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Schrader A, Netzer N, Hielscher T, Görtz M, Zhang KS, Schütz V, Stenzinger A, Hohenfellner M, Schlemmer HP, Bonekamp D. Prostate cancer risk assessment and avoidance of prostate biopsies using fully automatic deep learning in prostate MRI: comparison to PI-RADS and integration with clinical data in nomograms. Eur Radiol 2024:10.1007/s00330-024-10818-0. [PMID: 38955845 DOI: 10.1007/s00330-024-10818-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES Risk calculators (RCs) improve patient selection for prostate biopsy with clinical/demographic information, recently with prostate MRI using the prostate imaging reporting and data system (PI-RADS). Fully-automated deep learning (DL) analyzes MRI data independently, and has been shown to be on par with clinical radiologists, but has yet to be incorporated into RCs. The goal of this study is to re-assess the diagnostic quality of RCs, the impact of replacing PI-RADS with DL predictions, and potential performance gains by adding DL besides PI-RADS. MATERIAL AND METHODS One thousand six hundred twenty-seven consecutive examinations from 2014 to 2021 were included in this retrospective single-center study, including 517 exams withheld for RC testing. Board-certified radiologists assessed PI-RADS during clinical routine, then systematic and MRI/Ultrasound-fusion biopsies provided histopathological ground truth for significant prostate cancer (sPC). nnUNet-based DL ensembles were trained on biparametric MRI predicting the presence of sPC lesions (UNet-probability) and a PI-RADS-analogous five-point scale (UNet-Likert). Previously published RCs were validated as is; with PI-RADS substituted by UNet-Likert (UNet-Likert-substituted RC); and with both UNet-probability and PI-RADS (UNet-probability-extended RC). Together with a newly fitted RC using clinical data, PI-RADS and UNet-probability, existing RCs were compared by receiver-operating characteristics, calibration, and decision-curve analysis. RESULTS Diagnostic performance remained stable for UNet-Likert-substituted RCs. DL contained complementary diagnostic information to PI-RADS. The newly-fitted RC spared 49% [252/517] of biopsies while maintaining the negative predictive value (94%), compared to PI-RADS ≥ 4 cut-off which spared 37% [190/517] (p < 0.001). CONCLUSIONS Incorporating DL as an independent diagnostic marker for RCs can improve patient stratification before biopsy, as there is complementary information in DL features and clinical PI-RADS assessment. CLINICAL RELEVANCE STATEMENT For patients with positive prostate screening results, a comprehensive diagnostic workup, including prostate MRI, DL analysis, and individual classification using nomograms can identify patients with minimal prostate cancer risk, as they benefit less from the more invasive biopsy procedure. KEY POINTS The current MRI-based nomograms result in many negative prostate biopsies. The addition of DL to nomograms with clinical data and PI-RADS improves patient stratification before biopsy. Fully automatic DL can be substituted for PI-RADS without sacrificing the quality of nomogram predictions. Prostate nomograms show cancer detection ability comparable to previous validation studies while being suitable for the addition of DL analysis.
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Affiliation(s)
- Adrian Schrader
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg University Medical School, Heidelberg, Germany
| | - Nils Netzer
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg University Medical School, Heidelberg, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Magdalena Görtz
- Department of Urology, University of Heidelberg Medical Center, Heidelberg, Germany
- Junior Clinical Cooperation Unit 'Multiparametric Methods for Early Detection of Prostate Cancer', German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kevin Sun Zhang
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Viktoria Schütz
- Department of Urology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Markus Hohenfellner
- Department of Urology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Heinz-Peter Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - David Bonekamp
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Heidelberg University Medical School, Heidelberg, Germany.
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
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2
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Fuschi A, Suraci PP, Pastore AL, Al Salhi Y, Capodiferro P, Scalzo S, Rera OA, Valenzi FM, Di Dio M, Russo P, Al-Zubi MT, Al Demour S, Fathi Al-Rawashdah S, Mazzon G, Bellini D, Carbone I, Petrozza V, Bozzini G, Zucchi A, Pacini M, Tema G, De Nunzio C, Carbone A, Rengo M. Multiparametric Prostate MRI Accuracy of Prostate Imaging Reporting and Data System (v2.1) Scores 4 and 5: The Influence of Image Quality According to the Prostate Imaging Quality Score. J Clin Med 2024; 13:3785. [PMID: 38999353 PMCID: PMC11242596 DOI: 10.3390/jcm13133785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 07/14/2024] Open
Abstract
Purpose: The accuracy of multiparametric magnetic resonance imaging (mpMRI) heavily relies on image quality, as evidenced by the evolution of the prostate imaging quality (PI-QUAL) scoring system for the evaluation of clinically significant prostate cancer (csPC). This study aims to evaluate the impact of PI-QUAL scores in detecting csPC within PI-RADS 4 and 5 lesions. Methods: We retrospectively selected from our database all mpMRI performed from January 2019 to March 2022. Inclusion criteria were as follows: (1) mpMRI acquired in our institution according to the technical requirements from the PI-RADS (v2.1) guidelines; (2) single lesion scored as PI-RADS (v2.1) 4 or 5; (3) MRI-TBx performed in our institution; (4) complete histology report; and (5) complete clinical record. Results: A total of 257 male patients, mean age 70.42 ± 7.6 years, with a single PI-RADS 4 or 5 lesion undergoing MRI-targeted biopsy, were retrospectively studied. Of these, 61.5% were PI-RADS 4, and 38.5% were PI-RADS 5, with 84% confirming neoplastic cells. In high-quality image lesions (PI-QUAL ≥ 4), all PI-RADS 5 lesions were accurately identified as positive at the final histological examination (100% of CDR). For PI-RADS 4 lesions, 37 (23%) were negative, resulting in a cancer detection rate of 77% (95% CI: 67.51-84.83). Conclusions: The accuracy of mpMRI, independently of the PI-RADS score, progressively decreased according to the decreasing PI-QUAL score. These findings emphasize the crucial role of the PI-QUAL scoring system in evaluating PI-RADS 4 and 5 lesions, influencing mpMRI accuracy.
