Multicentre evaluation of targeted and systematic biopsies using magnetic resonance and ultrasound image-fusion guided transperineal prostate biopsy in patients with a previous negative biopsy

Advanced Imaging for Localized Prostate Cancer

BACKGROUND/OBJECTIVES

Prostate cancer is a prevalent malignancy often presenting without early symptoms. Advanced imaging technologies have revolutionized its diagnosis and management. This review discusses the principles, benefits, and clinical applications of multiparametric magnetic resonance imaging (mpMRI), micro-ultrasound (microUS), and prostate-specific membrane antigen positron emission tomography-computed tomography (PSMA PET/CT) in localized prostate cancer.

METHODS

We conducted a comprehensive literature review of recent studies and guidelines on mpMRI, microUS, and PSMA PET/CT in prostate cancer diagnosis, focusing on their applications in biopsy-naïve patients, those with previous negative biopsies, and patients under active surveillance.

RESULTS

MpMRI has demonstrated high sensitivity and negative predictive value in detecting clinically significant prostate cancer (csPCa). MicroUS, a newer technology, has shown promising results in early studies, with sensitivity and specificity comparable to mpMRI. PSMA PET/CT has emerged as a highly sensitive and specific imaging modality, particularly valuable for staging and detecting metastatic disease. All three technologies have been incorporated into urologic practice for prostate cancer diagnosis and management, with each offering unique advantages in different clinical scenarios.

CONCLUSIONS

Advanced imaging techniques, including mpMRI, microUS, and PSMA PET/CT, have significantly improved the accuracy of prostate cancer diagnosis, staging, and management. These technologies enable more precise targeting of suspicious lesions during biopsy and therapy planning. However, further research, especially randomized controlled trials, is needed to fully establish the optimal use and inclusion of these imaging modalities in various stages of prostate cancer care.

Assessment of diagnostic value of unilateral systematic biopsy combined with targeted biopsy in detecting clinically significant prostate cancer

Objectives

This retrospective study assessed the diagnostic accuracy of targeted biopsy (TB) and unilateral systematic biopsy in detecting clinically significant prostate cancer (csPCa) in 222 men with single magnetic resonance imaging (MRI) lesions (Prostate Imaging Reporting and Data System [PI-RADS] ≥ 3).

Methods

Patients underwent multiparametric MRI and MRI/ultrasound fusion TB and 12-needle standard biopsy (SB) from September 2016 to June 2021. The study compared the diagnostic performance of TB + iSB (ipsilateral), TB + contralateral system biopsy (cSB) (contralateral), and TB alone for csPCa using the χ 2 test and analysis of variance.

Results

Among 126 patients with csPCa (ISUP ≥ 2), detection rates for TB + iSB, TB + cSB, and TB were 100, 98.90, and 100% for lesions, respectively. TB + iSB showed the highest sensitivity and negative predictive value. No significant differences in accuracy were found between TB + iSB and the gold standard for type 3 lesions (P = 1). For types 4-5, detection accuracy was comparable across methods (P = 0.314, P = 0.314, P = 0.153). TB had the highest positive needle count rate, with TB + iSB being second for type 3 lesions (4.08% vs 6.57%, P = 0.127).

Conclusion

TB + iSB improved csPCa detection rates and reduced biopsy numbers, making it a viable alternative to TB + SB for single MRI lesions.

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.

A comparative study of 18F-PSMA-1007 PET/CT and pelvic MRI in newly diagnosed prostate cancer

PURPOSE

To evaluate the difference in the diagnostic efficacy of 18F-PSMA-1007 PET/CT and pelvic MRI in primary prostate cancer, as well as the correlation between the two methods and histopathological parameters and serum PSA levels.

METHODS

A total of 41 patients with suspected prostate cancer who underwent 18F-PSMA-1007 PET/CT imaging in our department from 2018 to 2023 were retrospectively collected. All patients underwent 18F-PSMA-1007 PET/CT and MRI scans. The sensitivity, PPV and diagnostic accuracy of MRI and 18F-PSMA-1007 PET/CT in the diagnosis of prostate cancer were calculated after comparing the results of MRI and 18F-PSMA-1007 PET/CT with biopsy. The Spearman test was used to calculate the correlation between 18F-PSMA-1007 PET/CT, MRI parameters, histopathological indicators, and serum PSA levels.

RESULTS

Compared with histopathological results, the sensitivity, PPV and diagnostic accuracy of 18F-PSMA-1007 PET/CT in the diagnosis of prostate cancer were 95.1%, 100.0% and 95.1%, respectively. The sensitivity, PPV and diagnostic accuracy of MRI in the diagnosis of prostate cancer were 82.9%, 100.0% and 82.9%, respectively. There was a mild to moderately positive correlation between Gleason (Gs) score, Ki-67 index, serum PSA level and 18F-PSMA-1007 PET/CT parameters (p < 0.05). There was a moderately negative correlation between the expression of AMACR (P504S) and 18F-PSMA-1007 PET/CT parameters (p < 0.05). The serum PSA level and the Gs score were moderately positively correlated with the MRI parameters (p < 0.05). There was no correlation between histopathological parameters and MRI parameters (p > 0.05).

CONCLUSION

Compared with MRI, 18F-PSMA-1007 PET/CT has higher sensitivity and diagnostic accuracy in the detection of malignant prostate tumors. In addition, the Ki-67 index and AMACR (P504S) expression were only correlated with 18F-PSMA-1007 PET/CT parameters. Gs score and serum PSA level were correlated with 18F-PSMA-1007 PET/CT and MRI parameters. 18F-PSMA-1007 PET/CT examination can provide certain reference values for the clinical diagnosis, evaluation, and treatment of malignant prostate tumors.

Targeted biopsy of the prostate

Diagnostic multiparametric MRI of the prostate has steadily evolved over the last three decades and can now reliably depict the dominant tumor in most men with prostate cancer. In response, several methods of targeted biopsy to direct tissue sampling of suspected tumor foci seen at multiparametric MRI have been developed and successfully tested in recent years, including software-assisted MRI-ultrasound (US) fusion biopsy and direct MRI-guided in-bore biopsy. These advances are leading to a sea change in the approach to prostate cancer diagnosis, with the traditional approach of blind systematic biopsy increasingly being replaced by MRI directed targeted biopsy. This review aims to describe the current status of targeted biopsy, with an emphasis on the relative accuracy of different techniques. The results of several critical large multicenter trials are presented, while unanswered questions that require more research are highlighted.

Diagnostic Performance of Prostate-specific Antigen Density for Detecting Clinically Significant Prostate Cancer in the Era of Magnetic Resonance Imaging: A Systematic Review and Meta-analysis

CONTEXT

There has been a dramatic increase in the use of prostate magnetic resonance imaging (MRI) in the diagnostic workup. With prostate volume calculated from MRI, prostate-specific antigen density (PSAD) now is a ready-to-use parameter for prostate cancer (PCa) risk stratification before prostate biopsy, especially among patients with negative MRI or equivocal lesions.

OBJECTIVE

In this review, we aimed to evaluate the diagnostic performance of PSAD for clinically significant prostate cancer (CSPCa) among patients who received MRI before prostate biopsy.

EVIDENCE ACQUISITION

Two investigators performed a systematic review according of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies (published between January 1, 2012, and December 31, 2021) reporting the diagnostic performance (outcomes) of PSAD (intervention) for CSPCa among men who received prebiopsy prostate MRI and subsequent prostate biopsy (patients), using biopsy pathology as the gold standard (comparison), were eligible for inclusion.

EVIDENCE SYNTHESIS

A total of 1536 papers were identified in PubMed, Scopus, and Embase. Of these, 248 studies were reviewed in detail and 39 were qualified. The pooled sensitivity (SENS) and specificity (SPEC) for diagnosing CSPCa among patients with positive MRI were, respectively, 0.87 and 0.35 for PSAD of 0.1 ng/ml/ml, 0.74 and 0.61 for PSAD of 0.15 ng/ml/ml, and 0.51 and 0.81 for PSAD of 0.2 ng/ml/ml. The pooled SENS and SPEC for diagnosing CSPCa among patients with negative MRI were, respectively, 0.85 and 0.36 for PSAD of 0.1 ng/ml/ml, 0.60 and 0.66 for PSAD of 0.15 ng/ml/ml, and 0.33 and 0.84 for PSAD of 0.2 ng/ml/ml. The pooled SENS and SPEC among patients with Prostate Imaging Reporting and Data System (PI-RADS) 3 or Likert 3 lesions were, respectively, 0.87 and 0.39 for PSAD of 0.1 ng/ml/ml, 0.61 and 0.69 for PSAD of 0.15 ng/ml/ml, and 0.42 and 0.82 for PSAD of 0.2 ng/ml/ml. The post-test probability for CSPCa among patients with negative MRI was 6% if PSAD was <0.15 ng/ml/ml and dropped to 4% if PSAD was <0.10 ng/ml/ml.

CONCLUSIONS

In this systematic review, we quantitatively evaluated the diagnosis performance of PSAD for CSPCa in combination with prostate MRI. It demonstrated a complementary performance and predictive value, especially among patients with negative MRI and PI-RADS 3 or Likert 3 lesions. Integration of PSAD into decision-making for prostate biopsy may facilitate improved risk-adjusted care.

PATIENT SUMMARY

Prostate-specific antigen density is a ready-to-use parameter in the era of increased magnetic resonance imaging (MRI) use in clinically significant prostate cancer (CSPCa) diagnosis. Findings suggest that the chance of having CSPCa was very low (4% or 6% for those with negative prebiopsy MRI or Prostate Imaging Reporting and Data System (Likert) score 3 lesion, respectively, if the PSAD was <0.10 ng/ml/ml), which may lower the need for biopsy in these patients.

Protocol for SNOTOB study: radical prostatectomy without prostate biopsy following 18F-PSMA-1007 PET/CT based on a diagnostic model: a single-centre, single-arm, open-label study

INTRODUCTION

Nowadays, invasive prostate biopsy is the standard diagnostic test for patients with suspected prostate cancer (PCa). However, it has some shortcomings such as perioperative complications, economic and psychological burden on patients, and some patients may undergo repeated prostate biopsy. In this study protocol, our aim is to provide a non-invasive diagnostic strategy we call the 'prostate-specific membrane antigen (PSMA) combined model' for the diagnosis of PCa. If patients are diagnosed with PCa using PSMA combined model, we want to prove these patients can receive radical prostatectomy directly without prior prostate biopsies.

