should be the initial step before considering prebiopsy mpMRI and defining those in whom biopsy may be omitted when the mpMRI is negative. PATIENT SUMMARY This systematic review examined if multiparametric magnetic resonance imaging (MRI) scan can be used to reliably predict the absence of prostate cancer in patients suspected of having prostate cancer, thereby avoiding a prostate biopsy. The results suggest that whilst it is a promising tool, it is not accurate enough to replace prostate biopsy in such patients, mainly because its accuracy is variable and influenced by the prostate cancer risk. However, its performance can be enhanced if there were more accurate ways of determining the risk of having prostate cancer. When such tools are available, it should be possible to use an MRI scan to avoid biopsy in patients at a low risk of prostate cancer.
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Affiliation(s)
- Paul C Moldovan
- Hospices Civils de Lyon, Department of Urinary and Vascular Radiology, Hôpital Edouard Herriot, Lyon, France
| | - Thomas Van den Broeck
- Department of Urology, University Hospitals Leuven, Leuven, Belgium; Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - Lorenzo Marconi
- Department of Urology, Coimbra University Hospital, Coimbra, Portugal
| | - Joaquim Bellmunt
- Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Michel Bolla
- Department of Radiation Therapy, CHU Grenoble, Grenoble, France
| | | | | | - Nicola Fossati
- Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Tobias Gross
- Department of Urology, University of Bern, Inselspital, Bern, Switzerland
| | - Ann M Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium; Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | | | | | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MCUniversity Medical Center, Rotterdam, The Netherlands; Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Cathy Yuhong Yuan
- Division of Gastroenterology and Cochrane UGPD Group, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada
| | - Philip Cornford
- Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
| | - Thomas B Lam
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Olivier Rouvière
- Hospices Civils de Lyon, Department of Urinary and Vascular Radiology, Hôpital Edouard Herriot, Lyon, France; Université Lyon 1, faculté de médecine Lyon Est, Lyon, France.
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Venderink W, van Luijtelaar A, Bomers JGR, van der Leest M, Hulsbergen-van de Kaa C, Barentsz JO, Sedelaar JPM, Fütterer JJ. Results of Targeted Biopsy in Men with Magnetic Resonance Imaging Lesions Classified Equivocal, Likely or Highly Likely to Be Clinically Significant Prostate Cancer. Eur Urol 2017; 73:353-360. [PMID: 28258784 DOI: 10.1016/j.eururo.2017.02.021] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Prostate Imaging Reporting and Data System (PI-RADS) is the most commonly used scoring system in prostate magnetic resonance imaging (MRI). One of the available techniques to target suspicious lesions is direct in-bore MRI-guided biopsy (MRGB). OBJECTIVE To report on the experience and results of MRGB in a large cohort of patients with lesions classified as equivocal (PI-RADS 3), likely (PI-RADS 4), or highly likely (PI-RADS 5) to be clinically significant (cs) prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS We retrospectively included 1057 patients having MRGB, between January 2012 and September 2016, of lesions classified as PI-RADS≥3 on multiparametric MRI. Biopsy-naïve patients, patients with prior negative systematic transrectal ultrasound-guided biopsy, and patients in active surveillance were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome measurement is the detection rate of csPCa. Descriptive statistics and chi-square tests were used to calculate the differences in proportions. We considered a Gleason score of ≥3+4 as csPCa. RESULTS AND LIMITATIONS PCa was diagnosed in 35% (55/156), 60% (223/373), and 91% (479/528), and csPCa in 17% (26/156), 34% (128/373), and 67% (352/528) of patients with PI-RADS 3, 4, and 5 lesions, respectively. Follow-up of patients with negative biopsy findings resulted in csPCa in 1.7% (5/300) after a median period of 41 (interquartile range 25-50) mo. The evaluation of prostate-specific antigen density (PSAD) to predict csPCa resulted in 42% of patients with a PI-RADS 3 lesion who could avoid biopsy in case a PSAD of ≥ 0.15ng/ml/ml would be used. In 6% (95% confidence interval, 2-15), csPCa would then be missed. The study is limited because of its retrospective character. CONCLUSIONS MRGB in lesions scored PI-RADS≥3 yields high detection rates of csPCa in daily clinical practice in cases with previous negative biopsy. PATIENT SUMMARY In daily clinical practice, direct in-bore magnetic resonance imaging-guided biopsy of suspicious lesions reported according to the Prostate Imaging Reporting and Data System yields high detection rates of clinically significant prostate cancer.