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Affiliation(s)
- Andrea Fuschi
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Paolo Pietro Suraci
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Antonio Luigi Pastore
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Yazan Al Salhi
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Paola Capodiferro
- Department of Radiological, Oncological and Pathological Sciences, Academic Diagnostic, Imaging Division, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Silvio Scalzo
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Onofrio Antonio Rera
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Fabio Maria Valenzi
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Michele Di Dio
- Division of Urology, Department of Surgery, Annunziata Hospital, 87100 Cosenza, Italy
| | - Pierluigi Russo
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
- Urology Unit, Fondazione Policlinico A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Mohammad Talal Al-Zubi
- Department of Surgery, Division of Urology, School of Medicine, Yarmouk University, Irbid 21110, Jordan
| | - Saddam Al Demour
- Department of Special Surgery, Division of Urology, School of Medicine, The University of Jordan, Amman 11972, Jordan
| | - Samer Fathi Al-Rawashdah
- Department of Special Surgery, Urology Unit, School of Medicine, Mutah University, Karak 61710, Jordan
| | - Giorgio Mazzon
- Institute of Urology, University College Hospital, London NW12BU, UK
| | - Davide Bellini
- Department of Radiological, Oncological and Pathological Sciences, Academic Diagnostic, Imaging Division, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, Academic Diagnostic, Imaging Division, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Vincenzo Petrozza
- Pathology Unit, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Giorgio Bozzini
- Division of Urology, Sant'Anna Hospital, San Fermo della Battaglia, 22042 Como, Italy
| | | | - Matteo Pacini
- Department of Urology, University of Pisa, 56126 Pisa, Italy
| | - Giorgia Tema
- Department of Urology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy
| | - Antonio Carbone
- Unit of Urology, Department of Medical-Surgical Sciences and Biotechnologies, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
| | - Marco Rengo
- Department of Radiological, Oncological and Pathological Sciences, Academic Diagnostic, Imaging Division, I.C.O.T. Hospital, University of Rome Sapienza, Via F. Faggiana 1668, 04100 Latina, Italy
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Nagayama H, Nakai H, Takahashi H, Froemming AT, Kawashima A, Bolan CW, Adamo DA, Carter RE, Fazzio RT, Tsuji S, Lomas DJ, Mynderse LA, Humphreys MR, Dora C, Takahashi N. Cancer Detection Rate and Abnormal Interpretation Rate of Prostate MRI Performed for Clinical Suspicion of Prostate Cancer. J Am Coll Radiol 2024; 21:398-408. [PMID: 37820833 DOI: 10.1016/j.jacr.2023.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE To report cancer detection rate (CDR) and abnormal interpretation rate (AIR) in prostate MRI performed for clinical suspicion of prostate cancer (PCa). MATERIALS AND METHODS This retrospective single-institution, three-center study included patients who underwent MRI for clinical suspicion of PCa between 2017 and 2021. Patients with known PCa were excluded. Patient-level Prostate Imaging-Reporting and Data System (PI-RADS) score was extracted from the radiology report. AIR was defined as number of abnormal MRI (PI-RADS score 3-5) / total number of MRIs. CDR was defined as number of clinically significant PCa (csPCa: Gleason score ≥7) detected at abnormal MRI / total number of MRI. AIR, CDR, and CDR adjusted for pathology confirmation rate were calculated for each of three centers and pre-MRI biopsy status (biopsy-naive and previous negative biopsy). RESULTS A total of 9,686 examinations (8,643 unique patients) were included. AIR, CDR, and CDR adjusted for pathology confirmation rate were 45.4%, 23.8%, and 27.6% for center I; 47.2%, 20.0%, and 22.8% for center II; and 42.3%, 27.2%, and 30.1% for center III, respectively. Pathology confirmation rate ranged from 81.6% to 88.0% across three centers. AIR and CDR for biopsy-naive patients were 45.5% to 52.6% and 24.2% to 33.5% across three centers, respectively, and those for previous negative biopsy were 27.2% to 39.8% and 11.7% to 14.2% across three centers, respectively. CONCLUSION We reported CDR and AIR in prostate MRI for clinical suspicion of PCa. CDR needs to be adjusted for pathology confirmation rate and pre-MRI biopsy status for interfacility comparison.
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Affiliation(s)
- Hiroki Nagayama
- Department of Radiology, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | | | | | - Adam T Froemming
- Division Chair of the Abdominal Imaging in Minnesota, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Candice W Bolan
- Chief, Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Daniel A Adamo
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Rickey E Carter
- Vice Chair, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Robert T Fazzio
- Division Chair of the Breast Imaging, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Derek J Lomas
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Chandler Dora
- Department of Urology, Mayo Clinic, Jacksonville, Florida
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Netzer N, Eith C, Bethge O, Hielscher T, Schwab C, Stenzinger A, Gnirs R, Schlemmer HP, Maier-Hein KH, Schimmöller L, Bonekamp D. Application of a validated prostate MRI deep learning system to independent same-vendor multi-institutional data: demonstration of transferability. Eur Radiol 2023; 33:7463-7476. [PMID: 37507610 PMCID: PMC10598076 DOI: 10.1007/s00330-023-09882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVES To evaluate a fully automatic deep learning system to detect and segment clinically significant prostate cancer (csPCa) on same-vendor prostate MRI from two different institutions not contributing to training of the system. MATERIALS AND METHODS In this retrospective study, a previously bi-institutionally validated deep learning system (UNETM) was applied to bi-parametric prostate MRI data from one external institution (A), a PI-RADS distribution-matched internal cohort (B), and a csPCa stratified subset of single-institution external public challenge data (C). csPCa was defined as ISUP Grade Group ≥ 2 determined from combined targeted and extended systematic MRI/transrectal US-fusion biopsy. Performance of UNETM was evaluated by comparing ROC AUC and specificity at typical PI-RADS sensitivity levels. Lesion-level analysis between UNETM segmentations and radiologist-delineated segmentations was performed using Dice coefficient, free-response operating characteristic (FROC), and weighted alternative (waFROC). The influence of using different diffusion sequences was analyzed in cohort A. RESULTS In 250/250/140 exams in cohorts A/B/C, differences in ROC AUC were insignificant with 0.80 (95% CI: 0.74-0.85)/0.87 (95% CI: 0.83-0.92)/0.82 (95% CI: 0.75-0.89). At sensitivities of 95% and 90%, UNETM achieved specificity of 30%/50% in A, 44%/71% in B, and 43%/49% in C, respectively. Dice coefficient of UNETM and radiologist-delineated lesions was 0.36 in A and 0.49 in B. The waFROC AUC was 0.67 (95% CI: 0.60-0.83) in A and 0.7 (95% CI: 0.64-0.78) in B. UNETM performed marginally better on readout-segmented than on single-shot echo-planar-imaging. CONCLUSION For same-vendor examinations, deep learning provided comparable discrimination of csPCa and non-csPCa lesions and examinations between local and two independent external data sets, demonstrating the applicability of the system to institutions not participating in model training. CLINICAL RELEVANCE STATEMENT A previously bi-institutionally validated fully automatic deep learning system maintained acceptable exam-level diagnostic performance in two independent external data sets, indicating the potential of deploying AI models without retraining or fine-tuning, and corroborating evidence that AI models extract a substantial amount of transferable domain knowledge about MRI-based prostate cancer assessment. KEY POINTS • A previously bi-institutionally validated fully automatic deep learning system maintained acceptable exam-level diagnostic performance in two independent external data sets. • Lesion detection performance and segmentation congruence was similar on the institutional and an external data set, as measured by the weighted alternative FROC AUC and Dice coefficient. • Although the system generalized to two external institutions without re-training, achieving expected sensitivity and specificity levels using the deep learning system requires probability thresholds to be adjusted, underlining the importance of institution-specific calibration and quality control.
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Affiliation(s)
- Nils Netzer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- Heidelberg University Medical School, Heidelberg, Germany
| | - Carolin Eith
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- Heidelberg University Medical School, Heidelberg, Germany
| | - Oliver Bethge
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Dusseldorf, D-40225, Dusseldorf, Germany
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Constantin Schwab
- Institute of Pathology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University of Heidelberg Medical Center, Heidelberg, Germany
| | - Regula Gnirs
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Heinz-Peter Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Klaus H Maier-Hein
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
- Medical Image Computing, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Pattern Analysis and Learning Group, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lars Schimmöller
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Dusseldorf, D-40225, Dusseldorf, Germany
| | - David Bonekamp
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
- Heidelberg University Medical School, Heidelberg, Germany.
- German Cancer Consortium (DKTK), Heidelberg, Germany.
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
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Sharqawi A, Drye N, Shugaba A, O'reilly A, Kadry AM, El-Sakka AI. Reliability of prostate imaging reporting and data system version 2.1 for excluding clinically significant prostate cancer using a 1.5 tesla scanner. BMC Urol 2023; 23:69. [PMID: 37118694 PMCID: PMC10148493 DOI: 10.1186/s12894-023-01241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 04/10/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Multiparametric magnetic resonance imaging (mpMRI) of the prostate gland is now the recommended initial investigation of choice for the detection of Prostate cancer (PCa). It effectively identifies patients who require prostate biopsies due to the risk of clinically significant PCa. It helps patients with clinically insignificant PCa avoid the invasive biopsies and possible accompanying complications. Large clinical trials have investigated the accuracy of mpMRI in detecting PCa. We performed a local review to examine the reliability of omitting tissue sampling in men with a negative (PIRADS 2 (P2) or less) mpMRI in the primary diagnostic setting. METHODS This was a retrospective study of patients with clinical suspicion of PCa within a 2-year period. Patients had a mpMRI prior to having trans-perineal prostate gland biopsies. Clinically significant disease was defined as Gleason 7 and above. The descriptive data was analysed using contingency table methods. A p-value less than 0.05 was statistically significant. RESULTS Out of 700 patients 90 had an mpMRI score of PIRADS 2. Seventy-seven (85.5%) of these patients had a negative biopsy, 9(10%) showed Gleason 6, 4 patients showed Gleason 7 or above. 78 patients with PIRADS 2 had a PSA density of < 0.15, none of which had a clinically significant biopsy result. The negative predictive value of mpMRI from this study is 95%. CONCLUSION Our results are in line with negative predictive values demonstrated in the current literature. This local study, likely applicable to other district general hospitals, shows that mpMRI is a safe and reliable initial investigation to aid decisions on which patients require biopsies.