METHODS

The SNOTOB trial adopts a prospective, single-centre, single-arm, open-label study design. The PSMA combined model consists of a diagnostic model based on what we previously reported and 18F-PSMA-1007 positron emission tomography/CT (18F-PSMA-1007 PET/CT) examinations in series. First, patients use the diagnostic model (online address: https://ustcprostatecancerprediction.shinyapps.io/dynnomapp/) to calculate the risk probability of clinically significant PCa (csPCa). When the risk probability of csPCa is equal or greater than 0.60, 18F-PSMA-1007 PET/CT will be applied for further diagnosis. If patients are still considered as csPCa after 18F-PSMA-1007 PET/CT examinations, we define this condition as positive results of PSMA combined model. Subsequently, we will recommend these patients to accept radical prostatectomy without prostate biopsy directly. Finally, the diagnostic performance of PSMA combined model will be verified with the pathological results. Totally, 57 patients need to be enrolled in this clinical trial.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee of The First Affiliated Hospital of USTC (No. 2022KY-142). The results of this study will be published in peer-reviewed journals and reported at academic conferences.

TRIAL REGISTRATION NUMBER

NCT05587192.

PI-RADS 3 score: A retrospective experience of clinically significant prostate cancer detection

Rationale and objectives

The study aims to propose an optimal workflow in patients with a PI-RADS 3 (PR-3) assessment category (AC) through determining the timing and type of pathology interrogation used for the detection of clinically significant prostate cancer (csPCa) in these men based upon a 5-year retrospective review in a large academic medical center.

Materials and methods

This United States Health Insurance Probability and Accountability Act (HIPAA)-compliant, institutional review board-approved retrospective study included men without prior csPCa diagnosis who received PR-3 AC on magnetic resonance (MR) imaging (MRI). Subsequent incidence and time to csPCa diagnosis and number/type of prostate interventions was recorded. Categorical data were compared using Fisher's exact test and continuous data using ANOVA omnibus F-test.

Results

Our cohort of 3238 men identified 332 who received PR-3 as their highest AC on MRI, 240 (72.3%) of whom had pathology follow-up within 5 years. csPCa was detected in 76/240 (32%) and non-csPCa in 109/240 (45%) within 9.0 ± 10.6 months. Using a non-targeted trans-rectal ultrasound biopsy as the initial approach (n = 55), another diagnostic procedure was required to diagnose csPCa in 42/55 (76.4%) of men, compared with 3/21(14.3%) men with an initial MR targeted-biopsy approach (n = 21); (p < 0.0001). Those with csPCa had higher median serum prostate-specific antigen (PSA) and PSA density, and lower median prostate volume (p < 0.003) compared with non-csPCa/no PCa.

Conclusion

Most patients with PR-3 AC underwent prostate pathology exams within 5 years, 32% of whom were found to have csPCa within 1 year of MRI, most often with a higher PSA density and a prior non-csPCa diagnosis. Addition of a targeted biopsy approach initially reduced the need for a second biopsy to reach a for csPCa diagnosis. Thus, a combination of systematic and targeted biopsy is advised in men with PR-3 and a co-existing abnormal PSA and PSA density.

Optimal PSA density threshold and predictive factors for the detection of clinically significant prostate cancer in patient with a PI-RADS 3 lesion on MRI

INTRODUCTION

While Prostate Imaging Reporting and Data System (PI-RADS) 4 and 5 lesions usually justify prostate biopsy (PBx), the management of a PI-RADS 3 lesion can be discussed. The aim of our study was to determine the optimal prostate-specific antigen density (PSAD) threshold and predictive factors of clinically significant prostate cancer (csPCa) in patients with a PI-RADS 3 lesion on MRI.

PATIENTS AND METHODS

Using our prospectively maintained database, we conducted a monocentric retrospective study, including all patients with a clinical suspicious of prostate cancer (PCa), all of them had a PI-RADS 3 lesion on the mpMRI prior to PBx. Patients under active surveillance or displaying suspicious digital rectal examination were excluded. Clinically significant (csPCa) was defined as PCa with any ISUP grade group ≥ 2 (Gleason ≥ 3 + 4).

RESULTS

We included 158 patients. The detection rate of csPCa was 22.2%. In case of PSAD ≤ 0.15 ng/ml/cm³, PBx would be omitted in 71.5% (113/158) of men at the cost of missing 15.0% (17/113) of csPCa. With a threshold of 0.15 ng/ml/cm³, the sensitivity and the specificity were 0.51 and 0.78 respectively. The positive predictive value was 0.40 and the negative predictive value was 0.85. According to multivariate analysis, age (OR = 1.10, CI95% 1.03-1.19, P = 0.007), and PSAD ≥ 0.15 ng/ml/cm³ (OR = 3.59, CI95% 1.41-9.47, P = 0.008) were independent predictive factors of csPCa. Previous negative PBx was negatively associated with csPCa (OR = 0.24, CI 95% 0.07-0.66, P = 0.01).

CONCLUSION

Our result suggests that the optimal PSAD threshold was 0.15 ng/ml/cm³. However, in this case omitting PBx in 71.5% of cases would be at the cost of missing 15.0% of csPCa. PSAD should not be used alone, other predictive factors as age and PBx history should also be considered in the discussion with the patient, to avoid PBx while missing few csPCa.

A Systematic Review of the Current Status of Magnetic Resonance-Ultrasound Images Fusion Software Platforms for Transperineal Prostate Biopsies

Given this new context, our objective is to recognize the suitability of the currently available software for image fusion and the reported series using the transperineal route, as well as to generate new evidence on the complementarity of the directed and systematic biopsies, which has been established through the transrectal approach.

EVIDENCE ACQUISITION

This systematic review, registered in Prospero (CRD42022375619), began with a bibliographic search that was carried out in PubMed, Cochrane, and Google Scholar databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and the studied eligibility based on the Participants, Intervention, Comparator, and Outcomes (PICO) strategy were followed. Warp analysis of selected studies was performed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. In addition, a Google search of all currently available fusion platforms was performed. Our Google search found 11 different commercially available robots to perform transperineal image fusion biopsies, of which 10 devices have published articles supporting their diagnostic effectiveness in transperineal prostate biopsies.

RESULTS

A total of 30 articles were selected and the characteristics and results of the biopsies of 11,313 patients were analyzed. The pooled mean age was 66.5 years (63-69). The mean pooled PSA level was 7.8 ng/mL (5.7-10.8). The mean pooled prostate volume was 45.4 cc. (34-56). The mean pooled PSA density was 0.17 (0.12-0.27). The overall cancer detection rate for all prostate cancers was 61.4%, while for csPCa it was 47.8%. PCa detection rate was more effective than that demonstrated in the systematic transrectal biopsy. However, the detection of csPCa in the systematic biopsy was only 9.5% in the reported series. To standardize our review, we grouped prostate cancer screening results according to the population studied and the software used. When the same populations were compared between elastic and rigid software, we found that rigid biopsies had a higher csPCa detection rate than biopsies with elastic fusion systems.

CONCLUSION

Platforms performing prostate biopsy using transperineal image fusion have better detection rates of csPCa than systematic transrectal biopsies. Rigid fusion systems have a better csPCa detection rate than elastic ones. We found no diagnostic differences between the different types of robotic systems currently available. The complementarity of systematic biopsy has also been demonstrated in transperineal imaging fusion biopsies.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

Value of machine learning-based transrectal multimodal ultrasound combined with PSA-related indicators in the diagnosis of clinically significant prostate cancer

Objective

To investigate the effect of transrectal multimodal ultrasound combined with serum prostate-specific antigen (PSA)-related indicators and machine learning for the diagnosis of clinically significant prostate cancer.

Methods

Based on Gleason score of postoperative pathological results, the subjects were divided into clinically significant prostate cancer groups(GS>6)and non-clinically significant prostate cancer groups(GS ≤ 6). The independent risk factors were obtained by univariate logistic analysis. Artificial neural network (ANN), logistic regression (LR), support vector machine (SVM), decision tree (DT), random forest (RF), and K-nearest neighbor (KNN) machine learning models were combined with clinically significant prostate cancer risk factors to establish the machine learning model, calculate the model evaluation indicators, construct the receiver operating characteristic curve (ROC), and calculate the area under the curve (AUC).

Results

Independent risk factor items (P< 0.05) were entered into the machine learning model. A comparison of the evaluation indicators of the model and the area under the ROC curve showed the ANN model to be best at predicting clinically significant prostate cancer, with a sensitivity of 80%, specificity of 88.6%, F1 score of 0.897, and the AUC was 0.855.

Conclusion

Establishing a machine learning model by rectal multimodal ultrasound and combining it with PSA-related indicators has definite application value in predicting clinically significant prostate cancer.

Prediction of Significant Prostate Cancer in Equivocal Magnetic Resonance Imaging Lesions: A High-volume International Multicenter Study

BACKGROUND

Decision of performing prostate biopsy in men with Prostate Imaging Reporting and Data System (PI-RADS) 3 findings in prostate magnetic resonance imaging (MRI) is challenging as they have a low but still relevant risk of harboring significant prostate cancer (sPC).

OBJECTIVE

To identify clinical predictors of sPC in men with PI-RADS 3 lesions in prostate MRI and to analyze the hypothetical effect of incorporating prostate-specific antigen density (PSAD) into biopsy decision.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed a retrospective multinational cohort from ten academic centers comprising 1476 men who underwent a combined prostate biopsy (MRI targeted plus systematic biopsy) between February 2012 and April 2021 due to a PI-RADS 3 lesion in prostate MRI.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the detection of sPC (ISUP ≥2) in a combined biopsy. Predictors were identified by a regression analysis. Descriptive statistics were applied to evaluate the hypothetical effect of involving PSAD into biopsy decision.

RESULTS AND LIMITATIONS

Of all patients, 273/1476 (18.5%) were diagnosed with sPC. MRI-targeted biopsy diagnosed fewer sPC cases than combined strategy: 183/1476 (12.4%) versus 273/1476 (18.5%), p < 0.01. Age (odds ratio [OR] 1.10 [95% confidence interval {CI}: 1.05-1.15], p < 0.001), prior negative biopsy (OR 0.46 [0.24-0.89], p = 0.022), and PSAD (p < 0.001) were found to be independent predictors of sPC. Applying a PSAD cutoff of 0.15, 817/1398 (58.4%) biopsies would have been avoided at the cost of missing sPC in 91 (6.5%) men. Limitations were the retrospective design, heterogeneity of the study cohort due to the long inclusion period, and no central revision of MRI.

CONCLUSIONS

Age, previous biopsy status, and PSAD were found to be independent predictors of sPC in men with equivocal prostate MRI. Implementation of PSAD into biopsy decision can avoid unnecessary biopsies. Clinical parameters such as PSAD need validation in a prospective setting.

