Single center analysis of an advisable control interval for follow-up of patients with PI-RADS category 3 in multiparametric MRI of the prostate

Long-Term Risk of Clinically Significant Prostate Cancer in Biopsy-Negative Patients With Baseline Biparametric Prostate MRI

BACKGROUND

The long-term prevalence of clinically significant prostate cancer (csPCa) in patients with initial negative prostate biopsy is unknown.

PURPOSE

To investigate the rate of csPCa of men with initial negative biopsy.

STUDY TYPE

Retrospective analysis of prospectively collected data.

POPULATION

A total of 197 men (mean age 63 years [SD ±6.98, range 29-79]) without csPCa on initial biopsy and available baseline biparametric prostate MRI (bpMRI).

FIELD STRENGTH/SEQUENCE

3.0 T, turbo spin-echo T2-weighted (axial and sagittal) and three sets of diffusion-weighted imaging using single-shot spin-echo planar imaging (5 b-values 0-500 seconds/mm2; 2 b-values 0 and 1500 seconds/mm2, and 2 b-values 0 and 2000 seconds/mm2).

ASSESSMENT

BpMRI was read using Prostate Imaging Reporting Data System (PI-RADS) v2.1. Systematic or targeted biopsy results served as reference standard.

STATISTICAL TESTS

Continuous variables were compared using Kruskal-Wallis rank sum test. Categorical variables were compared using either Fisher's exact test or Pearson's chi-square test. Uni- and multivariate regression odds ratios (95% confidence interval) were used to study factors affecting csPCa being diagnosed during follow-up. Time to diagnosis of csPCa is calculated using the Kaplan-Meier method.

RESULTS

Of 197 men, 74 (38%), 57 (29%), and 66 (34%) presented with PI-RADS 1-2, 3, and 4-5 findings in the baseline bpMRI. During the median follow-up of 52 months, 8.1%, 5.3%, and 18.2% of these men were diagnosed with csPCa, respectively. Baseline PI-RADS finding was the only factor that associated with csPCa found during the follow-up.

DATA CONCLUSION

Baseline bpMRI with PI-RADS scores 1-3 and initial biopsies negative of csPCa had low rate of csPCa during follow-up, which supports more conservative follow-up for them but further research with longer follow-up is warranted.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Enhancing Prostate Cancer Detection in PI-RADS 3 Cases: An In-depth Analysis of Radiological Indicators from Multiparametric MRI