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Affiliation(s)
- Abdallah Sharqawi
- Urology Dept, Royal Bolton Hospital, Bolton, UK.
- Urology Dept, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
| | - Naomi Drye
- Urology Dept, Royal Bolton Hospital, Bolton, UK
| | | | | | - Ahmed M Kadry
- Urology Dept, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - A I El-Sakka
- Urology Dept, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Pilatz A, Alidjanov J, Bonkat G, Wagenlehner F. [Prostate biopsy-infection prophylaxis and patient preparation]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:459-463. [PMID: 36882551 DOI: 10.1007/s00120-023-02065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 03/09/2023]
Abstract
Prostate biopsy has been at the center of controversy in recent years due to high infection complications associated with the transrectal route and the withdrawal of authorization for fluoroquinolones and fosfomycin trometemol as prophylaxis. The Urological Infections Guideline Group of the European Association of Urology (EAU) recently published a meta-analysis in two parts based on randomized controlled trials (RCTs) and annually updates the data for the EAU guidelines. The meta-analyses show that transperineal prostate biopsy is associated with significantly fewer infectious complications than transrectal biopsy and should therefore be preferred. If transrectal biopsy is still used, then intrarectal cleansing with povidone-iodine and antibiotic prophylaxis should be used. Antibiotic prophylaxis strategies include targeted prophylaxis after sensitivity testing of the rectal flora, augmented prophylaxis with several antibiotics and empirical monoprophylaxis. Data from RCTs are available for aminoglycosides and third-generation cephalosporins.
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Affiliation(s)
- A Pilatz
- Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland.
| | - J Alidjanov
- Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland
| | | | - F Wagenlehner
- Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland
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7
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Natural History of Patients with Prostate MRI Likert 1-3 and Development of RosCaP: a Multivariate Risk Score for Clinically Significant Cancer. Clin Genitourin Cancer 2023; 21:162-170. [PMID: 35970760 DOI: 10.1016/j.clgc.2022.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Clinically significant prostate cancer (csCaP) with Gleason ≥3 + 4 is found in 10% negative prebiopsy multiparametric (mp) MRI cases and varies widely for equivocal mpMRI cases. The objective of this study was to investigate long-term outcomes of patients with negative and equivocal mpMRIs and to develop a predictive score for csCaP risk stratification in this group. PATIENTS AND METHODS Patients who underwent an upfront mpMRI between May 2015 and March 2018 with an MRI score Likert 1 to 3 were included in the study. Patients had either a CaP diagnosis at MRI-targeted biopsy or were not diagnosed and attended follow-up in the community. Outcomes were analysed through the Kaplan-Meier estimator and Cox Model. Regression coefficients of significant variables were used to develop a Risk of significant Cancer of the Prostate score (RosCaP). RESULTS At first assessment 281/469 patients had mpMRI only and 188/469 mpMRI and biopsy, 26 csCaP were found at biopsy, including 10/26 in Likert 3 patients. 12/371 patients discharged without CaP after first assessment were diagnosed with csCaP during a median of 34.2 months' follow-up, 11/12 diagnosis occurred in patients omitting initial biopsy. csCaP diagnosis-free survival was 95.7% in the MRI group and 99.1% in the biopsy group. From these outcomes, a continuous RosCaP score was developed: RosCaP = 0.083 x Age - 0.202 x (1/PSA Density) + 0.786 (if Likert 3), and 4 risk classes were proposed. Limitations include retrospective design and absence of external validation. CONCLUSION Age, PSA Density and MRI Likert score were significantly associated to the risk of csCaP and utilised to devise the novel RosCap predictive score focused to support risk assessment in patients with negative or equivocal mpMRI results.
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Connor MJ, Gorin MA, Eldred-Evans D, Bass EJ, Desai A, Dudderidge T, Winkler M, Ahmed HU. Landmarks in the evolution of prostate biopsy. Nat Rev Urol 2023; 20:241-258. [PMID: 36653670 DOI: 10.1038/s41585-022-00684-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 01/19/2023]
Abstract
Approaches and techniques used for diagnostic prostate biopsy have undergone considerable evolution over the past few decades: from the original finger-guided techniques to the latest MRI-directed strategies, from aspiration cytology to tissue core sampling, and from transrectal to transperineal approaches. In particular, increased adoption of transperineal biopsy approaches have led to reduced infectious complications and improved antibiotic stewardship. Furthermore, as image fusion has become integral, these novel techniques could be incorporated into prostate biopsy methods in the future, enabling 3D-ultrasonography fusion reconstruction, molecular targeting based on PET imaging and autonomous robotic-assisted biopsy.
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Affiliation(s)
- Martin J Connor
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK. .,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK.
| | - Michael A Gorin
- Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Eldred-Evans
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Edward J Bass
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Ankit Desai
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton, Southampton, UK
| | - Mathias Winkler
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
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9
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Kamal O, Comerford J, Foster BR, Young DJ, Amling C, Coakley FV. Intermediate-term oncological outcomes after a negative endorectal coil multiparametric MRI of the prostate in patients without biopsy proven prostate cancer. Clin Imaging 2022; 92:112-116. [DOI: 10.1016/j.clinimag.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2022]
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10
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Sokhi H, Wilson A, Pindoria N, McNamara C, Padhani A, Meer Z, Pope A. Audit of cancer yields after prostate MRI using both the PI-RADS version 2 and Likert scoring systems. Clin Radiol 2022; 77:541-547. [DOI: 10.1016/j.crad.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/07/2022] [Indexed: 11/03/2022]
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11
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Kortenbach KC, Løgager V, Thomsen HS, Boesen L. Early experience in avoiding biopsies for biopsy-naïve men with clinical suspicion of prostate cancer but non-suspicious biparametric magnetic resonance imaging results and prostate-specific antigen density < 0.15 ng/mL 2: A 2-year follow-up study. Acta Radiol Open 2022; 11:20584601221094825. [PMID: 35464293 PMCID: PMC9024082 DOI: 10.1177/20584601221094825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Only limited data have been published on the diagnostic accuracy of combining biparametric (bp) magnetic resonance imaging (MRI) and prostate-specific antigen density (PSAd) to rule out biopsies. Purpose The purpose is to assess the 2-year risk of being diagnosed with sPCa following the strategy of avoiding immediate biopsies in men with non-suspicious bp MRIs and a PSAd <0.15 ng/mL2. Material and Methods Two hundred biopsy-naïve men with clinical suspicion of PCa underwent a pre-biopsy bp MRI from March to July 2019. Of these, 109 men had a Prostate Imaging Reporting and Data System (PI-RADS) score of 1–3 including 77 men with calculated PSAd <0.15 ng/mL2. As a result, no biopsies were performed in these 77 men, who were clinically followed up for at least 2 years and re-examined in case of rising suspicion of sPCa. The remaining 32 men with a calculated PSAd ≥0.15 ng/mL2 underwent systematic biopsies and targeted biopsies of any PI-RADS 3 lesion. Results One of the 77 men (1.3%) had an sPCa diagnosed within 2 years of follow-up. All men were referred back to their general practitioner within 1 year and 9% (7/77) were re-referred to the urology department during follow-up. Among these men, 43% (3/7) continued to have PSA levels that were above their individual thresholds at confirmatory testing and underwent secondary MRI scans. Conclusions No biopsies for men with bpMRI results exhibiting maximum PI-RADS 3 and with a PSAd <0.15 ng/mL2 resulted in a 2-year risk of being diagnosed with sPCa of 1.3%.