PATIENT SUMMARY

In this study, we looked for clinical predictors of significant prostate cancer in men with Prostate Imaging Reporting and Data System 3 lesions in prostate magnetic resonance imaging. We identified age, previous biopsy status, and especially prostate-specific antigen density as independent predictors.

Performance of multiparametric prostate magnetic resonance imaging validated by targeted and systematic transperineal biopsies

Objective

To measure the performance of multiparametric (mp) magnetic resonance imaging (MRI) to identify intraprostatic tumour deposits using a systematic and targeted MR-guided transperineal prostate biopsy technique.

Materials and Methods

Patients underwent a combined systematic and targeted MR-guided transperineal biopsy procedure in the dorsal lithotomy position under general anaesthesia. Systematic biopsies were spaced 10 mm or less apart and additional biopsies targeted any Prostate Imaging-Reporting and Data System (PI-RADS) 3, 4 or 5 lesions identified on mpMRI. Cancer detection rates were calculated on a per patient and per lesion basis.

Results

A total of 125 patients underwent the biopsy procedure. The positive predictive value (PPV) of mpMRI per patient was 59% for any cancer and 49% for Gleason score (GS) ≥ 7 cancer. The negative predictive value (NPV) of mpMRI per patient was 67% for any cancer and 88% for GS ≥ 7 cancer. On a per lesion basis, the PPV of PI-RADS 3 lesions for any and GS ≥ 7 cancer was 24% and 10%. For PI-RADS 4 lesions it was 42% and 32%. For PI-RADS 5 lesions, it was 76% and 70%. MpMRI failed to identify GS ≥ 7 cancer found on systematic biopsy in 22% of patients.

Conclusion

Based on a combination of systematic and targeted transperineal prostate biopsies, mpMRI showed a high NPV and low PPV for GS ≥ 7 cancer on a per patient basis. The PPV of mpMRI on a per lesion basis increased with increasing PI-RADS score. However, there were a significant number of both false positive as well as false negative (mpMRI invisible) areas within the prostate that contained GS ≥ 7 cancer. Therefore, pathologic confirmation using both targeted and systematic mapping biopsy is necessary to accurately identify all intraprostatic tumour deposits.

Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway

Multiparametric MRI of the prostate is now recommended as the initial diagnostic test for men presenting with suspected prostate cancer, with a negative MRI enabling safe avoidance of biopsy and a positive result enabling MRI-directed sampling of lesions. The diagnostic pathway consists of several steps, from initial patient presentation and preparation to performing and interpreting MRI, communicating the imaging findings, outlining the prostate and intra-prostatic target lesions, performing the biopsy and assessing the cores. Each component of this pathway requires experienced clinicians, optimized equipment, good inter-disciplinary communication between specialists, and standardized workflows in order to achieve the expected outcomes. Assessment of quality and mitigation measures are essential for the success of the MRI-directed prostate cancer diagnostic pathway. Quality assurance processes including Prostate Imaging-Reporting and Data System, template biopsy, and pathology guidelines help to minimize variation and ensure optimization of the diagnostic pathway. Quality control systems including the Prostate Imaging Quality scoring system, patient-level outcomes (such as Prostate Imaging-Reporting and Data System MRI score assignment and cancer detection rates), multidisciplinary meeting review and audits might also be used to provide consistency of outcomes and ensure that all the benefits of the MRI-directed pathway are achieved.

Radiomics in PI-RADS 3 Multiparametric MRI for Prostate Cancer Identification: Literature Models Re-Implementation and Proposal of a Clinical-Radiological Model

PI-RADS 3 prostate lesions clinical management is still debated, with high variability among different centers. Identifying clinically significant tumors among PI-RADS 3 is crucial. Radiomics applied to multiparametric MR (mpMR) seems promising. Nevertheless, reproducibility assessment by external validation is required. We retrospectively included all patients with at least one PI-RADS 3 lesion (PI-RADS v2.1) detected on a 3T prostate MRI scan at our Institution (June 2016-March 2021). An MRI-targeted biopsy was used as ground truth. We assessed reproducible mpMRI radiomic features found in the literature. Then, we proposed a new model combining PSA density and two radiomic features (texture regularity (T2) and size zone heterogeneity (ADC)). All models were trained/assessed through 100-repetitions 5-fold cross-validation. Eighty patients were included (26 with GS ≥ 7). In total, 9/20 T2 features (Hector's model) and 1 T2 feature (Jin's model) significantly correlated to biopsy on our dataset. PSA density alone predicted clinically significant tumors (sensitivity: 66%; specificity: 71%). Our model obtained a sensitivity of 80% and a specificity of 76%. Standard-compliant works with detailed methodologies achieve comparable radiomic feature sets. Therefore, efforts to facilitate reproducibility are needed, while complex models and imaging protocols seem not, since our model combining PSA density and two radiomic features from routinely performed sequences appeared to differentiate clinically significant cancers.

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

To evaluate if follow-up mpMRI scans of patients in PI-RADS category 3 are safe enough to omit or delay prostate biopsy in the future and to determine an optimal control interval. This retrospective single center study includes consecutive PI-RADS category 3 patients with one or more follow-up mpMRI (T2WI, DWI, DCE) and subsequent MRI-targeted and systematic TRUS-guided biopsy between 2012 and 2018. Primary study objective was the verification of a significant PI-RADS category upgrade in follow-up mpMRI in patients with subsequent PCA positive biopsy versus patients with negative biopsy. Further objectives were development of the PI-RADS category and clinical parameters between initial and follow-up mpMRI in the context of histopathologic results and time interval. Eighty-nine patients (median PSA 6.6 ng/ml; PSAD 0.13 ng/ml/ml) were finally included (follow-up period 31 ± 18 months). 19 cases had PCA (median PSA 7.8 ng/ml; PSAD 0.14 ng/ml/ml). 4 cases had csPCA (median PSA 5.4 ng/ml; PSAD 0.13 ng/ml/ml) for which there was a significant PI-RADS upgrade after 12-24 months (mean 3.75; p = 0.01) compared to patients without PCA (mean 2.74). Without PCA the mean PI-RADS category decreased after 25-36 months (mean 2.74; p = 0.02). Clinical parameters did not change significantly except a PSAD increase for PCA patients after 24 months. Patients within PI-RADS category 3 may not need prompt biopsy since those with PCA reliably demonstrate a PI-RADS category upgrade in follow-up mpMRI after 12-24 months. PI-RADS 3 patients with negative biopsy do not benefit from follow-up mpMRI earlier than 24 months.

A clinical available decision support scheme for optimizing prostate biopsy based on mpMRI

BACKGROUND

Combined MRI/Ultrasound fusion targeted biopsy (TBx) and systematic biopsy (SBx) results in better prostate cancer (PCa) detection relative to either TBx or SBx alone, while at the cost of higher number of biopsy cores and greater detection of clinically insignificant PCa. We therefore developed and evaluated a simple decision support scheme for optimizing prostate biopsy based on multiparametric (mp) MRI assessment.

METHODS

Total 229 patients with suspicion of PCa underwent mpMRI before combined TBx/SBx were retrospectively included. Impacts of MRI characteristics such as Prostate Imaging-Reporting and Data System (PI-RADS) score, lesion size, zonal origination, and location on biopsy performance were evaluated. A clinically available decision support scheme relying on mpMRI assessment was subsequently developed as a triage test to optimize prostate biopsy process. Cost (downgrade, upgrade, and biopsy core)-to-Effectiveness (detection rate) was systemically compared.

RESULTS

TBx achieved comparable detection rate to combined TBx/SBx in diagnosis of PCa and clinically significant PCa (csPCa) (PCa, 59% [135/229] vs 60.7% [139/229]; csPCa, 45.9% [105/229] vs 47.2% [108/229]; p-values > 0.05) and outperformed SBx (PCa, 42.4% [97/229]; csPCa, 28.4% [65/229]; p-values < 0.001). Specially, in personalized decision support scheme, TBx accurately detected all PCa (72.5% [74/102]) in PI-RADS 5 and larger (≥1 cm) PI-RADS 3-4 observations, adding SBx to TBx only resulted in 1.4% (1/74) upgrading csPCa. For smaller (<1 cm) PI-RADS 3-4 lesions, combined TBx/SBx resulted in relatively higher detection rate (51.2% [65/127] vs 48.0% [61/127]) and lower upgrading rate (30.6% [15/49] vs 36.7% [18/49]) than TBx.

CONCLUSIONS

The benefit of SBx added to TBx was largely restricted to smaller PI-RADS score 3-4 lesions. Using our personalized strategy of solo TBx for PI-RADS 5 and larger (≥1 cm) PI-RADS score 3-4 lesions would avoid excess SBx in 44.5% (102/229) of all biopsy-naïve patients without compromising detection rate.

Optimal biopsy approach for detection of clinically significant prostate cancer

Prostate cancer (PCa) diagnostic and therapeutic work-up has evolved significantly in the last decade, with pre-biopsy multiparametric MRI now widely endorsed within international guidelines. There is potential to move away from the widespread use of systematic biopsy cores and towards an individualised risk-stratified approach. However, the evidence on the optimal biopsy approach remains heterogeneous, and the aim of this review is to highlight the most relevant features following a critical assessment of the literature. The commonest biopsy approaches are via the transperineal (TP) or transrectal (TR) routes. The former is considered more advantageous due to its negligible risk of post-procedural sepsis and reduced need for antimicrobial prophylaxis; the more recent development of local anaesthetic (LA) methods now makes this approach feasible in the clinic. Beyond this, several techniques are available, including cognitive registration, MRI-Ultrasound fusion imaging and direct MRI in-bore guided biopsy. Evidence shows that performing targeted biopsies reduces the number of cores required and can achieve acceptable rates of detection whilst helping to minimise complications and reducing pathologist workloads and costs to health-care facilities. Pre-biopsy MRI has revolutionised the diagnostic pathway for PCa, and optimising the biopsy process is now a focus. Combining MR imaging, TP biopsy and a more widespread use of LA in an outpatient setting seems a reasonable solution to balance health-care costs and benefits, however, local choices are likely to depend on the expertise and experience of clinicians and on the technology available.

Evidence-based guideline recommendations on multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer: A Cancer Care Ontario updated clinical practice guideline

INTRODUCTION

This clinical practice guideline is based on a systematic review to assess the use of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis of clinically significant prostate cancer (csPCa) for biopsy-naive men and men with a prior negative transrectal ultrasound-guided systematic biopsy (TRUS-SB) at elevated risk.

METHODS

The methods of the clinical practice guideline included searches to September of 2020 of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Internal and external reviews were conducted.