Prostate cancer (PCa) diagnosis using multiparametric magnetic resonance imaging (mpMRI) remains challenging, especially in Prostate Imaging Reporting and Data System 3 (PI-RADS 3) lesions, which present an intermediate risk of malignancy. This study aims to evaluate the diagnostic efficacy of various radiological parameters in PI-RADS 3 lesions to improve the decision-making process for prostate biopsies.This retrospective study included 76 patients with PI-RADS 3 lesions who underwent mpMRI and transrectal prostate biopsy at a tertiary university hospital between 2015 and 2022. Radiological parameters such as signal intensity, lesion size, border definition, morphological features, lesion location, and prostate volume were analyzed. Apparent diffusion coefficient (ADC) values and the patients' clinical data including age, prostate-specific antigen (PSA), and histopathological findings were also evaluated. Results: Among the 76 patients meeting the inclusion criteria, prostate cancer was detected in 17, with only one case being clinically significant (csPCa). Factors increasing malignancy risk in PI-RADS 3 lesions included poorly defined lesion borders, ADC values below 1180 μm²/sec, and prostate volume below 50.5 cc. The study highlighted the need for additional radiological and clinical parameters in the risk classification of PI-RADS 3 cases.This retrospective study included 76 patients with PI-RADS 3 lesions who underwent mpMRI and transrectal prostate biopsy at a tertiary university hospital between 2015 and 2022. Radiological parameters such as signal intensity, lesion size, border definition, morphological features, lesion location, and prostate volume were analyzed. Apparent diffusion coefficient (ADC) values and the patients' clinical data including age, prostate-specific antigen (PSA), and histopathological findings were also evaluated.Among the 76 patients meeting the inclusion criteria, prostate cancer was detected in 17, with only one case being clinically significant (csPCa). Factors increasing malignancy risk in PI-RADS 3 lesions included poorly defined lesion borders, ADC values below 1180 μm²/sec, and prostate volume below 50.5 cc. The study highlighted the need for additional radiological and clinical parameters in the risk classification of PI-RADS 3 cases.The findings suggest that incorporating additional radiological parameters into the evaluation of PI-RADS 3 lesions can enhance the accuracy of prostate cancer diagnosis. This approach could minimize unnecessary biopsies and ensure that significant malignancies are not overlooked. Future multicenter, large-scale studies are recommended to establish more definitive risk stratification criteria. · The study emphasizes the complexity of diagnosing prostate cancer in PI-RADS 3 lesions and the importance of detailed radiological assessment.. · It highlights the significance of specific radiological parameters, including lesion border definition and ADC values, in predicting malignancy.. · The research provides valuable insight for clinicians in order to make informed decisions regarding prostate biopsies, particularly in ambiguous PI-RADS 3 cases.. · Mersinlioğlu İ, Keven A, Tezel ZE et al. Enhancing Prostate Cancer Detection in PI-RADS 3 Cases: An In-depth Analysis of Radiological Indicators from Multiparametric MRI. Fortschr Röntgenstr 2024; DOI 10.1055/a-2374-2531.

Refining clinically relevant cut-offs of prostate specific antigen density for risk stratification in patients with PI-RADS 3 lesions

BACKGROUND

Prostate Imaging Reporting and Data System (PI-RADS) 3 lesions, identified through multiparametric magnetic resonance imaging (mpMRI), present a clinical challenge due to their equivocal nature in predicting clinically significant prostate cancer (csPCa). Aim of the study is to improve risk stratification of patients with PI-RADS 3 lesions and candidates for prostate biopsy.

METHODS

A cohort of 4841 consecutive patients who underwent MRI and subsequent MRI-targeted and systematic biopsies between January 2016 and April 2023 were retrospectively identified from independent prospectively maintained database. Only patients who have PI-RADS 3 lesions were included in the final analysis. A multivariable logistic regression analysis was performed to identify covariables associated with csPCa defined as International Society of Urological Pathology (ISUP) grade group ≥2. Performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC), calibration, and net benefit. Significant predictors were then selected for further exploration using a Chi-squared Automatic Interaction Detection (CHAID) analysis.

RESULTS

Overall, 790 patients had PI-RADS 3 lesions and 151 (19%) had csPCa. Significant associations were observed for age (OR: 1.1 [1.0-1.1]; p = 0.01) and PSA density (OR: 1643 [2717-41,997]; p < 0.01). The CHAID analysis identified PSAd as the sole significant factor influencing the decision tree. Cut-offs for PSAd were 0.13 ng/ml/cc (csPCa detection rate of 1% vs. 18%) for the two-nodes model and 0.09 ng/ml/cc and 0.16 ng/ml/cc for the three-nodes model (csPCa detection rate of 0.5% vs. 2% vs. 17%).

CONCLUSIONS

For individuals with PI-RADS 3 lesions on prostate mpMRI and a PSAd below 0.13, especially below 0.09, prostate biopsy can be omitted, in order to avoid unnecessary biopsy and overdiagnosis of non-csPCa.

Long-term follow-up results of multiparametric prostate MRI and the prognostic value of PI-RADS: a single-center retrospective cohort study

PURPOSE

We aim to examine the long-term outcomes of patients who underwent multiparametric prostate magnetic resonance imaging (mp-MRI) for suspected prostate cancer (PCa), specifically based on their initial Prostate Imaging Reporting and Data System (PI-RADS) categories and various clinical factors. Our secondary aim is to evaluate the prognostic value of the PI-RADS through the National Comprehensive Cancer Network (NCCN) risk group distribution.