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Affiliation(s)
| | - Vibeke Løgager
- Department of Radiology, Herlev Gentofte University Hospital, Herlev, Denmark
| | - Henrik S Thomsen
- Department of Radiology, Herlev Gentofte University Hospital, Herlev, Denmark
| | - Lars Boesen
- Department of Urological Research, Herlev Gentofte University Hospital, Herlev, Denmark
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12
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Patient- and tumor-level risk factors for MRI-invisible prostate cancer. Prostate Cancer Prostatic Dis 2021; 24:794-801. [PMID: 33568751 DOI: 10.1038/s41391-021-00330-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/21/2020] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Multiparametric MRI is highly sensitive for detection of clinically significant prostate cancer, but has a 10-20% false negative rate. It is unknown if there are clinical factors that predict MRI invisibility. We sought to identify predictors of MRI-invisible (MRI(-)) disease. METHODS Men undergoing MRI/US-fusion targeted + systematic biopsy by two surgeons at our institution from 2015 to 2018 were reviewed. Patient demographics, clinical data, MRI metrics, and biopsy pathology results were obtained by chart review. An MRI(-) tumor was defined as a positive systematic biopsy in a zone without an MRI lesion. Factors associated with presence of MRI(-) tumors were identified using stepwise multivariable logistic regression. RESULTS Of 194 men included in the analysis, 79 (41%) and 25 (13%) men had GG1+ and GG2+ MRI(-) tumors, respectively. On multivariable analysis, only Black race was associated with presence of GG1+ MRI(-) tumors (OR 2.2, 95% CI 1.02-4.96). Black race (OR 3.5, 95% CI 1.24-9.87) and higher PSA density (OR 2.0, 95% CI 1.34-3.20) were associated with presence of GG2+ MRI(-) tumors. In non-Black and Black men, detection of MRI(-) tumors on systematic biopsy upgraded patients from no disease to GG2+ disease 1% and 11% of the time, respectively, and from GG1 to GG2+ disease 42% and 60% of the time, respectively. CONCLUSIONS Black race and PSA density were associated with presence of MRI(-) prostate cancer. Further study on racial differences is warranted based on these results. Surgeons should consider pre-biopsy risk factors before deciding to omit systematic prostate biopsy regardless of mpMRI results.
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13
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Israël B, Immerzeel J, van der Leest M, Hannink G, Zámecnik P, Bomers J, Schoots IG, van Basten JP, Debruyne F, van Oort I, Sedelaar M, Barentsz J. Clinical implementation of pre-biopsy magnetic resonance imaging pathways for the diagnosis of prostate cancer. BJU Int 2021; 129:480-490. [PMID: 34358388 PMCID: PMC9291303 DOI: 10.1111/bju.15562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To assess the outcomes of pre‐biopsy magnetic resonance imaging (MRI) pathways, as a tool in biopsy‐naïve men with suspicion of prostate cancer, in routine clinical practice. Secondary outcomes included a comparison of transrectal MRI‐directed biopsy (TR‐MRDB) and transperineal (TP)‐MRDB in men with suspicious MRI. Patients and Methods We retrospectively assessed a two‐centre cohort of consecutive biopsy‐naïve men with suspicion of prostate cancer who underwent a Prostate Imaging‐Reporting and Data System version 2 (PI‐RADS v2) compliant pre‐biopsy MRI in a single, high‐volume centre between 2015 and 2019 (Centre 1). Men with suspicious MRI scans underwent TR‐MRDB in Centre 1 and TP‐MRDB with additional random biopsies (RB) in Centre 2. The MRI and histopathology were assessed in the same institution (Centre 1). Outcomes included: (i) overall detection rates of Grade Group (GG) 1, GG ≥2, and GG ≥3 cancer in men with suspicious MRI; (ii) Biopsy‐avoidance due to non‐suspicious MRI; and (iii) Cancer detection rates and biopsy‐related complications between TR‐ and TP‐MRDB. To reduce confounding bias for MRDB comparisons, inverse probability weighting (IPW) was performed for age, digital rectal examination, prostate‐specific antigen (PSA), prostate volume, PSA density, and PI‐RADS category. Results Of the 2597 men included, the overall GG 1, GG ≥2, and GG ≥3 prevalence was 8% (210/2597), 27% (697/2597), and 15% (396/2597), respectively. Biopsy was avoided in 57% (1488/2597) of men. After IPW, the GG 1, GG ≥2 and GG ≥3 detection rates after TR‐ and TP‐MRDB were comparable at 24%, 57%, and 32%; and 18%, 64%, and 38%, respectively; with mean differences of −5.7% (95% confidence interval [CI] −13% to 1.4%), 6.1% (95% CI −2.1% to 14%), and 5.7% (95% CI −1.7% to 13%). Complications were similar in TR‐MRDB (0.50%) and TP‐MRDB with RB (0.62%; mean difference 0.11%, 95% CI −0.87% to 1.1%). Conclusion This high‐volume, two‐centre study shows pre‐biopsy MRI as a decision tool is implementable in daily clinical practice. Compared to recent trials, a substantially higher biopsy avoidance rate was achieved without compromising GG ≥2/GG ≥3 detection and coinciding with lower over detection rates of GG 1 cancer. Prostate cancer detection and complication rates were comparable for TR‐ and TP‐MRDB.
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Affiliation(s)
- Bas Israël
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands.,Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Jos Immerzeel
- Department of Urology, Andros Clinics, Arnhem, the Netherlands
| | - Marloes van der Leest
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Patrik Zámecnik
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Joyce Bomers
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Frans Debruyne
- Department of Urology, Andros Clinics, Arnhem, the Netherlands
| | - Inge van Oort
- Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Michiel Sedelaar
- Department of Urology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Jelle Barentsz
- Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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14
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Van Poppel H, Hogenhout R, Albers P, van den Bergh RCN, Barentsz JO, Roobol MJ. A European Model for an Organised Risk-stratified Early Detection Programme for Prostate Cancer. Eur Urol Oncol 2021; 4:731-739. [PMID: 34364829 DOI: 10.1016/j.euo.2021.06.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Overdiagnosis as the argument to stop prostate cancer (PCa) screening is less valid since the introduction of new technologies such as risk calculators (RCs) and magnetic resonance imaging (MRI). These new technologies result in fewer unnecessary biopsy procedures and fewer cases of both overdiagnosis and underdetection. Therefore, we can now adequately respond to the growing and urgent need for a structured risk assessment to detect PCa early. OBJECTIVE To provide expert discussion on the existing evidence for a previously published risk-stratified strategy regarding an organised population-based early detection programme for PCa. EVIDENCE ACQUISITION The proposed algorithm for early detection of PCa emerged from expert consensus by the authors based on available evidence derived from a nonsystematic review of the current literature using Medline/PubMed, Cochrane Library database, ClinicalTrials.gov, ISRCTN Registry, and the European Association of Urology guidelines on PCa. EVIDENCE SYNTHESIS Although not confirmed by the highest level of evidence, current literature and guidelines point towards an algorithm for early detection of PCa that starts with risk-based prostate-specific antigen (PSA) testing, followed by multivariable risk stratification with RCs. All men who are classified to be at intermediate and high risk are then offered prostate MRI. The combined data from RCs and MRI results can be used to select men for prostate biopsy. Low-risk men return to a risk-based safety net that includes individualised PSA-interval tests and, if necessary, repeated MRI. Depending on local availability, the use of the different risk stratification tools may be adapted. CONCLUSIONS We present a risk-stratified algorithm for an organised population-based early detection programme for clinically significant PCa. Although the proposed strategy has not yet been analysed prospectively, it exploits and may even improve the most important available benefits of "PSA-only" screening studies, while at the same time reduces unnecessary biopsies and overdiagnosis by using new risk stratification tools. PATIENT SUMMARY This paper presents a personalised strategy that enables selective early detection of prostate cancer by combining prostate-specific antigen (interval) testing' prediction models (risk calculators), and magnetic resonance imaging scans. This will likely lead to reduced prostate cancer-related morbidity and mortality, while reducing the need for prostate biopsy and limiting overdiagnosis.