RESULTS

The recommendations are:Recommendation 1: For biopsy-naive patients at elevated risk of csPCa, mpMRI is recommended prior to biopsy in patients who are candidates for curative management with suspected clinically localized prostate cancer.- If the mpMRI is positive, mpMRI-targeted biopsy (TB) and TRUS-SB should be performed together to maximize detection of csPCa.- If the mpMRI is negative, consider forgoing any biopsy after discussion of the risks and benefits with the patient as part of shared decision-making and ongoing followup.Recommendation 2: In patients who had a prior negative TRUS-SB and demonstrate a high risk of having csPCa in whom curative management is being considered:- mpMRI should be performed.- If the mpMRI is positive, targeted biopsy should be performed. Concomitant TRUS-SB can be considered depending on the patient's risk profile and time since prior TRUS-SB biopsy.- If the mpMRI is negative, consider forgoing a TRUS-SB only after discussion of the risks and benefits with the patient as part of shared decision-making and ongoing followup.Recommendation 3: mpMRI should be performed and interpreted in compliance with the current Prostate Imaging Reporting & Data System (PI-RADS) guidelines.

Prostate cancer detection rate in men undergoing transperineal template-guided saturation and targeted prostate biopsy

OBJECTIVES

To compare prostate cancer (PCa) detection rate of transperineal template-guided saturation prostate biopsy (SBx) and multiparametric magnetic resonance imaging (mpMRI)/transrectal ultrasound fusion guided targeted biopsy (TBx). MATERIALS AND METHODS: We prospectively enrolled 392 men who underwent SBx and TBx in case of suspicious lesions from November 2016 to October 2019. Triggers for a biopsy were an elevated prostate-specific antigen (PSA) and/or positive digital rectal examination and only treatment naïve patients without a previous diagnosis of PCa were included. Study inclusion occurred before biopsy and a prebiopsy mpMRI was available in all men. SBx were taken from 20 different locations according to the modified Barzell zones. The primary endpoint was the detection rate of clinically significant PCa (csPCa) and insignificant PCa (ciPCa) by SBx and/or TBx by comparing the two methods alone and in combination. Additional TBx were taken for any prostate imaging-reporting and data system (PI-RADS) lesion ≥3 seen on the mpMRI. csPCa was defined as any Gleason score ≥7 and ciPCa as Gleason score 6.

RESULTS

A total of 392 men with a median age of 64 years (interquartile range [IQR]: 58-69), a median PSA of 7.0 ng/ml (IQR: 4.8-10.1) were enrolled. Overall, PCa was found in 200 (51%) of all biopsied men, with 158 (79%) being csPCa and 42 (21%) ciPCa. A total of 268 (68%) men with a suspicious mpMRI and underwent a combined TBx and SBx, of whom csPCa was found in 139 (52%). In this subgroup, 116/139 (83%) csPCa would have been detected by TBx alone, and an additional 23 (17%) were found by SBx. Men with a negative mpMRI (PI-RADS < 3, n = 124, 32%) were found to have csPCa in 19 (15%) cases. In patients with a negative mpMRI in combination with a PSA density <0.1 ng/ml² , only 8% (3/36) had csPCa. If only TBx would have been performed and all men with a negative mpMRI would not have been biopsed, 42/158 (27%) of csPCa would have been missed, and 38/42 (90%) ciPCa would have not been detected. On multivariable analysis, significant predictors of csPCa were increasing PSA (odds ratio, OR: 1.07 [95% confidence interval, CI: 1.03-1.11]), increasing age (OR: 1.07 [95% CI: 1.03-1.11]), PI-RADS score ≥ 3 (OR: 6.49 [95% CI: 3.55-11.89]), and smaller prostate volume (OR: 0.96 [95% CI: 0.95 -0.97] (p < 0.05 for all parameters).

CONCLUSION

In comparison to SBx, TBx alone detects csPCa in only ¾ of all men with a positive mpMRI lesion. Thus, systematic biopsies in addition to TBx have to be considered at least in some who undergo a prostate biopsy. In men with a negative mpMRI, SBx still detects 15% csPCa, but similarly overdetecting ciPCa. According to our results, low PSA density and negative mpMRI findings could be used to decide which men can safely avoid biopsy.

THE ROLE OF THE APPARENT DIFFUSION COEFFICIENT OF THE BIPARAMETRIC MRI AS AN IMAGING MARKER OF PROSTATE CANCER

Prostate cancer (PCa) is the most common malignancy in men. The role of the apparent diffusion coefficient (ADC)of biparametric MRI (biMRI) which is a study without the use of dynamic contrast enhancement (DCE), in detectionof PCa is still not comprehensively investigated.

OBJECTIVE

The goal of the study was to assess the role of ADC of biMRI as an imaging marker of clinically significant PCaMaterials and methods. The study involved 78 men suspected of having PCa. All patients underwent a comprehensive clinical examination, which included multiparametric MRI of the prostate, a component of which was biMRI. TheMRI data was evaluated according to the PIRADS system version 2.1.

RESULTS

The distribution of patients according to the PIRADS system was as follows: 1 point - 9 (11.54 %)patients, 2 points - 12 (15.38 %) patients, 3 points - 25 (32.05 %) patients, 4 points - 19 (24.36 %) patients and5 points - 13 (16.67 %) patients. In a subgroup of patients with 5 points, clinically significant PCa was detected in 100 % of cases. In the subgroup of patients with tumors of 4 points clinically significant PCa was diagnosed in 16of 19 (84.21 %) cases, and in 3 (15.79 %) patients - clinically insignificant tumor. In the subgroup of patients with3 points, clinically significant PCa was diagnosed in 11 of 25 (44.0 %) cases, in 8 (32.0 %) patients - clinicallyinsignificant tumor and in 6 (24.0 %) patients - benign prostatic hyperplasia. PCa with a score of 7 on the Gleasonscale showed significantly lower mean values of ADC of the diffusion weighted MRI images compared to tumors witha score of < 7 on the Gleason scale: (0.86 ± 0.07) x 103 mm2/s vs (1.08 ± 0.04) x 103 mm2/s (р < 0.05).

CONCLUSIONS

The obtained results testify to the high informativeness of biMRI in the diagnosis of prostate cancer.The use of ADC allowed to differentiate clinically significant and insignificant variants of the tumor, as well asbenign changes in prostate tissues and can be considered as a potential imaging marker of PCa.

Utility of multiple core biopsies during transperineal template-guided mapping biopsy for patients with large prostates and PI-RADS 1–2 on multiparametric magnetic resonance imaging

Background

We investigated the necessity of multiple core biopsies when performing transperineal template-guided mapping biopsy (TTMB) for patients with large prostates and no suspicious lesions on multiparametric magnetic resonance imaging (mpMRI).

Materials and methods

We retrospectively analyzed 304 patients on active surveillance (AS), 212 patients with previously negative transrectal ultrasound-guided biopsy (TRUS-Bx) and 67 biopsy naïve patients who underwent TTMB between May 2017 and December 2020. The number of core biopsies and acute urinary retention (AUR) rates were analyzed in relation to the prostate volume (PV). Cancer detection rate according to the prostate volume and Prostate Imaging-Reporting and Data System (PI-RADS) scores were compared using the Pearson Chi-square test.

Results

AUR occurred more frequently in patients with PV over 39 cc (5.5% vs. 24.4%, P < 0.001). In addition, incidence of AUR was more in patients with PV over 39 cc and PI-RADS score of 1–2 on mpMRI (3.7% vs. 22.2%, P < 0.001). There was no significant difference in the detection rates of any prostate cancer or clinically significant prostate cancer (csPCA) between the patients on AS with PV < 39 cc and PV ≥ 39 cc and PI-RADS score 1–2 (57.4% vs. 50%, P = 0.507; 17% vs. 8.8%, P = 0.412, respectively). Additionally, no significant difference was found in the detection rates of any prostate cancer or csPCA between the patients with PV < 39 cc and PV ≥ 39 cc and PI-RADS score 1–2 who either had a previously negative TRUS-Bx or were biopsy naïve (27.9% vs. 16.2%, P = 0.101, 8.2% vs. 4.1%, P = 0.31, respectively).

Conclusion

Increasing the number of core biopsies of prostates measuring ≥39 cc with PI-RADS 1–2 on mpMRI does not significantly increase the detection rates of any prostate cancer or csPCA.

Multiparametric Magnetic Resonance Imaging in the Diagnosis of Clinically Significant Prostate Cancer: an Updated Systematic Review

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.

Magnetic resonance imaging /ultrasonography fusion transperineal prostate biopsy for prostate cancer: Initial experience at a Middle Eastern tertiary medical centre

Objective: To report on the outcomes of magnetic resonance imaging (MRI)/ultrasonography (US)-fusion transperineal prostate (TP) biopsy at a tertiary medical centre in the Middle East including detection rate of clinically significant prostate cancer (csPCa), complications, and tolerability of the procedure. Patients and methods: Between May 2019 and June 2020, 98 MRI/US-fusion TP biopsies were performed in the US suite using light sedation. All patients had pre-biopsy 3-T multiparametric MRI. Data on patient characteristics, PCa detection rate and complication rates were collected retrospectively. A Gleason score ≥3 + 4 was defined as csPCa.

RESULTS

There were 98 patients, with a mean (SD) age of 65 (9.1) years, and a median (SD) prostate-specific antigen level prior to biopsy of 7.53 (12.97) ng/mL and prostate volume of 51 (31.1) mL. PCa was detected in 54 (55%) patients, with csPCa detected in 43 (44%). A total of 124 Prostate Imaging-Reporting and Data System (PI-RADS) 3-5 lesions were targeted. Grade Group ≥2 PCa was found in 35.5% of the targeted lesions. Random biopsies detected one csPCa Gleason score 3 + 4 in one patient with a negative target. None of the patients had post-biopsy haematuria or retention. Only one patient developed acute prostatitis requiring in-patient intravenous antibiotics.

CONCLUSIONS

MRI/US-fusion TP biopsy has an adequate detection rate of csPCa with minimal complications and low infection rates after biopsy. This is one of the first TP biopsy series in the Middle East paving the way for wider adoption in the region.

ABBREVIATIONS

AS: active surveillance; AUR: acute urinary retention; GG: Grade Group; IQR: interquartile range; mpMRI: multiparametric MRI; (cs)PCa: (clinically significant) prostate cancer; PI-RADS: Prostate Imaging-Reporting and Data System; TP: transperineal; US: ultrasonography; TRUS: transrectal Ultrasound guided.