METHODS

This research was conducted as a single-center retrospective cohort study in a tertiary care hospital. A total of 1,359 cases having at least one histopathological examination after the initial mp-MRI and/or adequate clinical/radiological follow-up data were included in the clinically significant PCa (cs-PCa) diagnosis-free survival analysis. Initial mp-MRI dates were accepted as the start of follow-up for the time-to-event analysis. The event was defined as cs-PCa diagnosis (International Society of Urological Pathology ≥2). Patients who were not diagnosed with cs-PCa during follow-up were censored according to predefined literature-based criteria at the end of the maximum follow-up duration with no reasonable suspicion of PCa and no biopsy indication. The impact of various factors on survival was assessed using a log-rank test and multivariable Cox regression. Subsequently, 394 cases diagnosed with PCa during follow-up were evaluated, based on initial PI-RADS categories and NCCN risk groups.

RESULTS

Three main risk factors for cs-PCa diagnosis during follow-up were an initial PI-RADS 5 category, initial PI-RADS 4 category, and high MRI-defined PSA density (mPSAD), with average hazard ratios of 29.52, 14.46, and 3.12, respectively. The PI-RADS 3 category, advanced age group, and biopsy-naïve status were identified as additional risk factors (hazard ratios: 2.03, 1.54-1.98, and 1.79, respectively). In the PI-RADS 1-2 cohort, 1, 3, and 5-year cs-PCa diagnosis-free survival rates were 99.1%, 96.5%, and 93.8%, respectively. For the PI-RADS 3 cohort, 1, 3, and 5-year cs-PCa diagnosis-free survival rates were 94.9%, 90.9%, and 89.1%, respectively. For the PI-RADS 4 cohort, 1, 3, and 5-year cs-PCa diagnosis-free survival rates were 56.6%, 55.1%, and 55.1%, respectively. These rates were found to all be 24.2% in the PI-RADS 5 cohort. Considering the 394 cases diagnosed with PCa during follow-up, PI-RADS ≥4 cases were more likely to harbor unfavorable PCa compared to PI-RADS ≤3 cases (P < 0.001). In the PI-RADS 3 subgroup analysis, a low mPSAD (<0.15 ng/mL2) was found to be a protective prognostic factor against unfavorable PCa (P = 0.005).

CONCLUSION

The PI-RADS category has a significant impact on patient management and provides important diagnostic and prognostic information. Higher initial PI-RADS categories are associated with decreased follow-up losses, a shorter time to PCa diagnosis, increased biopsy rates, a higher likelihood of developing cs-PCa during follow-up, and a worse PCa prognosis. Combining mPSAD with PI-RADS categories could enhance diagnostic stratification in the identification of cs-PCa.

PI-RADS upgrading as the strongest predictor for the presence of clinically significant prostate cancer in patients with initial PI-RADS-3 lesions

PURPOSE

Unclear lesions on multiparametric magnetic resonance tomography (mpMRI) are challenging for the indication of biopsy in patients with clinical suspicion of prostate cancer (PCa). The aim of this study is the validation of the detection rate of clinically significant PCa (csPCa) in patients with PI-RADS 3 findings and to determine the appropriate follow-up strategy.

METHODS

In this retrospective single-center study, patients with maximum PI-RADS 3 lesions underwent targeted MRI/ultrasound-fusion biopsy (tPbx) combined with systematic 12-core biopsy (sPbx) and follow-up mpMRI with further control biopsy. We assessed the evolution of MRI findings (PI-RADS, volume of the lesion), clinical parameters and histopathology in follow-up MRI and biopsies. The primary objective is the detection rate of csPCa, defined as ISUP ≥ 2 findings.