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Affiliation(s)
- Hendrik Van Poppel
- Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium.
| | - Renée Hogenhout
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter Albers
- Department of Urology, Heinrich-Heine University Medical Faculty, Düsseldorf, Germany; Division of Personalized Early Detection of Prostate Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Jelle O Barentsz
- Department of Medical Imaging, Radboudumc, Nijmegen, The Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
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15
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Wagenlehner F, Bonkat G, Pilatz A. [Prostate biopsy 2021: current management]. Aktuelle Urol 2021; 52:356-359. [PMID: 33979884 DOI: 10.1055/a-1478-2793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Infectious complications following prostate biopsy are on the rise due to an increase in antimicrobial resistance, mainly against fluoroquinolones. The use of fluoroquinolones for perioperative prophylaxis is no longer approved by the national authorities in Germany. The EAU guideline group on urological infections has recently published a meta-analysis in two parts based on randomised controlled trials (RCTs). Transperineal prostate biopsy is associated with a significantly reduced rate of infectious complications compared with transrectal biopsy and should therefore be preferred. If transrectal biopsy is performed, intrarectal cleaning with povidone-iodine and antibiotic prophylaxis without fluoroquinolones should be chosen. Antibiotic prophylactic strategies include targeted prophylaxis after susceptibility testing of the rectal flora, augmented prophylaxis with multiple antibiotics and empiric mono-prophylaxis with non-fluoroquinolones. Data from RCTs are available for aminoglycosides, third-generation cephalosporins and fosfomycin trometamol.
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Affiliation(s)
- Florian Wagenlehner
- Justus-Liebig-Universität Gießen, Klinik für Urologie, Kinderurologie und Andrologie, Giessen
| | | | - Adrian Pilatz
- Justus-Liebig-Universität Gießen, Klinik für Urologie, Kinderurologie und Andrologie, Giessen
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16
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Apfelbeck M, Pfitzinger P, Bischoff R, Rath L, Buchner A, Mumm JN, Schlenker B, Stief CG, Chaloupka M, Clevert DA. Predictive clinical features for negative histopathology of MRI/Ultrasound-fusion-guided prostate biopsy in patients with high likelihood of cancer at prostate MRI: Analysis from a urologic outpatient clinic1. Clin Hemorheol Microcirc 2021; 76:503-511. [PMID: 33337358 DOI: 10.3233/ch-209225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate clinical features associated with benign histopathology of Prostate Imaging Reporting and Data System (PI-RADS) category 4 and 5 lesions. MATERIALS AND METHODS Between March 2015 and November 2020, 1161 patients underwent mpMRI/Ultrasound-fusion-guided prostate biopsy (FBx) and concurrent 12-core systematic prostate biopsy (SBx) at the Department of Urology of the Ludwig-Maximilians-University of Munich, Germany. 848/ 1161 (73%) patients presented with either PI-RADS 4 or 5 index lesion and were retrospectively evaluated. Multivariate analysis was performed to evaluate clinical parameters associated with a negative outcome of PI-RADS 4 or 5 category lesions after FBx. Area under the receiver operating characteristics (ROC) curve (AUC) was conducted using ROC-analysis. RESULTS 676/848 (79.7%) patients with either PI-RADS 4 or 5 index lesion were diagnosed with prostate cancer (PCa) by FBx and 172/848 (20.3%) patients had a negative biopsy (including the concurrent systematic prostate biopsy), respectively. Prostate volume (P-Vol) (OR 0.99, 95% CI = 0.98-1.00, p = 0.038), pre-biopsy-status (OR 0.48, 95% CI = 0.29-0.79, p = 0.004) and localization of the lesion in the transitional zone (OR 0.28, 95% CI = 0.13-0.60, p = 0.001) were independent risk factors for a negative outcome of FBx. Age (OR 1.09, 95% CI = 1.05-1.13, p < 0.001) and PSA density (PSAD) (OR 75.92, 95% CI = 1.03-5584.61, p = 0.048) increased the risk for PCa diagnosis after FBx. The multivariate logistic regression model combining all clinical characteristics achieved an AUC of 0.802 (95% CI = 0.765-0.835; p < 0.001) with a sensitivity and specificity of 66% and 85%. CONCLUSION Lesions with high or highly likelihood of PCa on multiparametric magnetic resonance imaging (mpMRI) but subsequent negative prostate biopsy occur in a small amount of patients. Localization of the lesion in the transitional zone, prostate volume and prebiopsy were shown to be predictors for benign histopathology of category 4 or 5 lesions on mpMRI. Integration of these features into daily clinical routine could be used for risk-stratification of these patients after negative biopsy of PI-RADS 4 or 5 index lesions.
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Affiliation(s)
- Maria Apfelbeck
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Paulo Pfitzinger
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Robert Bischoff
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lukas Rath
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Buchner
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jan-Niklas Mumm
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Boris Schlenker
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christian G Stief
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Chaloupka
- Department of Urology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dirk-André Clevert
- Interdisciplinary Ultrasound-Center, Department of Radiology, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
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17
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Abstract
Pre-biopsy multiparametric MRI is now recommended by multiple guidelines, not only for men with persistent suspicion of prostate cancer after prior negative systematic biopsy, but also at initial screening before the first biopsy. The major benefit of pre-biopsy MRI in the diagnostic work-up is to promote individualized risk-adapted approaches for biopsy-decision management. Multiple MRI-directed diagnostic pathways can be conceived, with each approach having net-benefit trade-offs between benefits and harms, based on improved diagnostic yields of significant cancers and reduced biopsy testing and reduced detection of indolent prostate cancer. In this paper, we illustrate how clinical benefits can be maximized in men with MRI-negative and MRI-positive results, using the PI-RADS Multiparametric MRI and MRI-directed biopsy pathway. From a practice perspective, we emphasize five golden rules: (1) that multiparametric MRI approach including targeted biopsies be reserved for men likely to benefit from early detection and treatment of prostate cancer; (2) that there is a need to carefully assess risk of significant disease using PSA and clinical parameters before and after MRI; (3) do not offer immediate biopsy if the MRI is negative, unless other high-risk factors are present; (4) accept that not all significant cancers are found immediately and have robust 'safety nets' for men with negative MRI scans who avoid immediate biopsy and for positive MRI patients with negative or non-explanatory histology; and (5) use MRI-directed biopsy methods that minimize overdiagnosis and improve risk stratification.
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Affiliation(s)
- Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, 's-Gravendijkwal 230, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK
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18
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Pilatz A, Veeratterapillay R, Dimitropoulos K, Omar MI, Pradere B, Yuan Y, Cai T, Mezei T, Devlies W, Bruyère F, Bartoletti R, Köves B, Geerlings S, Schubert S, Grummet J, Mottet N, Wagenlehner F, Bonkat G. European Association of Urology Position Paper on the Prevention of Infectious Complications Following Prostate Biopsy. Eur Urol 2020; 79:11-15. [PMID: 33172721 DOI: 10.1016/j.eururo.2020.10.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 02/01/2023]
Abstract
The transperineal approach is preferred to reduce prostate biopsy (PB)-related infections. Fluoroquinolones are suspended for prophylaxis of PB in the European Union; therefore, alternative antibiotics based on local resistance, or targeted prophylaxis, in conjunction with povidone-iodine rectal preparation are recommended for transrectal PB.