Diagnostic efficacy and safety of transperineal prostate targeted and systematic biopsy: The preliminary experience of first 100 cases

BACKGROUND

Post-biopsy urosepsis is a major concern for patient morbidity and cost. Trasperineal biopsy is reported to have less complications and higher detection rate of clinically significant prostate cancer (csPCa).

OBJECTIVES

To determine the diagnostic efficacy and safety of transperineal prostate biopsy in patients with elevated prostatic specific antigen (PSA).

MATERIAL AND METHODS

A prospective study included men with elevated PSA > 3 ng/ml and previous negative biopsy from January 2018 to April 2019. All patients had multiparametric magnetic resonance imaging (mpMRI) and suspicious lesions reported as Prostate Imaging Reporting and Data System (PIRADS) score version 2. Average twelve systematic and two targeted cores were biopsied under general anaesthesia. Patients received single dose of antibiotic prebiopsy.

RESULTS

100 Consecutive patients having median age 64.0 years and median PSA of 6.1ng/ml were included for mpMRI-US fusion transperineal biopsies. Cancer detection rate was 45% (targeted 38% and systematic 22%) and csPCa were detected in 75.55% (targeted 86.84% and systematic 59.09%). MRI-US fusion targeted biopsies detected 63.88% csPCa in PIRADS 5, 33.33% in PIRADS 4 and 5.88% in PIRADS 3 lesions. PSA > 10 (p = 0.012), PSA density > 0.15 (p = 0.0002), and PIRADS 5 (0.0001) were significantly associated with PCa. Factors like Age (0.0001), initial PSA (0.022) and PSA density (0.006) were significant on univariate analysis while age (0.0001) was significant on multivariate analysis. There was no case of urinary tract infection.

CONCLUSIONS

Transperineal prostate biopsy is safe and effective in diagnosing csPCa. There is no risk of sepsis and major complications.

Micro-Ultrasound: a way to bring imaging for prostate cancer back to urology

Only a decade ago, there were insufficient imaging options for the detection and local staging of prostate cancer. However, the introduction of multiparametric magnetic resonance imaging (mpMRI) has advanced a much-needed tool for this scope of application. The possibilities and limitations of mpMRI have been well studied. Imaging must be acquired and evaluated using a standardized protocol (the latest version of Prostate Imaging-Reporting and Data System). Sensitivity has been shown to increase with higher grades and larger tumors, and while the detection rate on a per patient basis is relatively high, the per-lesion detection rate is far inferior. Various specialists have attempted to elevate the use of transrectal ultrasound, a tool frequently used by all urologists. Encouragement for this idea comes from a recently introduced system of high frequency transrectal ultrasound. The level of evidence supporting its use in the detection and staging of prostate cancer is not comparable with mpMRI yet, but initial prospective studies indicate good potential. The sensitivity of micro-ultrasound and mpMRI for clinically significant prostate cancer ranges from 94% to 100% and from 88% to 90%, respectively. Further areas of application, such as local staging for prostate and bladder cancer, are currently being evaluated. In summary, microultrasound presents a promising technology for further improving urological imaging and allows for the possibility of returning prostate cancer imaging to urologists. This review will summarize the current scientific basis for the use of micro-ultrasound in the detection of prostate cancer.

Evaluation of the Ginsburg Scheme: Where Is Significant Prostate Cancer Missed?

Simple Summary

Systematic biopsy according to the Ginsburg scheme is widely used to complement MRI-targeted biopsy for the diagnosis of prostate cancer. This is the first study to evaluate the distribution of cancerous lesions that were missed by the Ginsburg scheme. We found that significant prostate cancer lesions were missed in 3.6% of patients. The majority of the missed lesions (17/39, 43.6%) were localized within the anterior region of the prostate. Complementing the Ginsburg scheme by adding biopsy cores to this region may be considered in certain patients who were extensively pre-biopsied without a conclusive diagnosis or when targeted biopsy was not possible. Moreover, based on Ginsburg scheme sectors and newly defined blind sectors, we developed a new sector map of the prostate that can be applied to focal therapy planning and for the follow-up management of patients under active surveillance.

Abstract

Background: Systematic biopsy (SB) according to the Ginsburg scheme (GBS) is widely used to complement MRI-targeted biopsy (MR-TB) for optimizing the diagnosis of clinically significant prostate cancer (sPCa). Knowledge of the GBS’s blind sectors where sPCa is missed is crucial to improve biopsy strategies. Methods: We analyzed cancer detection rates in 1084 patients that underwent MR-TB and SB. Cancerous lesions that were missed or underestimated by GBS were re-localized onto a prostate map encompassing Ginsburg sectors and blind-sectors (anterior, central, basodorsal and basoventral). Logistic regression analysis (LRA) and prostatic configuration analysis were applied to identify predictors for missing sPCa with the GBS. Results: GBS missed sPCa in 39 patients (39/1084, 3.6%). In 27 cases (27/39, 69.2%), sPCa was missed within a blind sector, with 17/39 lesions localized in the anterior region (43.6%). Neither LRA nor prostatic configuration analysis identified predictors for missing sPCa with the GBS. Conclusions: This is the first study to analyze the distribution of sPCa missed by the GBS. GBS misses sPCa in few men only, with the majority localized in the anterior region. Adding blind sectors to GBS defined a new sector map of the prostate suited for reporting histopathological biopsy results.

Detection limits of significant prostate cancer using multiparametric MR and digital rectal examination in men with low serum PSA: Up-date of the Italian Society of Integrated Diagnostic in Urology

Reasons why significant prostate cancer is still missed in early stage were investigated at the 22nd National SIEUN (Italian Society of integrated diagnostic in Urology, Andrology, Nephrology) congress took place from 30th November to 1st December 2020, in virtual modality. Even if multiparametric magnetic resonance (MR) has been introduced in the clinical practice several, limitations are emerging in patient with regular digital rectal examination (DRE) and serum prostate specific antigen (PSA) levels approaching the normal limits. The present paper summarizes highlights observed in those cases where significant prostate cancer may be missed by PSA or imaging and DRE. The issue of multidisciplinary interest had been subdivided and deepened under four main topics: biochemical, clinical, pathological and radiological point of view with a focus on PI-RADS 3 lesions.

The Prostate Health Index aids multi-parametric MRI in diagnosing significant prostate cancer

To evaluate the performance of the Prostate Health Index (PHI) in magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion prostate biopsy for the detection of clinically significant prostate cancer (csPCa). We prospectively enrolled 164 patients with at least one Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) ≥ 3 lesions who underwent MRI-TRUS fusion prostate biopsy. Of the PSA-derived biomarkers, the PHI had the best performance in predicting csPCa (AUC 0.792, CI 0.707–0.877) in patients with PI-RADS 4/5 lesions. Furthermore, the predictive power of PHI was even higher in the patients with PI-RADS 3 lesions (AUC 0.884, CI 0.792–0.976). To minimize missing csPCa, we used a PHI cutoff of 27 and 7.4% of patients with PI-RADS 4/5 lesions could have avoided a biopsy. At this level, 2.0% of cases with csPCa would have been missed, with sensitivity and NPV rates of 98.0% and 87.5%, respectively. However, the subgroup of PI-RADS 3 was too small to define the optimal PHI cutoff. PHI was the best PSA-derived biomarker to predict csPCa in MRI-TRUS fusion prostate biopsies in men with PI-RADS ≥ 3 lesions, especially for the patients with PI-RADS 3 lesions who gained the most value.

The Value of Prostate-specific Antigen Density for Prostate Imaging-Reporting and Data System 3 Lesions on Multiparametric Magnetic Resonance Imaging: A Strategy to Avoid Unnecessary Prostate Biopsies

BACKGROUND

Multiparametric magnetic resonance imaging (mpMRI) has excellent sensitivity in detecting significant prostate cancer (sPC). Nevertheless, uncertainty exists regarding the management of Prostate Imaging-Reporting and Data System (PI-RADS) 3 lesions.

OBJECTIVE

To investigate whether PI-RADS 3 lesions in combination with clinical parameters, especially prostate-specific antigen density (PSAD), can be used to exclude sPC.

DESIGN, SETTING, AND PARTICIPANTS

A total of 455 consecutive biopsy-naïve men underwent MRI-guided transperineal prostate fusion biopsy at our department between 2017 and 2018. We identified 101 patients who had exclusively one or more PI-RADS 3 lesions on mpMRI. sPC was defined as intermediate- and high-risk PC (according to the D'Amico risk classification).

OUTCOME MEASURES AND STATISTICAL ANALYSIS

Univariate logistic regression analysis was performed to test different clinical factors as predictors of sPC in men with PI-RADS 3 lesions. The probability of sPC prediction was calculated for different PSAD thresholds.

RESULTS AND LIMITATIONS

Among patients with PI-RADS 3 lesions, PSAD was a significant predictor of sPC (p = 0.005). For a PI-RADS score of 3 the probability of excluding sPC was 85% (86/101), which increased to 98% (42/43) when combined with PSAD <0.1 ng/ml/ml.

CONCLUSIONS

Inclusion of PSAD < 0.1 ng/ml/ml in the strategy for biopsy-naïve patients with equivocal mpMRI findings would allow a reduction in prostate biopsies in 43% (43/101) of cases at the cost of missing a very small number (2%, 1/43) of intermediate-risk PCs.

PATIENT SUMMARY

At high-volume tertiary care centers with significant experience in prostate multiparametric magnetic resonance imaging, immediate biopsies could be safely omitted for men with lesions with a Prostate Imaging-Reporting and Data System score of 3 and prostate-specific antigen density of PSAD < 0.1 ng/ml/ml. Any decision to omit an immediate biopsy should be associated with close monitoring.

Assessment of magnetic resonance imaging (MRI)-fusion prostate biopsy with concurrent standard systematic ultrasound-guided biopsy among men requiring repeat biopsy

INTRODUCTION

The role of magnetic resonance imaging (MRI)-fusion biopsy (FB) remains unclear in men with prior negative prostate biopsies. This study aimed to compare the diagnostic accuracy of FB with concurrent systematic biopsy (SB) in patients requiring repeat prostate biopsies.

METHODS

Patients with previous negative prostate biopsies requiring repeat biopsies were included. Those without suspicious lesions (≥Prostate Imaging-Reporting and Data System [PI-RADS] 3) on MRI were excluded. All patients underwent FB followed by SB. The primary outcome was the sensitivity for clinically significant prostate cancer (Gleason score ≥7). The secondary objective was identification of potential predictive factors of biopsy performance.

