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Jeganathan T, Salgues E, Schick U, Tissot V, Fournier G, Valéri A, Nguyen TA, Bourbonne V. Inter-Rater Variability of Prostate Lesion Segmentation on Multiparametric Prostate MRI. Biomedicines 2023; 11:3309. [PMID: 38137530 PMCID: PMC10741937 DOI: 10.3390/biomedicines11123309] [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: 11/25/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION External radiotherapy is a major treatment for localized prostate cancer (PCa). Dose escalation to the whole prostate gland increases biochemical relapse-free survival but also acute and late toxicities. Dose escalation to the dominant index lesion (DIL) only is of growing interest. It requires a robust delineation of the DIL. In this context, we aimed to evaluate the inter-observer variability of DIL delineation. MATERIAL AND METHODS Two junior radiologists and a senior radiation oncologist delineated DILs on 64 mpMRIs of patients with histologically confirmed PCa. For each mpMRI and each reader, eight individual DIL segmentations were delineated. These delineations were blindly performed from one another and resulted from the individual analysis of the T2, apparent diffusion coefficient (ADC), b2000, and dynamic contrast enhanced (DCE) sequences, as well as the analysis of combined sequences (T2ADC, T2ADCb2000, T2ADCDCE, and T2ADCb2000DCE). Delineation variability was assessed using the DICE coefficient, Jaccard index, Hausdorff distance measure, and mean distance to agreement. RESULTS T2, ADC, T2ADC, b2000, T2 + ADC + b2000, T2 + ADC + DCE, and T2 + ADC + b2000 + DCE sequences obtained DICE coefficients of 0.51, 0.50, 0.54, 0.52, 0.54, 0.55, 0.53, respectively, which are significantly higher than the perfusion sequence alone (0.35, p < 0.001). The analysis of other similarity metrics lead to similar results. The tumor volume and PI-RADS classification were positively correlated with the DICE scores. CONCLUSION Our study showed that the contours of prostatic lesions were more reproducible on certain sequences but confirmed the great variability of prostatic contours with a maximum DICE coefficient calculated at 0.55 (joint analysis of T2, ADC, and perfusion sequences).
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Affiliation(s)
- Thibaut Jeganathan
- Radiology Department, University Hospital, 29200 Brest, France; (T.J.); (E.S.); (V.T.)
| | - Emile Salgues
- Radiology Department, University Hospital, 29200 Brest, France; (T.J.); (E.S.); (V.T.)
| | - Ulrike Schick
- Radiation Oncology Department, University Hospital, 29200 Brest, France;
- INSERM, LaTIM UMR 1101, University of Western Brittany, 29238 Brest, France; (G.F.); (A.V.); (T.-A.N.)
| | - Valentin Tissot
- Radiology Department, University Hospital, 29200 Brest, France; (T.J.); (E.S.); (V.T.)
| | - Georges Fournier
- INSERM, LaTIM UMR 1101, University of Western Brittany, 29238 Brest, France; (G.F.); (A.V.); (T.-A.N.)
- Urology Department, University Hospital, 29200 Brest, France
| | - Antoine Valéri
- INSERM, LaTIM UMR 1101, University of Western Brittany, 29238 Brest, France; (G.F.); (A.V.); (T.-A.N.)
- Urology Department, University Hospital, 29200 Brest, France
| | - Truong-An Nguyen
- INSERM, LaTIM UMR 1101, University of Western Brittany, 29238 Brest, France; (G.F.); (A.V.); (T.-A.N.)
- Urology Department, University Hospital, 29200 Brest, France
| | - Vincent Bourbonne
- Radiation Oncology Department, University Hospital, 29200 Brest, France;
- INSERM, LaTIM UMR 1101, University of Western Brittany, 29238 Brest, France; (G.F.); (A.V.); (T.-A.N.)