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Affiliation(s)
- Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany.
| | | | | | | | - Benjamin Pradere
- Department of Urology, CHRU Bretonneau, Tours, France; Université Francois Rabelais, PRES Centre Val de Loire, Tours, France
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
| | - Tommaso Cai
- Department of Urology, Santa Chiara, Reg. Hospital, Trento, Italy
| | - Tunde Mezei
- Department of Urology, Telemark Hospital, Skien, Norway
| | - Wout Devlies
- Department of Urology, UZ Leuven, Leuven, Belgium
| | - Franck Bruyère
- Department of Urology, CHRU Bretonneau, Tours, France; Université Francois Rabelais, PRES Centre Val de Loire, Tours, France
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies, University of Pisa, Italy
| | - Bela Köves
- Department of Urology, South-Pest Teaching Hospital, Budapest, Hungary
| | - Suzanne Geerlings
- Department of Internal Medicine, Amsterdam University Medical Center, The Netherlands
| | - Sören Schubert
- Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Germany
| | - Jeremy Grummet
- Department of Surgery, Alfred Health, Central Clinical School, Monash University, Melbourne, Australia
| | - Nicolas Mottet
- Department of Urology, University Jean Monnet St Etienne, Saint-Étienne, France
| | - Florian Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Gernot Bonkat
- Alta Uro AG, Merian Iselin Klinik, Center of Biomechanics and Calorimetry, University Basel, Basel, Switzerland
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19
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Pilatz A, Bonkat G, Wagenlehner F. [Infectious complications following prostate biopsy-Major changes 2020]. Urologe A 2020; 59:1486-1491. [PMID: 33044635 DOI: 10.1007/s00120-020-01365-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been suspended in Germany by the national authorities. OBJECTIVES This review is intended to highlight current strategies for reducing infectious complications following prostate biopsy. MATERIALS AND METHODS The European Association of Urology (EAU) guideline group on urological infections recently published a meta-analysis in two parts based on randomized controlled trials (RCTs). The most important contents shall be presented here. RESULTS Transperineal prostate biopsy is associated with significantly reduced infectious complications than transrectal biopsy. If transrectal biopsy is performed, intrarectal cleaning with povidone-iodine and antibiotic prophylaxis without fluoroquinolones should be chosen. Antibiotic prophylactic strategies include targeted prophylaxis after susceptibility testing of the rectal flora, augmented prophylaxis with multiple antibiotics and empiric monoprophylaxis with nonfluoroquinolones. Here data from RCTs are available for aminoglycosides, third generation cephalosporines, and fosfomycin trometamol. CONCLUSIONS The transperineal approach is preferred to reduce prostate biopsy-related infections. Fluoroquinolones are no longer approved for prophylaxis. Thus, alternative antibiotics based on local resistance, or targeted prophylaxis, in conjunction with povidone-iodine rectal preparation are recommended for transrectal prostate biopsy.
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Affiliation(s)
- A Pilatz
- Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland.
| | | | - F Wagenlehner
- Klinik und Poliklinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland
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20
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Hietikko R, Kilpeläinen TP, Kenttämies A, Ronkainen J, Ijäs K, Lind K, Marjasuo S, Oksala J, Oksanen O, Saarinen T, Savolainen R, Taari K, Tammela TLJ, Mirtti T, Natunen K, Auvinen A, Rannikko A. Expected impact of MRI-related interreader variability on ProScreen prostate cancer screening trial: a pre-trial validation study. Cancer Imaging 2020; 20:72. [PMID: 33036660 PMCID: PMC7547469 DOI: 10.1186/s40644-020-00351-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study is to investigate the potential impact of prostate magnetic resonance imaging (MRI) -related interreader variability on a population-based randomized prostate cancer screening trial (ProScreen). METHODS From January 2014 to January 2018, 100 men aged 50-63 years with clinical suspicion of prostate cancer (PCa) in Helsinki University Hospital underwent MRI. Nine radiologists individually reviewed the pseudonymized MRI scans of all 100 men in two ProScreen trial centers. All 100 men were biopsied according to a histological composite variable comprising radical prostatectomy histology (N = 38) or biopsy result within 1 year from the imaging (N = 62). Fleiss' kappa (κ) was used to estimate the combined agreement between all individual radiologists. Sample data were subsequently extrapolated to 1000-men subgroups of the ProScreen cohort. RESULTS Altogether 89% men of the 100-men sample were diagnosed with PCa within a median of 2.4 years of follow-up. Clinically significant PCa (csPCa) was identified in 76% men. For all PCa, mean sensitivity was 79% (SD ±10%, range 62-96%), and mean specificity 60% (SD ±22%, range 27-82%). For csPCa (Gleason Grade 2-5) MRI was equally sensitive (mean 82%, SD ±9%, range 67-97%) but less specific (mean 47%, SD ±20%, range 21-75%). Interreader agreement for any lesion was fair (κ 0.40) and for PI-RADS 4-5 lesions it was moderate (κ 0.60). Upon extrapolating these data, the average sensitivity and specificity to a screening positive subgroup of 1000 men from ProScreen with a 30% prevalence of csPCa, 639 would be biopsied. Of these, 244 men would be true positive, and 395 false positive. Moreover, 361 men would not be referred to biopsy and among these, 56 csPCas would be missed. The variation among the radiologists was broad as the least sensitive radiologist would have twice as many men biopsied and almost three times more men would undergo unnecessary biopsies. Although the most sensitive radiologist would miss only 2.6% of csPCa (false negatives), the least sensitive radiologist would miss every third. CONCLUSIONS Interreader agreement was fair to moderate. The role of MRI in the ongoing ProScreen trial is crucial and has a substantial impact on the screening process.
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Affiliation(s)
- Ronja Hietikko
- Department of Urology, University of Helsinki and Helsinki University Hospital, PL900, 00029 HUS, Helsinki, Finland. .,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, PL900, 00029 HUS, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Anu Kenttämies
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,HUS Diagnostic Center, HUS Medical Imaging Center / Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Ronkainen
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Kirsty Ijäs
- HUS Diagnostic Center, HUS Medical Imaging Center / Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kati Lind
- HUS Diagnostic Center, HUS Medical Imaging Center / Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi Marjasuo
- HUS Diagnostic Center, HUS Medical Imaging Center / Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Oksala
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Outi Oksanen
- HUS Diagnostic Center, HUS Medical Imaging Center / Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas Saarinen
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Ritja Savolainen
- HUS Diagnostic Center, HUS Medical Imaging Center / Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kimmo Taari
- Department of Urology, University of Helsinki and Helsinki University Hospital, PL900, 00029 HUS, Helsinki, Finland
| | - Teuvo L J Tammela
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Tuomas Mirtti
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,HUSLAB Laboratory Services, Department of Pathology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Kari Natunen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Anssi Auvinen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Antti Rannikko
- Department of Urology, University of Helsinki and Helsinki University Hospital, PL900, 00029 HUS, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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21
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MRI-targeted or systematic random biopsies for prostate cancer diagnosis in biopsy naïve patients: follow-up of a PRECISION trial-like retrospective cohort. Prostate Cancer Prostatic Dis 2020; 24:406-413. [PMID: 32989259 DOI: 10.1038/s41391-020-00290-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/04/2020] [Accepted: 09/16/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To test clinically significant prostate cancer (csPCa) rates during follow-up in biopsy naïve patients that underwent two different diagnostic pathways: (1) SB GROUP (n = 354): systematic random biopsies (SB) vs. (2) TB GROUP (n = 264): multiparametric magnetic resonance imaging (mpMRI) and only targeted biopsies (TB) of PI-RADS ≥ 3 lesions. Patients with PI-RADS ≤ 2 score avoided prostate biopsies. METHODS Retrospective single centre study of 618 biopsy naive patients (2015-2018). Two different definitions of csPCa were used: (1) csPCa ISUP GG ≥ 2 (ISUP grade group [GG] ≥ 2) and (2) csPCa ISUP GG ≥ 3. Kaplan-Meier plots and univariable Cox regression models tested rates over time of csPCa ISUP GG ≥ 2 and caPCa ISUP GG ≥ 3 in SB GROUP vs. TB GROUP. RESULTS At initial biopsy, TB achieved higher rates of csPCa ISUP GG ≥ 2 (35.3 vs. 18.9%; p < 0.001) and csPCa ISUP GG ≥ 3 (12.6 vs. 6.2%; p = 0.04), relative to SB. After a median time follow-up of 36 months, the rates of csPCa ISUP GG ≥ 2 (6.1 vs. 4.4%; p = 0.6) and csPCa ISUP GG ≥ 3 (3.3 vs. 1.1%; p = 0.2) were similar in SB GROUP vs. TB GROUP. Moreover, in TB GROUP patients that avoided prostate biopsies because of negative baseline mpMRI (n = 145), only 4.1% exhibited csPCa ISUP GG ≥ 2 during follow-up. Moreover, none of these patients (PI-RADS ≤ 2) had csPCa ISUP GG ≥ 3. CONCLUSIONS In biopsy naïve setting, a diagnostic pathway including pre-biopsy mpMRI and TB of only PCa suspicious lesions is not associated with higher rates of csPCa during follow-up, relative to a diagnostic pathway of SB. Moreover, patients with negative baseline mpMRI could safely avoid prostate biopsies and could be followed with repeated PSA testing, since only a small proportion of them would harbor csPCa.