RESULTS

A total of 126 patients (median PSA 6.65 ng/ml; median PSA-density (PSAD) 0.13 ng/ml2) were included. The initial biopsy identified low-risk PCa in 24 cases (19%). During follow-up biopsy, 22.2% of patients showed PI-RADS upgrading (PI-RADS > 3), and 29 patients (23%) exhibited a tumor upgrading. Patients with PI-RADS upgrading had a higher risk of csPCa compared to those without PI-RADS upgrading (42.9% vs. 9.18%, p < 0.05). PI-RADS upgrading was identified as an independent predictor for csPCa in follow-up biopsy (OR 16.20; 95% CI 1.17-224.60; p = 0.038).

CONCLUSION

Patients with stable PI-RADS 3 findings may not require a follow-up biopsy. Instead, it is advisable to schedule an MRI, considering that PI-RADS upgrading serves as an independent predictor for csPCa.

Management Strategy for Prostate Imaging Reporting and Data System Category 3 Lesions

PURPOSE OF REVIEW

Prostate Imaging Reporting and Data System (PI-RADS) category 3 lesions present a clinical dilemma due to their uncertain nature, which complicates the development of a definitive management strategy. These lesions have an incidence rate of approximately 22-32%, with clinically significant prostate cancer (csPCa) accounting for about 10-30%. Therefore, a thorough evaluation is warranted.

RECENT FINDINGS

This review highlights the need for radiology peer review, including the confirmation of dynamic contrast-enhanced (DCE) compliance, as the initial step. Additional MRI models such as VERDICT or Tofts need to be verified. Current evidence shows that imaging and clinical indicators can be used for risk stratification of PI-RADS 3 lesions. For low-risk lesions, a safety net monitoring approach involving annual repeat MRI can be employed. In contrast, lesions deemed potentially risky based on prostate-specific antigen density (PSAD), 68 Ga-PSMA PET/CT, MPS, Proclarix, or AI/machine learning models should undergo biopsy. It is recommended to establish a multidisciplinary team that takes into account factors such as age, PSAD, prostate, and lesion size, as well as previous biopsy pathological findings. Combining expert opinions, clinical-imaging indicators, and emerging methods will contribute to the development of management strategies for PI-RADS 3 lesions.

Outcomes of a Diagnostic Pathway for Prostate Cancer Based on Biparametric MRI and MRI-Targeted Biopsy Only in a Large Teaching Hospital

BACKGROUND

Diagnostic pathways for prostate cancer (PCa) balance detection rates and burden. MRI impacts biopsy indication and strategy.

METHODS

A prospectively collected cohort database (N = 496) of men referred for elevated PSA and/or abnormal DRE was analyzed. All underwent biparametric MRI (3 Tesla scanner) and ERSPC prostate risk-calculator. Indication for biopsy was PIRADS ≥ 3 or risk-calculator ≥ 20%. Both targeted (cognitive-fusion) and systematic cores were combined. A hypothetical full-MRI-based pathway was retrospectively studied, omitting systematic biopsies in: (1) PIRADS 1-2 but risk-calculator ≥ 20%, (2) PIRADS ≥ 3, receiving targeted biopsy-cores only.

RESULTS

Significant PCa (GG ≥ 2) was detected in 120 (24%) men. Omission of systematic cores in cases with PIRADS 1-2 but risk-calculator ≥ 20%, would result in 34% less biopsy indication, not-detecting 7% significant tumors. Omission of systematic cores in PIRADS ≥ 3, only performing targeted biopsies, would result in a decrease of 75% cores per procedure, not detecting 9% significant tumors. Diagnosis of insignificant PCa dropped by 52%. PCa undetected by targeted cores only, were ipsilateral to MRI-index lesions in 67%.

CONCLUSIONS

A biparametric MRI-guided PCa diagnostic pathway would have missed one out of six cases with significant PCa, but would have considerably reduced the number of biopsy procedures, cores, and insignificant PCa. Further refinement or follow-up may identify initially undetected cases. Center-specific data on the performance of the diagnostic pathway is required.