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Affiliation(s)
- Wulphert Venderink
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Annemarijke van Luijtelaar
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joyce G R Bomers
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marloes van der Leest
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jelle O Barentsz
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J P Michiel Sedelaar
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Cost-Effectiveness Comparison of Imaging-Guided Prostate Biopsy Techniques: Systematic Transrectal Ultrasound, Direct In-Bore MRI, and Image Fusion. AJR Am J Roentgenol 2017; 208:1058-1063. [PMID: 28225639 DOI: 10.2214/ajr.16.17322] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Three commonly used prostate biopsy approaches are systematic transrectal ultrasound guided, direct in-bore MRI guided, and image fusion guided. The aim of this study was to calculate which strategy is most cost-effective. MATERIALS AND METHODS A decision tree and Markov model were developed to compare cost-effectiveness. Literature review and expert opinion were used as input. A strategy was deemed cost-effective if the costs of gaining one quality-adjusted life year (incremental cost-effectiveness ratio) did not exceed the willingness-to-pay threshold of €80,000 (≈$85,000 in January 2017). A base case analysis was performed to compare systematic transrectal ultrasound- and image fusion-guided biopsies. Because of a lack of appropriate literature regarding the accuracy of direct in-bore MRI-guided biopsy, a threshold analysis was performed. RESULTS The incremental cost-effectiveness ratio for fusion-guided biopsy compared with systematic transrectal ultrasound-guided biopsy was €1386 ($1470) per quality-adjusted life year gained, which was below the willingness-to-pay threshold and thus assumed cost-effective. If MRI findings are normal in a patient with clinically significant prostate cancer, the sensitivity of direct in-bore MRI-guided biopsy has to be at least 88.8%. If that is the case, the incremental cost-effectiveness ratio is €80,000 per quality-adjusted life year gained and thus cost-effective. CONCLUSION Fusion-guided biopsy seems to be cost-effective compared with systematic transrectal ultrasound-guided biopsy. Future research is needed to determine whether direct in-bore MRI-guided biopsy is the best pathway; in this study a threshold was calculated at which it would be cost-effective.
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44
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Novel biparametric MRI and targeted biopsy improves risk stratification in men with a clinical suspicion of prostate cancer (IMPROD Trial). J Magn Reson Imaging 2017; 46:1089-1095. [DOI: 10.1002/jmri.25641] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/04/2017] [Indexed: 12/31/2022] Open
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Haider MA, Yao X, Loblaw A, Finelli A. Evidence-based guideline recommendations on multiparametric magnetic resonance imaging in the diagnosis of prostate cancer: A Cancer Care Ontario clinical practice guideline. Can Urol Assoc J 2017; 11:E1-E7. [PMID: 28163805 PMCID: PMC5262504 DOI: 10.5489/cuaj.3968] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This clinical guideline focuses on: 1) the use of multiparametric magnetic resonance imaging (mpMRI) in diagnosing clinically significant prostate cancer (CSPC) in patients with an elevated risk of CSPC and who are biopsy-naïve; and 2) the use of mpMRI in diagnosing CSPC in patients with a persistently elevated risk of having CSPC and who have a negative transrectal ultrasound (TRUS)-guided systematic biopsy. The methods of the Practice Guideline Development Cycle were used. MEDLINE, EMBASE, the Cochrane Library (1997‒April 2014), main guideline websites, and relevant annual meeting abstracts (2011‒2014) were searched. Internal and external reviews were conducted. The two main recommendations are: Recommendation 1: In patients with an elevated risk of CSPC (according to prostate-specific antigen [PSA] levels and/or nomograms) who are biopsy-naïve: mpMRI followed by targeted biopsy (biopsy directed at cancer-suspicious foci detected with mpMRI) should not be considered the standard of care.Data from future research studies are essential and should receive high-impact trial funding to determine the value of mpMRI in this clinical context.Recommendation 2: In patients who had a prior negative TRUS-guided systematic biopsy and demonstrate an increasing risk of having CSPC since prior biopsy (e.g., continued rise in PSA and/or change in findings from digital rectal examination): mpMRI followed by targeted biopsy may be considered to help in detecting more CSPC patients compared with repeated TRUS-guided systematic biopsy.