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22
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Hosseiny M, Felker ER, Azadikhah A, Suvannarerg V, Sayre J, Ponzini D, Ahuja P, Lu D, Raman SS. Efficacy of 3T Multiparametric MR Imaging followed by 3T in-Bore MR-Guided Biopsy for Detection of Clinically Significant Prostate Cancer Based on PIRADSv2.1 Score. J Vasc Interv Radiol 2020; 31:1619-1626. [PMID: 32921565 DOI: 10.1016/j.jvir.2020.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/17/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To evaluate the diagnostic yield of 3T in-Bore magnetic resonance-guided biopsy (3T IB-MRGB) for detection of clinically significant prostate cancer (csPCa), based on assessment using the Prostate Imaging Reporting and Data System version 2.1 (PIRADSv2.1). MATERIALS AND METHODS This single-center study examined individuals who underwent 3T multiparametric prostate magnetic resonance (MR) imaging and subsequent 3T IB-MRGB. The final study cohort included 379 men (with 475 targets) divided into 3 subcohorts: biopsy-naïve men (n = 123), individuals with a history of negative trans-rectal-ultrasonography (TRUS) biopsy results (n = 106), and men with low-grade PCa under active surveillance (n = 150). csPCa was defined as having a Gleason score (GS) ≥3+4. RESULTS 3T IB-MRGB detected PCa and csPCa in 69.1% (262 of 379) and 50.3% (193 of 379) of patients, respectively. The PCa and csPCa detection rates per target were 64.2% (305 of 475) and 43.8% (208 of 475), respectively. The rate of urosepsis, treated with intravenous antibiotics, was 1% (4 patients). In TRUS biopsy negative results and biopsy-naïve subcohorts, csPCa was found in 36.8% (39 of 106) and 52.8% (65 of 123), respectively. In 50.7% (76 of 150) of the active surveillance subcohort, 3T IB-MRGB upgraded the GS assigned in prior TRUS biopsies. Positive predictive values of PIRADSv2.1 categories 3, 4, and 5 for csPCa detection were 24.8%, 44.4%, and 67.1%, respectively. Higher PIRADSv2.1 categories were significantly associated with PCa (odds ratio [OR], 3.97; 95% confidence interval [CI], 2.98-5.28) and csPCa (OR, 1.41; 95% CI, 1.03-1.94) detection. Of 137 PIRADSv2 category 3 lesions, 28 were downgraded to PIRADSv2.1 category 2, in which there were no occurrences of csPCa in histology. CONCLUSIONS Use of 3T IB-MRGB resulted in detection of csPCa in 50.9% of individuals. 3T IB-MRGB has a high diagnostic yield in individuals with negative TRUS biopsy results and those under active surveillance. The PIRADSv2.1 category is a strong predictor of PCa and csPCa detection.
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Affiliation(s)
- Melina Hosseiny
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Ely R Felker
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Afshin Azadikhah
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Voraparee Suvannarerg
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - James Sayre
- Department of Bioinformatics, University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Danielle Ponzini
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Preeti Ahuja
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David Lu
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Steven S Raman
- Department of Radiology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Urology, Ronald Reagan-University of California Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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23
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Sokhi HK, Padhani AR, Patel S, Pope A. Diagnostic yields in patients with suspected prostate cancer undergoing MRI as the first-line investigation in routine practice. Clin Radiol 2020; 75:950-956. [PMID: 32919755 DOI: 10.1016/j.crad.2020.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022]
Abstract
AIM To document cancer yields of magnetic resonance imaging (MRI)-directed biopsies in men with suspected prostate cancer referred to secondary care. MATERIALS AND METHODS Men with suspected cancer undergoing multiparametric prostate MRI as the first-line investigation were included in the present study. Systematic transrectal prostate biopsies with/without cognitive targeted biopsies were performed. Diagnostic yields of International Society of Urological Pathology (ISUP) ≥2 cancers by the Prostate Imaging Reporting and Data System (PI-RADS) category were recorded. Impacts of prostate-specific antigen (PSA) density on biopsy results and yields of non-targeted biopsies in MRI non-suspicious prostate sextants assessed. RESULTS Of 262 men (90.5% biopsy naive), 86 (33%) MRI examinations were negative (PI-RADS 1-2) and 176 (67%) positive (PI-RADS 3: 8%; PI-RADS 4: 21%; PI-RADS 5: 38%). Two hundred and thirteen of 262 patients underwent a biopsy. ISUP ≥2 cancer detection rates were 8% (5/61) for PI-RADS 1-2, 18% (3/17) for PI-RADS 3, 49% (22/45) for PI-RADS 4, and 80% (72/90) for PI-RADS 5. Proportions of ISUP ≥2 increased with higher PSA densities in positive patients (%ISUP ≥2 for PSA density groups <0.12, 0.12 to <0.15 and ≥ 0.15 was 0%, 0%, 25% for PI-RADS 3, 21%, 33%, 68% for PI-RADS 4 and 40%, 83%, 89% for PI-RADS 5 respectively). ISUP ≥2 cancers were twice as likely in tumour adjacent sextants (52% versus 24%), without upgrading of gland level histology from insignificant to clinically significant prostate cancer by the sampling of normal-appearing tumour non-adjacent sextants. CONCLUSIONS One third of men can avoid biopsy after negative MRI. Cancer detection rates increase with PSA density values within positive MRI suspicion categories. Sampling normal-appearing tumour non-adjacent sextants may be unnecessary for whole-gland therapy.
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Affiliation(s)
- H K Sokhi
- Department of Radiology, Hillingdon and Mount Vernon Hospitals, The Hillingdon Hospitals NHS Foundation Trust, Pield Heath Road, Uxbridge UB83NN, UK; Paul Strickland Scanner Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, HA62RN, UK.
| | - A R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Hospital, Rickmansworth Road, Northwood, HA62RN, UK
| | - S Patel
- Department of Radiology, Hillingdon and Mount Vernon Hospitals, The Hillingdon Hospitals NHS Foundation Trust, Pield Heath Road, Uxbridge UB83NN, UK
| | - A Pope
- Department of Urology, Hillingdon and Mount Vernon Hospitals, The Hillingdon Hospitals NHS Foundation Trust, Pield Heath Road, Uxbridge UB83NN, UK
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24
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Multiparametric magnetic resonance imaging and multiparametric magnetic resonance imaging-guided biopsy in the diagnostic pathway of prostate cancer. Radiologe 2020; 60:63-69. [PMID: 32666150 DOI: 10.1007/s00117-020-00716-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multiparametric magnetic resonance imaging (mpMRI) of the prostate and mpMRI-guided biopsy have proved to be a valuable part of the diagnostic pathway for prostate cancer. This review reports on the current results in terms of clinical performance of these diagnostic tools and their role in clinical decision-making.