RESULTS

A total of 53 patients were included; 41 (77%) patients were found to have clinically significant prostate cancer. FB had a higher detection rate of significant cancer compared to SB (85% vs. 76%, respectively, p=0.20) and lower diagnosis of indolent (Gleason score 3+3=6) cancer (10% vs. 27%, respectively, p=0.05). FB alone missed six (15%) clinically significant cancers, compared to 10 (24%) with SB. SB performance was significantly impaired in patients with anterior lesions and high prostate volumes (p<0.05). There was high degree of pathological discordance between the two approaches, with concordance seen in only 34% of patients.

CONCLUSIONS

In patients with prior negative biopsies and ongoing suspicion for prostate cancer, a combined approach of FB with SB is needed for optimal detection and risk classification of clinically significant disease. Anterior tumors and large prostates were significant predictors of poor SB performance and an MRI-fusion alone approach in these settings could be considered.

Reasons for missing clinically significant prostate cancer by targeted magnetic resonance imaging/ultrasound fusion-guided biopsy

OBJECTIVES

This study evaluates cases with clinically significant prostate cancer (csPCa) missed by targeted biopsy (TB) and analyzes the diagnostic impact of an additional systematic biopsy (SB) in a large patient collective.

METHODS

Consecutive patients with a 3 T multiparametric prostate MRI (mpMRI) and a subsequent MRI/US fusion-guided TB plus 12-core US-guided SB from 01/2014 to 04/2019 were included in this study. Primary study endpoint was the analysis of cases with a csPCa missed by TB and detected by SB. Secondary study objectives were the PCa detection and the correlation with clinical and MRI parameters.

RESULTS

In total 785 patients met the inclusion criteria. 342 patients had a csPCa (median PSAD 0.29 ng/mL/cm³). In 42 patients (13 %), a csPCa was detected only by SB. In 36 of these cases, the localization of the positive SB cores matched with the cancer suspicious region described on mpMRI (mCSR). Cases with a csPCA missed by TB showed either an insufficient MRI segmentation (prostate boundary correlation) (31 %) and/or insufficient lesion registration (lesion transfer, tracking, and/or matching) (48 %), a missed small lesion (14 %), or a failed center of a large lesion (10 %). Median PSAD of patients with non-significant PCa detected by SB was 0.15 ng/mL/cm³.

CONCLUSIONS

Main reasons for missing a csPCa by TB were insufficient prostate segmentation or imprecise lesion registration within MRI/US fusion-guided biopsy. Consequently, verification of MRI quality, exact mCSR assessment, and advanced biopsy experience may improve accuracy. Altogether, an additional SB adds limited clinical benefit in men with PSAD ≤ 0.15 ng/mL/cm³.

Predictors of erectile dysfunction after transperineal template prostate biopsy

Purpose

To investigate the incidence and possible contributing factors of erectile dysfunction (ED) after transperineal template prostate biopsy (TTPB).

Materials and Methods

Males undergoing TTPB were prospectively administered a Sexual Health Inventory for Men (SHIM) questionnaire before biopsy and one month after. SHIM questionnaires were repeated at 3- and 9-months for males not receiving interventional treatment. Sexually inactive males were excluded. Interval change in SHIM categories based upon baseline characteristics were evaluated. Multivariable logistic regression models were used to evaluate predictors of change in SHIM score category.

Results

A total of 576 males were included in our sample. Of these, 450 (78%) males underwent their first biopsy. A decline in SHIM category within the immediate 4-weeks post-biopsy was reported by 167 males (31% of total eligible sample). Age was the strongest predictor of decline in SHIM category, the predicted probability of a decline in SHIM at age 50 was 10% (95% confidence interval [CI], 1%–19%), 32% at age 60 (95% CI, 25%–40%) and 36% at age 70 (95% CI, 29%–44%). For new onset ED, the predicted probability of ED within 4-weeks post-TTPB were 6.7% at age 50 (95% CI, 0%–15%), 26% at age 60 (95% CI, 17%–34%) and 31% at age 70 (95% CI, 21%–40%).

Conclusions

Older age at biopsy is an independent predictor of immediate ED after TTPB in sexually active males. This association was observed in the subgroup with no pre-existing ED. These findings provide useful information when counselling males undergoing TTPB.

Equivocal PI-RADS Three Lesions on Prostate Magnetic Resonance Imaging: Risk Stratification Strategies to Avoid MRI-Targeted Biopsies

We aimed to investigate the relation between largest lesion diameter, prostate-specific antigen density (PSA-D), age, and the detection of clinically significant prostate cancer (csPCa) using first-time targeted biopsy (TBx) in men with Prostate Imaging-Reporting and Data System (PI-RADS) 3 index lesions. A total of 292 men (2013-2019) from two referral centers were included. A multivariable logistic regression analysis was performed. The discrimination and clinical utility of the built model was assessed by the area under the receiver operation curve (AUC) and decision curve analysis, respectively. A higher PSA-D and higher age were significantly related to a higher risk of detecting csPCa, while the largest index lesion diameter was not. The discrimination of the model was 0.80 (95% CI 0.73-0.87). When compared to a biopsy-all strategy, decision curve analysis showed a higher net benefit at threshold probabilities of ≥2%. Accepting a missing ≤5% of csPCa diagnoses, a risk-based approach would result in 34% of TBx sessions and 23% of low-risk PCa diagnoses being avoided. In men with PI-RADS 3 index lesions scheduled for first-time TBx, the balance between the number of TBx sessions, the detection of low-risk PCa, and the detection of csPCa does not warrant a biopsy-all strategy. To minimize the risk of missing the diagnosis of csPCa but acknowledging the need of avoiding unnecessary TBx sessions and overdiagnosis, a risk-based approach is advisable.

Arguments against using an abbreviated or biparametric prostate MRI protocol

Currently there is a lot of interest in the use of a "biparametric" or "abbreviated" prostate MR protocol, which usually refers to removal of the dynamic contrast-enhanced (DCE) MRI, in the detection of clinically significant prostate cancer. In this article we describe the benefits of DCE as part of the PI-RADS lexicon, with particular reference to its role in PI-RADS V2 category 3 peripheral zone lesions. We also discuss the benefits of triplanar T2-weighted images, and finally discuss how a mpMRI protocol is of benefit in prostate cancer staging, in evaluating for local disease recurrence, and as a biomarker for neoadjuvant therapy response.

Consecutive transperineal prostatic template biopsies employing cognitive and systematic approach: a single center study

INTRODUCTION

The role of transperineal template biopsy for prostate cancer diagnosis is well established. Pre-biopsy multiparametric magnetic resonance imaging (MRI) is used in most centers for planning of prostate biopsies and staging. Cognitive and software fusion techniques are increasingly getting popular.

METHODS

We retrospectively reviewed patients who underwent transperineal template biopsies from January 2016 till December 2018. This included patients on active surveillance, previous negative transrectal ultrasonography biopsies with persistently raised prostate-specific antigen/abnormal prostate on digital rectal examination and de-novo template biopsies. Two specialist uro-radiologists reported all the scans and the biopsies were performed by one experienced urologist. The cognitive biopsies were performed for PIRADS 3-5 lesions on MRI. Total of 330 patients underwent transperineal template biopsies and cognitive target biopsies were carried out in 75 patients who were included in the study. We evaluated the results as positive/negative cognitive biopsies and also according to the PIRAD scoring. Only the patients with prostate cancer on template biopsy histology were included.

RESULTS

Fifty-seven (76%) of the cognitive biopsies were positive out of total 75.[Table: see text].

CONCLUSIONS

Combined cognitive and systematic biopsies have excellent diagnostic rate especially for PIRAD 4-5 MRI areas.

What to expect from a non-suspicious prostate MRI? A review

BACKGROUND

Many guidelines now recommend multiparametric MRI (mpMRI) prior to an initial or repeat prostate biopsy. However, clinical decision making for men with a non-suspicious mpMRI (Likert or PIRADS score 1-2) varies.

OBJECTIVES

To review the most recent literature to answer three questions. (1) Should we consider systematic biopsy if mpMRI is not suspicious? (2) Are there additional predictive factors that can help decide which patient should have a biopsy? (3) Can the low visibility of some cancers be explained and what are the implications?

SOURCES

A narrative review was performed in Medline databases using two searches with the terms "MRI" and "prostate cancer" and ("diagnosis" or "biopsy") and ("non-suspicious" or "negative" or "invisible"); "prostate cancer MRI visible". References of the selected articles were screened for additional articles.

STUDY SELECTION

Studies published in the last 5 years in English language were assessed for eligibility and selected if data was available to answer one of the three study questions.

RESULTS

Considering clinically significant cancer as ISUP grade≥2, the negative predictive value (NPV) of mpMRI in various settings and populations ranges from 76% to 99%, depending on cancer prevalence and the type of confirmatory reference test used. NPV is higher among patients with prior negative biopsy (88-96%), and lower for active surveillance patients (85-90%). The PSA density (PSAd) with a threshold of PSAd<0.15ng/ml/ml was the most studied and relevant predictive factor used in combination with mpMRI to rule out clinically significant cancer. Finally, mpMRI-invisible tumours appear to differ from a histopathological and genetic point of view, conferring clinical advantage to invisibility.

LIMITATIONS

Most published data come from expert centres and results may not be reproducible in all settings.

CONCLUSION

mpMRI has high diagnostic accuracy and in cases of negative mpMRI, PSA density can be used to determine which patient should have a biopsy. Growing knowledge of the mechanisms and genetics underlying MRI visibility will help develop more accurate risk calculators and biomarkers.

Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in the Detection of Clinically Significant Prostate Cancer in the Prostate Imaging Reporting and Data System Era: A Systematic Review and Meta-analysis

CONTEXT

Prebiopsy multiparametric magnetic resonance imaging (mpMRI) is increasingly used in prostate cancer diagnosis. The reported negative predictive value (NPV) of mpMRI is used by some clinicians to aid in decision making about whether or not to proceed to biopsy.

OBJECTIVE

We aim to perform a contemporary systematic review that reflects the latest literature on optimal mpMRI techniques and scoring systems to update the NPV of mpMRI for clinically significant prostate cancer (csPCa).

EVIDENCE ACQUISITION

We conducted a systematic literature search and included studies from 2016 to September 4, 2019, which assessed the NPV of mpMRI for csPCa, using biopsy or clinical follow-up as the reference standard. To ensure that studies included in this analysis reflect contemporary practice, we only included studies in which mpMRI findings were interpreted according to the Prostate Imaging Reporting and Data System (PIRADS) or similar Likert grading system. We define negative mpMRI as either (1) PIRADS/Likert 1-2 or (2) PIRADS/Likert 1-3; csPCa was defined as either (1) Gleason grade group ≥2 or (2) Gleason grade group ≥3. We calculated NPV separately for each combination of negative mpMRI and csPCa.