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Affiliation(s)
- Masoom A. Haider
- University of Toronto and Sunnybrook Research Institute, Toronto, ON, Canada
| | - Xiaomei Yao
- Cancer Care Ontario, Program in Evidence-Based Care; McMaster University, Hamilton, ON, Canada
| | - Andrew Loblaw
- University of Toronto and Sunnybrook Research Institute, Toronto, ON, Canada
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Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) plays an emerging role in prostate cancer diagnosis. We compared the cancer detection rates of targeted biopsy (tB) of suspicious lesions in mpMRI versus systematic transperineal saturation biopsy (sB) in men with primary suspicion of prostate cancer (PCa). METHODS A total of 437 consecutive primary biopsy patients, who underwent transperineal systematic and fusion-guided biopsy between 2012 and 2014, were enrolled. mpMRI was evaluated based on PI-RADS. Analysis of biopsy specimen was performed following START criteria. RESULTS Of the 437 men, 334 harbored 426 MR lesions. Overall, 274 PCa and 203 significant PCa (Gleason score (GS) ≥ 3 + 4, GS = 3 + 3 and PSA values ≥ 10 ng/ml) were detected. There were 52 (26 %) significant PCa exclusively found by sB, whereas only 18 (9 %) were identified by tB (p < 0.001). Of 80 high-grade PCa with GS ≥ 4 + 3, 70 were diagnosed by sB, and 60 by tB (p = 0.007). In addition, 54 % of all insignificant PCa (GS < 7, PSA < 10 ng/ml) were detected by sB alone (p < 0.001). AUC of mpMRI was 0.76-0.78. CONCLUSION The combination of tB + sB detects PCa most accurately. Ongoing prospective (multicenter) studies are evaluating the status of the 12 core TRUS-guided random biopsy.
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47
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Bass EJ, Ahmed HU. Focal therapy in prostate cancer: A review of seven common controversies. Cancer Treat Rev 2016; 51:27-34. [PMID: 27846402 DOI: 10.1016/j.ctrv.2016.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
Abstract
Radical treatments such as prostatectomy and radiotherapy have demonstrated success in terms of biochemical and disease-specific survival for localised prostate cancer. However, whilst the end goal of any cancer treatment is to control or cure disease it must also do so by minimising any side effects that may be experienced by the patient. Focal therapy as a concept aims to redress this established therapeutic ratio by treating areas of the prostate affected by significant disease as opposed to treating the entire gland. However, there are a number of common criticisms of focal therapy - we deem the seven sins - that require further interrogation.
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Affiliation(s)
- Edward J Bass
- Division of Surgery and Interventional Science, UCL, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK.