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25
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Eineluoto JT, Sandeman K, Pohjonen J, Sopyllo K, Nordling S, Stürenberg C, Malén A, Kilpeläinen TP, Santti H, Petas A, Matikainen M, Pellinen T, Järvinen P, Kenttämies A, Rannikko A, Mirtti T. Associations of PTEN and ERG with Magnetic Resonance Imaging Visibility and Assessment of Non-organ-confined Pathology and Biochemical Recurrence After Radical Prostatectomy. Eur Urol Focus 2020; 7:1316-1323. [PMID: 32620540 DOI: 10.1016/j.euf.2020.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/18/2020] [Accepted: 06/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Diagnosing clinically significant prostate cancer (PCa) is challenging, but may be facilitated by biomarkers and multiparametric magnetic resonance imaging (MRI). OBJECTIVE To determine the association between biomarkers phosphatase and tensin homolog (PTEN) and ETS-related gene (ERG) with visible and invisible PCa lesions in MRI, and to predict biochemical recurrence (BCR) and non-organ-confined (non-OC) PCa by integrating clinical, MRI, and biomarker-related data. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of a population-based cohort of men with PCa, who underwent preoperative MRI followed by radical prostatectomy (RP) during 2014-2015 in Helsinki University Hospital (n = 346), was conducted. A tissue microarray corresponding to the MRI-visible and MRI-invisible lesions in RP specimens was constructed and stained for PTEN and ERG. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Associations of PTEN and ERG with MRI-visible and MRI-invisible lesions were examined (Pearson's χ2 test), and predictions of non-OC disease together with clinical and MRI parameters were determined (area under the receiver operating characteristic curve and logistic regression analyses). BCR prediction was analyzed by Kaplan-Meier and Cox proportional hazard analyses. RESULTS AND LIMITATIONS Patients with MRI-invisible lesions (n = 35) had less PTEN loss and ERG-positive expression compared with patients (n = 90) with MRI-visible lesions (17.2% vs 43.3% [p = 0.006]; 8.6% vs 20.0% [p = 0.125]). Patients with invisible lesions had better, but not statistically significantly improved, BCR-free survival probability in Kaplan-Meier analyses (p = 0.055). Rates of BCR (5.7% vs 21.1%; p = 0.039), extraprostatic extension (11.4% vs 44.6%; p < 0.001), seminal vesicle invasion (0% vs 21.1%; p = 0.003), and lymph node metastasis (0% vs 12.2%; p = 0.033) differed between the groups in favor of patients with MRI-invisible lesions. Biomarkers had no independent role in predicting non-OC disease or BCR. The short follow-up period was a limitation. CONCLUSIONS PTEN loss, BCR, and non-OC RP findings were more often encountered with MRI-visible lesions. PATIENT SUMMARY Magnetic resonance imaging (MRI) of the prostate misses some cancer lesions. MRI-invisible lesions seem to be less aggressive than MRI-visible lesions.
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Affiliation(s)
- Juho T Eineluoto
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Kevin Sandeman
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland; Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Joona Pohjonen
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland
| | - Konrad Sopyllo
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland
| | - Stig Nordling
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Carolin Stürenberg
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland
| | - Adrian Malén
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Henrikki Santti
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anssi Petas
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Matikainen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Teijo Pellinen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland
| | - Petrus Järvinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anu Kenttämies
- HUS Medical Imaging Center Department of Diagnostic Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Rannikko
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland; Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas Mirtti
- Research Program in Systems Oncology, University of Helsinki, Helsinki, Finland; Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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26
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Radtke JP, Hadaschik B. Re: MRI-Targeted, Systematic, and Combined Biopsy for Prostate Cancer Diagnosis. Eur Urol 2020; 78:291-292. [PMID: 32381459 DOI: 10.1016/j.eururo.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Boris Hadaschik
- Department of Urology, University of Duisburg-Essen, Essen, Germany.
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27
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Panebianco V, Pecoraro M, Fiscon G, Paci P, Farina L, Catalano C. Prostate cancer screening research can benefit from network medicine: an emerging awareness. NPJ Syst Biol Appl 2020; 6:13. [PMID: 32382028 PMCID: PMC7206063 DOI: 10.1038/s41540-020-0133-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/09/2020] [Indexed: 01/03/2023] Open
Abstract
Up to date, screening for prostate cancer (PCa) remains one of the most appealing but also a very controversial topics in the urological community. PCa is the second most common cancer in men worldwide and it is universally acknowledged as a complex disease, with a multi-factorial etiology. The pathway of PCa diagnosis has changed dramatically in the last few years, with the multiparametric magnetic resonance (mpMRI) playing a starring role with the introduction of the “MRI Pathway”. In this scenario the basic tenet of network medicine (NM) that sees the disease as perturbation of a network of interconnected molecules and pathways, seems to fit perfectly with the challenges that PCa early detection must face to advance towards a more reliable technique. Integration of tests on body fluids, tissue samples, grading/staging classification, physiological parameters, MR multiparametric imaging and molecular profiling technologies must be integrated in a broader vision of “disease” and its complexity with a focus on early signs. PCa screening research can greatly benefit from NM vision since it provides a sound interpretation of data and a common language, facilitating exchange of ideas between clinicians and data analysts for exploring new research pathways in a rational, highly reliable, and reproducible way.
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Affiliation(s)
- Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I of Rome, Rome, Italy.
| | - Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I of Rome, Rome, Italy
| | - Giulia Fiscon
- Institute for System Analysis and Computer Science (IASI), National Research Council, Rome, Italy
| | - Paola Paci
- Institute for System Analysis and Computer Science (IASI), National Research Council, Rome, Italy
| | - Lorenzo Farina
- Department of Computer, Control and Management Engineering, Sapienza University of Rome, Rome, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I of Rome, Rome, Italy
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28
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Tops SCM, Koldewijn EL, Somford DM, Huis AMP, Kolwijck E, Wertheim HFL, Hulscher MEJL, Sedelaar JPM. Prostate biopsy techniques and pre-biopsy prophylactic measures: variation in current practice patterns in the Netherlands. BMC Urol 2020; 20:24. [PMID: 32164686 PMCID: PMC7066741 DOI: 10.1186/s12894-020-00592-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 02/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The clinical landscape of prostate biopsy (PB) is evolving with changes in procedures and techniques. Moreover, antibiotic resistance is increasing and influences the efficacy of pre-biopsy prophylactic regimens. Therefore, increasing antibiotic resistance may impact on clinical care, which probably results in differences between hospitals. The objective of our study is to determine the (variability in) current practices of PB in the Netherlands and to gain insight into Dutch urologists' perceptions of fluoroquinolone resistance and biopsy related infections. METHODS An online questionnaire was prepared using SurveyMonkey® platform and distributed to all 420 members of the Dutch Association of Urology, who work in 81 Dutch hospitals. Information about PB techniques and periprocedural antimicrobial prophylaxis was collected. Urologists' perceptions regarding pre-biopsy antibiotic prophylaxis in an era of antibiotic resistance was assessed. Descriptive statistical analysis was performed. RESULTS One hundred sixty-one responses (38.3%) were analyzed representing 65 (80.3%) of all Dutch hospitals performing PB. Transrectal ultrasound guided prostate biopsy (TRUSPB) was performed in 64 (98.5%) hospitals. 43.1% of the hospitals (also) used other image-guided biopsy techniques. Twenty-three different empirical prophylactic regimens were reported among the hospitals. Ciprofloxacin was most commonly prescribed (84.4%). The duration ranged from one pre-biopsy dose (59.4%) to 5 days extended prophylaxis. 25.2% of the urologists experienced ciprofloxacin resistance as a current problem in the prevention of biopsy related infections and 73.6% as a future problem. CONCLUSIONS There is a wide variation in practice patterns among Dutch urologists. TRUSPB is the most commonly used biopsy technique, but other image-guided biopsy techniques are increasingly used. Antimicrobial prophylaxis is not standardized and prolonged prophylaxis is common. The wide variation in practice patterns and lack of standardization underlines the need for evidence-based recommendations to guide urologists in choosing appropriate antimicrobial prophylaxis for PB in the context of increasing antibiotic resistance.
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Affiliation(s)
- Sofie C. M. Tops
- Department of Medical Microbiology, Radboud Center Infectious Diseases, Radboudumc, huispost 777, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | | | - Diederik M. Somford
- Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Anita M. P. Huis
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Eva Kolwijck
- Department of Medical Microbiology, Radboud Center Infectious Diseases, Radboudumc, huispost 777, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Heiman F. L. Wertheim
- Department of Medical Microbiology, Radboud Center Infectious Diseases, Radboudumc, huispost 777, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Marlies E. J. L. Hulscher
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
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29
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Re: can prostate cancer be NICE? A reply. Clin Radiol 2020; 75:233-234. [DOI: 10.1016/j.crad.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/05/2019] [Indexed: 11/24/2022]
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