EVIDENCE SYNTHESIS

A total of 42 studies with 7321 patients met our inclusion criteria and were included for analysis. Using definition (1) for negative mpMRI and csPCa, the pooled NPV for biopsy-naïve men was 90.8% (95% confidence interval [CI] 88.1-93.1%). When defining csPCa using definition (2), the NPV for csPCa was 97.1% (95% CI 94.9-98.7%). Calculation of the pooled NPV using definition (2) for negative mpMRI and definition (1) for csPCa yielded the following: 86.8% (95% CI 80.1-92.4%). Using definition (2) for both negative mpMRI and csPCa, the pooled NPV from two studies was 96.1% (95% CI 93.4-98.2%).

CONCLUSIONS

Multiparametric MRI of the prostate is generally an accurate test for ruling out csPCa. However, we observed heterogeneity in the NPV estimates, and local institutional data should form the basis of decision making if available.

PATIENT SUMMARY

The negative predictive values should assist in decision making for clinicians considering not proceeding to biopsy in men with elevated age-specific prostate-specific antigen and multiparametric magnetic resonance imaging reported as negative (or equivocal) on Prostate Imaging Reporting and Data System/Likert scoring. Some 7-10% of men, depending on the setting, will miss a diagnosis of clinically significant cancer if they do not proceed to biopsy. Given the institutional variation in results, it is of upmost importance to base decision making on local data if available.

Evaluating the efficacy of a low-cost cognitive MRI-targeted prostate biopsy protocol: is there still a role for lower volume centers in the Prostate Imaging Reporting and Data System (PI-RADS) version 2 era?

PURPOSE

MRI-targeted biopsy has improved prostate biopsy yield. However, cost constraints have made it difficult for many institutions to implement the newer methods. We evaluated the performance of a low-cost cognitive-targeting biopsy protocol based on 1.5 T multiparametric MRI graded with Prostate Imaging Reporting and Data System (PI-RADS) version 2 to examine the role for these institutions moving forward.

METHODS

Retrospective analysis of 251 consecutive patients with prostate-specific antigen (PSA) under 50 who underwent MRI and subsequent prostate biopsy at a single facility. In addition to systematic biopsy, targeted cores were obtained with cognitive recognition under ultrasound. A control group of 267 consecutive patients with PSA under 50 biopsied without prior MRI was analyzed.

RESULTS

Prostate biopsy preceded by MRI had a significantly higher probability of detecting both prostate cancer (68.1% vs. 51.3%) and clinically significant prostate cancer (57.4% vs. 39.7%) (p values < 0.01). Combination of systematic and targeted biopsy outperformed either regimen alone. PSA density and PI-RADS score were identified as independent risk factors, and a proposed diagnostic model (PSA density ≥ 0.25 or PI-RADS score ≥ 4) showed sensitivity of 88.6%, specificity of 55%, PPV of 81.2%, NPV of 68.8%, and accuracy of 78.0%.

CONCLUSIONS

Both pre-biopsy MRI and cognitive-targeted biopsy contributed to improvement of cancer yield. Future alterations of possible benefit included increasing target cores per lesion, and combining PI-RADS score and PSA density as indicators for biopsy. Similar protocols may represent an on-going role for lower volume centers in the diagnosis of prostate cancer.

Detection of Significant Prostate Cancer Using Target Saturation in Transperineal Magnetic Resonance Imaging/Transrectal Ultrasonography-fusion Biopsy

BACKGROUND

Multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies (TBs) facilitate accurate detection of significant prostate cancer (sPC). However, it remains unclear how many cores should be applied per target.

OBJECTIVE

To assess sPC detection rates of two different target-dependent magnetic resonance imaging (MRI)/transrectal ultrasonography (TRUS)-fusion biopsy approaches (TB and target saturation [TS]) compared with extended systematic biopsies (SBs).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective single-centre outcome of transperineal MRI/TRUS-fusion biopsies of 213 men was evaluated. All men underwent TB with a median of four cores per MRI lesion, followed by a median of 24 SBs, performed by experienced urologists. Cancer and sPC (International Society of Urological Pathology grade group ≥2) detection rates were analysed. TB was compared with SB and TS, with nine cores per target, calculated by the Ginsburg scheme and using individual cores of the lesion and its "penumbra".

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cancer detection rates were calculated for TS, TB, and SB at both lesion and patient level. Combination of SB + TB served as a reference. Statistical differences in prostate cancer (PC) detection between groups were calculated using McNemar's tests with confidence intervals.

RESULTS AND LIMITATIONS

TS detected 99% of 134 sPC lesions, which was significantly higher than the detection by TB (87%, p = 0.001) and SB (82%, p < 0.001). SB detected significantly more of the 72 low-risk PC lesions than TB (99% vs 68%, p < 0.001) and 10% (p = 0.15) more than that detected by TS. At a per-patient level, 99% of men harbouring sPC were detected by TS. This was significantly higher than that by TB and SB (89%, p = 0.03 and 81%, p = 0.001, respectively). Limitations include limited generalisability, as a transperineal biopsy route was used.

CONCLUSIONS

TS detected significantly more cases of sPC than TB and extended SB. Given that both 99% of sPC lesions and men harbouring sPC were identified by TS, the results suggest that this approach allows to omit SB cores without compromising sPC detection.

PATIENT SUMMARY

Target saturation of magnetic resonance imaging-suspicious prostate lesions provides excellent cancer detection and finds fewer low-risk tumours than the current gold standard combination of targeted and systematic biopsies.

Using decision curve analysis to benchmark performance of a magnetic resonance imaging-based deep learning model for prostate cancer risk assessment

OBJECTIVES

To benchmark the performance of a calibrated 3D convolutional neural network (CNN) applied to multiparametric MRI (mpMRI) for risk assessment of clinically significant prostate cancer (csPCa) using decision curve analysis (DCA).

METHODS

We retrospectively analyzed 499 patients who had positive mpMRI (PI-RADSv2 ≥ 3) and MRI-targeted biopsy. The training cohort comprised 449 men, including a calibration set of 50 men. Biopsy decision strategies included using risk estimates from the CNN (original and calibrated), to perform biopsy in men with PI-RADSv2 ≥ 4 only, or additionally in men with PI-RADSv2 3 and PSA density (PSAd) ≥ 0.15 ng/ml/ml. Discrimination, calibration and clinical usefulness in the unseen test cohort (n = 50) were assessed using C-statistic, calibration plots and DCA, respectively.

RESULTS

The calibrated CNN achieved moderate calibration (Hosmer-Lemeshow calibration test, p = 0.41) and good discrimination (C = 0.85). DCA revealed consistently higher net benefit and net reduction in biopsies for the calibrated CNN compared with the original CNN, PI-RADSv2 ≥ 4 and the combined strategy of PI-RADSv2 and PSAd. Original CNN predictions were severely miscalibrated (p < 0.0001) resulting in net harm compared with a 'biopsy all' patients strategy. At-risk thresholds ≥ 10% using the calibrated CNN and the combined strategy reduced the number of biopsies by an estimated 201 and 55 men, respectively, per 1000 men at risk, without missing csPCa, while original CNN and PI-RADSv2 ≥ 4 could not achieve a net reduction in biopsies.

CONCLUSIONS

DCA revealed that our calibrated 3D-CNN resulted in fewer unnecessary biopsies compared with using PI-RADSv2 alone or in combination with PSAd. CNN calibration is important in achieving clinical utility.

KEY POINTS

• A 3D deep learning model applied to multiparametric MRI may help to prevent unnecessary prostate biopsies in patients eligible for MRI-targeted biopsy. • Owing to miscalibration, original risk estimates by the deep learning model require prior calibration to enable clinical utility. • Decision curve analysis confirmed a net benefit of using our calibrated deep learning model for biopsy decisions compared with alternative strategies, including PI-RADSv2 alone and in combination with prostate-specific antigen density.

Role of Multiparametric Magnetic Resonance Imaging in Predicting Pathologic Outcomes in Prostate Cancer

Multiparametric magnetic resonance imaging (mpMRI) and the introduction of standardized protocols for its interpretation have had a significant impact on the field of prostate cancer (PC). Multiple randomized controlled trials have shown that the sensitivity for detection of clinically significant PC is increased when mpMRI results are the basis for indication of a prostate biopsy. The added value with regards to sensitivity has been strongest for patients with persistent suspicion for PC after a prior negative biopsy. Although enhanced sensitivity of mpMRI is convincing, studies that have compared mpMRI with prostatectomy specimens prepared by whole-mount section analysis have shown a significant number of lesions that were not detected by mpMRI. In this context, the importance of an additional systematic biopsy (SB) is still being debated. While SB in combination with targeted biopsies leads to an increased detection rate, most of the tumors detected by SB only are considered clinically insignificant. Currently, multiple risk calculation tools are being developed that include not only clinical parameters but mpMRI results in addition to clinical parameters in order to improve risk stratification for PC, such as the Partin tables. In summary, mpMRI of the prostate has become a standard procedure recommended by multiple important guidelines for the diagnostic work-up of patients with suspicion of PC.

Clinical utility of PSAD combined with PI-RADS category for the detection of clinically significant prostate cancer

PURPOSE

The goal of this study was to determine the predictive value of prostate-specific antigen density (PSAD) plus Prostate Imaging Reporting and Data System (PI-RADS) category for the detection of clinically significant prostate cancer.

MATERIALS AND METHODS

This retrospective study included 526 men without known prostate cancer (initial diagnosis group) and 133 men with prostate cancer grade group 1 (active surveillance group) who underwent magnetic resonance imaging-guided and/or systematic prostate biopsy procedures between August 2014 and October 2018. Prostate specific antigen (PSA), PSAD, and PI-RADS category were entered into logistic regression models for predicting clinically significant prostate cancer (grade group ≥2) at biopsy. Receiver operating characteristic curve analysis was performed to assess model accuracy.

RESULTS

The area under the curve (AUC) increased when PSAD was combined with PI-RADS in the initial diagnosis group (difference in AUC = 0.031; 95% confidence interval: 0.012, 0.050; P = 0.002) but not in the active surveillance group (difference in AUC = 0.016; 95% confidence interval: -0.040, 0.071; P = 0.579). When a PSAD threshold of 0.15 was applied, the frequency of clinically significant prostate cancer in patients with a PI-RADS score of 3 or lower decreased from 9.8% to 5.6% in the initial diagnosis group and from 10.7% to 2.7% in the active surveillance group.

CONCLUSIONS

The addition of PSAD improves the predictive performance of PI-RADS in men without known prostate cancer. A PSAD threshold of 0.15 can help to minimize the number of missed clinically significant prostate cancer cases in men with a PI-RADS score of 3 or lower who decide to defer biopsy.