| | - Hashim U Ahmed
- Division of Surgery and Interventional Science, UCL, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK
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48
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Harvey H, deSouza NM. The role of imaging in the diagnosis of primary prostate cancer. JOURNAL OF CLINICAL UROLOGY 2016; 9:11-17. [PMID: 28344811 PMCID: PMC5356180 DOI: 10.1177/2051415816656120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/31/2016] [Indexed: 11/15/2022]
Abstract
Ultrasound and magnetic resonance imaging (MRI) are key imaging modalities in prostate cancer diagnosis. MRI offers a range of intrinsic contrast mechanisms (T2, diffusion-weighted imaging (DWI), MR spectroscopy (MRS)) and extrinsic contrast-generating options based on tumour vascular state following injection of weakly paramagnetic agents such as gadolinium. Together these parameters are referred to as multiparametric (mp)MRI and are used for detecting and guiding biopsy and staging prostate cancer. Although sensitivity of mpMRI is <75% for disease detection, specificity is >90% and a standardised reporting system together with MR-guided targeted biopsy is the optimal diagnostic pathway. Shear wave ultrasound elastography is a new technique which also holds promise for future studies. This article describes the developments in imaging the primary site of prostate cancer and reviews their current and future utility for screening, diagnosis and T-staging the disease.
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Affiliation(s)
- Hugh Harvey
- Cancer Imaging Centre, The Institute of Cancer Research, UK
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49
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Dynamic contrast-enhanced imaging has limited added value over T2-weighted imaging and diffusion-weighted imaging when using PI-RADSv2 for diagnosis of clinically significant prostate cancer in patients with elevated PSA. Clin Radiol 2016; 72:23-32. [PMID: 27726850 DOI: 10.1016/j.crad.2016.09.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/30/2016] [Accepted: 09/09/2016] [Indexed: 12/19/2022]
Abstract
AIM To determine the added value of dynamic contrast-enhanced imaging (DCE) over T2-weighted imaging (T2-WI) and diffusion-weighted imaging (DWI) for detection of clinically significant prostate cancer (csPC) in patients with elevated prostate-specific antigen (PSA). METHODS AND MATERIALS Two hundred and forty-five patients with elevated PSA underwent multiparametric (mp) magnetic resonance imaging (MRI) of the prostate before biopsy. mpMRI was performed using a 3 T MRI system without an endorectal coil. Patients underwent transrectal ultrasound-guided systematic 12 core biopsy followed by radical prostatectomy (n=68), radiation therapy (n=91), or clinical follow-up for at least 2 years (n=86). csPC was defined as Gleason score ≥3+4 and/or tumour volume of ≥0.5 ml, and/or tumour stage ≥T3a. The MRI findings were scored according to the Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) and an alternative overall assessment category (PI-RADSv2Alt) based on only T2-WI and DWI. RESULTS In 144 patients (58.8%), csPC was found within 2 years after MRI. With scoring according to the PI-RADSv2 guidelines, DCE was not needed for determination of the overall assessment category in 80.8% (198/245) of patients. Receiver operating characteristic (ROC) analysis showed an area under the curve of 0.79 (95% confidence interval [CI]: 0.74-0.85) for PI-RADSv2 and 0.79 (95% CI: 0.73-0.85) for PI-RADSv2Alt. CONCLUSION The added value of DCE over T2-WI and DWI is limited when using PI-RADSv2 for diagnosis of csPC in patients with elevated PSA before biopsy. An alternative overall assessment score using only T2-WI and DWI yielded similar performance to PI-RADSv2.
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50
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Abstract
Prostate cancer is the most common cancer (other than skin cancer) in American men, with one in seven men being diagnosed with this disease during his lifetime. The estimated number of new prostate cancer cases in 2016 is 180,890. For the first time, imaging has become the center of the search for contained, intraglandular, small-volume, and unifocal disease, and an increasing number of academic institutions as well as private practices are implementing programs for prostate multiplanar magnetic resonance imaging (MRI) as parts of their routine offerings. This article reviews the role of MRI-guided focal prostate ablation, as well as opportunities for further growth in this minimally invasive therapy of prostate cancer.
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Affiliation(s)
- Sherif G Nour
- Interventional MRI Program, Emory University Hospitals and School of Medicine, Atlanta, Georgia; Divisions of Abdominal Imaging, Interventional Radiology, and Image-Guided Medicine, Emory University Hospitals and School of Medicine, Atlanta, Georgia
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