The role of MRI/TRUS fusion biopsy in the diagnosis of clinically significant prostate cancer

Background

The aim of this work is to evaluate the detection rate of magnetic resonance imaging/transrectal ultrasound (MRI/TRUS) fusion-guided biopsy for clinically significant prostate cancers (Cs PCas), with particular interest in biopsy-naive patients and patients in active surveillance. MRI-targeted biopsy improves cancer detection rate (DR) in patients with prior negative biopsies; the current literature focuses on biopsy naive patients. We also evaluated the pathologic concordance between biopsies and surgical specimens.

Methods

MRI/TRUS fusion-guided biopsies were performed between February 2016 and February 2019. Patients with previous negative biopsies, biopsy-naive or in active surveillance (AS) were included. Cs PCas were defined through Epstein's criteria.

Results

A total of 416 men were enrolled. The overall DRs and Cs PCa DRs were 49% and 34.3%, respectively. Cs PCas were 17.2%, 44.9% and 73.4%, respectively for PI-RADS 3, 4 or 5. Among biopsy-naive patients, 34.8% were found to have a Cs PCa, while a 43.6% tumour upgrading was achieved in men with a low risk of PCa. In patients who underwent radical prostatectomy (RP), the concordance between biopsy Gleason score (GS) (bGS) and pathological GS (pGS) was 90.8%.

Conclusion

Our study highlights the role of MRI/TRUS fusion prostate biopsy in the detection of PCa in patients with previous negative biopsies focusing on Cs PCa diagnosis. The MRI/TRUS fusion biopsy is also emerging as a diagnostic tool in biopsy-naïve patients and deserves a fundamental role in AS protocols. A greater concordance between bGS and pGS can be achieved with targeted biopsies.

Prospective Evaluation of 68Ga-labeled Prostate-specific Membrane Antigen Ligand Positron Emission Tomography/Computed Tomography in Primary Prostate Cancer Diagnosis

BACKGROUND

Positron emission tomography (PET)/computed tomography (CT) with ⁶⁸Ga-labeled prostate-specific membrane antigen ligand (⁶⁸Ga-PSMA) may represent the most promising alternative to multiparametric magnetic resonance imaging (mpMRI) for prostate cancer (PCa) diagnosis.

OBJECTIVE

To test the diagnostic performance of ⁶⁸Ga-PSMA PET/CT in this clinical context.

DESIGN, SETTING, AND PARTICIPANTS

From January 2017 to December 2018 we prospectively enrolled 97 patients with persistently elevated prostate-specific antigen and/or Prostate Health Index score, negative digital rectal examination, and previous negative biopsy. We also included patients with either negative mpMRI or contraindications to or positive mpMRI but previous negative biopsy.

INTERVENTION

Patients underwent 68Ga-PSMA PET/CT with additional pelvic reconstruction.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint of the study was the diagnostic performance of ⁶⁸Ga-PSMA PET/CT in detecting malignant lesions and clinically significant PCa (Gleason score [GS] ≥7).

RESULTS AND LIMITATIONS

⁶⁸Ga-PSMA PET/transrectal ultrasound fusion biopsy was performed in 64 of 97 patients (66%) for 114 regions of interest (ROIs). Forty patients (41%) had already undergone mpMRI with either a negative result for PCa (n = 15; 22 ROIs) or a positive mpMRI result but a previous negative biopsy. According to pathology, 23 patients (36%) had evidence of PCa: eight (16 ROIs) with GS 6, 13 (21 ROIs) with GS 7 (3 + 4 or 4 + 3), one (2 ROIs) with GS 8, and one (2 ROIs) with GS 10. Clinically significant PCa was identified in four patients with previous negative mpMRI (25%). PET/CT demonstrated PCa in seven patients (14 ROIs) with previous positive mpMRI and negative biopsy. The median maximum standardized uptake value (SUVmax) and median SUV ratio were significantly higher for PCa lesions than for benign lesions (p <  0.001). Optimal cutoff points obtained for SUVmax (>5.4) and SUV ratio (>2.2) could identify clinically significant PCa with accuracy of 81% and 90%, respectively.

CONCLUSIONS

In our cohort of patients with high suspicion of cancer,⁶⁸Ga-PSMA PET/CT was capable of detecting malignancy and accurately identifying clinically relevant PCa.

PATIENT SUMMARY

Positron emission tomography/computed tomography with a ⁶⁸Ga-labeled ligand for prostate-specific membrane antigen is capable of detecting prostate cancer in patients with a high suspicion of cancer and a previous negative biopsy.

Negative Biopsy Histology in Men With PI-RADS Score 5 in Daily Clinical Practice: Incidence of Granulomatous Prostatitis

INTRODUCTION

The purpose of this study was to evaluate the biopsy histology of men who underwent transperineal multi-parametric magnetic resonance imaging (mpMRI)/transrectal ultrasound fusion biopsy for Prostate Imaging Reporting and Data System (PI-RADS) score 5 lesions.

PATIENTS AND METHODS

From January 2016 to June 2019, 105 men with PI-RADS score 5 underwent mpMRI/transrectal ultrasound fusion biopsy combined with systematic prostate biopsy. All the patients underwent a 3.0 Tesla pelvic mpMRI for the first time before prostate biopsy. In detail, the detection rate for clinically significant prostate cancer (PCa) and the follow-up of the patients without proven diagnosis of PCa has been reported.

RESULTS

In 91 (86.7%) of 105 patients, a stage T1c PCa was diagnosed, and 89 (84.5%) of 105 of them were classified as clinically significant PCa. Among the 16 (15.5%) of 105 patients with absence of cancer, 5 (31.5%) of 16 had an aspecific granulomatous prostatitis, 1 (6.2%) of 16 had a specific granulomatous prostatitis secondary to prostatic Mycobacterium Tubercolosis, and 10 (62.3%) of 16 had a diagnosis of normal parenchyma. The 6 patients with granulomatous prostatitis underwent specific antibiotic therapy followed by laboratory (ie, semen and urine cultures) and clinical evaluation. Six months from prostate biopsy, none of the 16 patients underwent repeat prostate biopsy because prostate-specific antigen (PSA) (15/16 cases) plus PSA density significantly decreased; in addition, in all the cases the initial PI-RADS score 5 was downgraded at mpMRI revaluation to PI-RADS score ≤ 3.

CONCLUSION

The reduction of PSA plus PSA density values and the downgrading of PI-RADS score to ≤ 3 allow avoiding a repeated prostate biopsy in men with initial mpMRI PI-RADS score 5 lesion and negative biopsy histology.

Is it worth carrying out ultrasound-magnetic resonance imaging fusion targeted biopsy on Prostate Imaging Reporting and Data System score 3 prostate lesions?

OBJECTIVES

To evaluate the use of ultrasound-magnetic resonance imaging fusion targeted biopsy for Prostate Imaging Reporting and Data System 3 prostate lesions.

METHODS

We identified 227 patients with prostate-specific antigen levels ≥4 ng/mL who underwent concurrent transrectal ultrasound-guided systemic biopsy and fusion biopsy. Suspicious prostatic lesions were assessed in accordance with Prostate Imaging Reporting and Data System version 2.0. We compared ultrasound-magnetic resonance imaging fusion targeted biopsy and ultrasound-guided biopsy cancer detection rates in Prostate Imaging Reporting and Data System 3 lesions with those in other Prostate Imaging Reporting and Data System score lesions. In Prostate Imaging Reporting and Data System 3 patients, we identified clinically significant prostate cancer risk factors by logistic regression analysis.

RESULTS

In total, 2770 transrectal ultrasound-guided and 867 fusion biopsy cores were obtained; where 332 (12.0%) and 194 (22.4%) cores were prostate cancer-positive, respectively (P < 0.001). The fusion biopsy cancer detection rate (8.0%) in Prostate Imaging Reporting and Data System 3 lesions was similar to that in Prostate Imaging Reporting and Data System 1-2 lesions, but was lower than that of Prostate Imaging Reporting and Data System 4 (30.0%; P < 0.001) and 5 lesions (65.2%; P < 0.001), and ultrasound-guided biopsy (12.0%; P = 0.023). For clinically significant prostate cancer detection, fusion biopsy in Prostate Imaging Reporting and Data System 3 lesions was inferior to that in Prostate Imaging Reporting and Data System 4 and 5 lesions, and non-superior to ultrasound-guided biopsy. Cancer detection rate trends were similar in biopsy-naïve patients. In Prostate Imaging Reporting and Data System 3 patients, prostate-specific antigen density was the only significant predictor of clinically significant prostate cancer.

CONCLUSIONS

The present findings do not support the use of ultrasound-magnetic resonance imaging fusion targeted biopsy for Prostate Imaging Reporting and Data System 3 lesions. Thus, we recommend the use of transrectal ultrasound-guided systemic biopsy for patients with Prostate Imaging Reporting and Data System 3 index lesions.

Investigating the equivalent performance of biparametric compared to multiparametric MRI in detection of clinically significant prostate cancer

PURPOSE

PIRADS v2 stipulates that dynamic contrast-enhanced (DCE) imaging be used to categorize diffusion-weighted-imaging (DWI) score 3 (DWI 3) peripheral zone (PZ) lesions as PIRADS score 3 (PIRADS 3; DCE -) or PIRADS 4 (DCE +). It's controversial for the value of DCE in improving clinically significant prostate cancer (csPCa) detection. We aimed to figure out whether DCE improves csPCa detection and explore new available measures to improve csPCa detection.

PATIENTS AND METHODS

We retrospectively enrolled 375 patients who underwent mp MRI before MRI/ultrasound (US) fusion-targeted biopsy (TB) with transperineal systematic biopsy (SB). All lesions were classified as DWI 3/DCE -, DWI 3/DCE +, DWI 4/PIRADS 4 lesions. Detection rates of csPCa for each lesion group were analyzed. The diagnostic performance of each approach was analyzed by receiver operating characteristics (ROC) analysis and decision curve analysis.

RESULTS

Totally, 109 DWI 3 or DWI 4 single lesions in PZ were analyzed (n = 109). The rates of csPCa detection for Group A, Group B, Group C is 10.3%, 13.9%, 55.9%, respectively (A vs. B, p = 0.625; B vs. C, p < 0.001). ROC analysis and decision curve analysis showed the method of combining Age, PSA Density (PSAD) and the mean apparent diffusion coefficient value (ADC_mean) outperforms individual approaches for csPCa detection.

CONCLUSION

For DWI 3 lesions in PZ, DCE sequence has not additional value for improving detection of csPCa. The integration of clinical characteristics and bpMRI parameter improves the detection of csPCa.