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Li J, Wang K, Li S, Wu P, Wang X, He Y, Tang W. Clinical study of multifactorial diagnosis in prostate biopsy. Prostate 2023; 83:1494-1503. [PMID: 37545333 DOI: 10.1002/pros.24608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/14/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE To study the feasibility of using an artificial intelligence (AI) algorithm for the diagnosis of clinically significant prostate cancer (csPCa) on multiparametric MRI (mpMRI) in combination with conventional clinical information. METHODS A retrospective study cohort with 505 patients was collected, with complete information on age (≤60, 60-80, and >80 years), PSA (≤4, 4-10, and >10 ng/dL), and pathology results. The patients with ISUP group >2 were classified as csPCa, and the patients with ISUP = 1 or no evidence of prostate cancer were classified as non-csPCa. The diagnosis of mpMRI was made by experienced radiologists following the prostate imaging reporting and data system (PIRADS ≤ 2, PIRADS = 3, and PIRADS > 3). The mpMRI images were processed by a homemade AI algorithm, and the AI results were obtained as positive or negative for csPCa. Two logistic regression models were fitted, with pathological findings as the dependent variable, that is, a conventional model and an AI model. The conventional model used age, PSA, and PIRADS as the independent variables. The AI model took the AI result and the abovementioned clinical information as the independent variables. The predicted probability of the patients from the conventional model and the AI model were used to test the prediction efficacy of the models. The DeLong test was performed to compare differences in the area under the receiver operating characteristic (ROC) area under the curve (AUC) between the conventional model and the AI model. RESULTS In total, 505 patients were included in the study; 280 were diagnosed with csPCa, and 225 were non-csPCa. The median age was 72.0 (67.0, 76.0) years, with a median PSA value of 13.0 (7.46, 27.5) ng/dL. Statically significant differences were found in age, PSA, PIRADS score and AI results between the csPCa and non-csPCa groups (all p < 0.001). In the multivariable regression models, all the variables were independently associated with csPCa. The conventional model (R2 = 0.361) and the AI model (R2 = 0.474) were compared with analysis of variance (ANOVA) and showed statistically significant differences (χ2 = 63.695, p < 0.001). The AUC of the ROC curve for the conventional model was 0.782 (95% confidence interval [CI]: 0.742-0.823), which was less than the AUC of the AI model with statistical significance (0.849 [95% CI: 0.815-0.883], p < 0.001). CONCLUSION In combination with routine clinical information, such as age, PSA, and PIRADS category, adding information from the AI algorithm based on mpMRI could improve the diagnosis of csPCa.
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Affiliation(s)
- Jialei Li
- Zhejiang Chinese Medical University, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Kexin Wang
- School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Song Li
- Zhejiang Chinese Medical University, The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Pengsheng Wu
- Beijing Smart Tree Medical Technology Co. Ltd., Beijing, China
| | - Xiangpeng Wang
- Beijing Smart Tree Medical Technology Co. Ltd., Beijing, China
| | - Yi He
- The Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Wenrui Tang
- The Affiliated Hospital of Jiaxing University, Jiaxing, China
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Erlich G, Savin Z, Fahoum I, Barnes S, Dahan E, Bar-Yosef Y, Yossepowitch O, Keren-Paz G, Mano R. The role of tumor density in predicting significant cancer on targeted biopsy of the prostate. Urol Oncol 2023; 41:323.e9-323.e15. [PMID: 37210246 DOI: 10.1016/j.urolonc.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Multiparametric magnetic resonance imaging (mpMRI) is central to diagnosing prostate cancer; however, not all imaged lesions represent clinically significant tumors. We aimed to evaluate the association between the relative tumor volume on mpMRI and clinically significant prostate cancer on biopsy. MATERIALS AND METHODS We retrospectively reviewed the medical records of 340 patients who underwent combined transperineal targeted and systematic prostate biopsies between 2017 and 2021. Tumor volume was estimated based on the mpMRI diameter of suspected lesions. Relative tumor volume (tumor density) was calculated by dividing the tumor and prostate volumes. The study outcome was clinically significant cancer on biopsy. Logistic regression analyses were used to evaluate the association between tumor density and the outcome. The cutoff for tumor density was determined with ROC curves. RESULTS Median estimated prostate and peripheral zone tumor volumes were 55cm3 and 0.61cm3, respectively. Median PSA density was 0.13 and peripheral zone tumor density was 0.01. Overall, 231 patients (68%) had any cancer and 130 (38%) had clinically significant cancer. On multivariable logistic regression age, PSA, previous biopsy, maximal PI-RADS score, prostate volume, and peripheral zone tumor density were significant predictors of outcome. Using a threshold of 0.006, the sensitivity, specificity, positive and negative predictive values of peripheral zone tumor density were 0.9, 0.51, 0.57, and 0.88, respectively. CONCLUSION Peripheral zone tumor density is associated with clinically significant prostate cancer in patients with PI-RADS 4 and 5 mpMRI lesions. Future studies are required to validate our findings and evaluate the role of tumor density in avoiding unnecessary biopsies.
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Affiliation(s)
- Guy Erlich
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ziv Savin
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ibrahim Fahoum
- Department of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Sophie Barnes
- Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Eliran Dahan
- Department of Emergency Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Yuval Bar-Yosef
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ofer Yossepowitch
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Gal Keren-Paz
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Roy Mano
- Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.
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Veerman H, Hoeks CMA, Sluijter JH, van der Eijk JA, Boellaard TN, Roeleveld TA, van der Sluis TM, Nieuwenhuijzen JA, Wit E, Rijkhorst EJ, Heymans MW, van Alphen MJA, van Veen RLP, Vis AN, van der Poel HG, van Leeuwen PJ. 3D-Reconstructed Contact Surface Area and Tumour Volume on Magnetic Resonance Imaging Improve the Prediction of Extraprostatic Extension of Prostate Cancer. J Digit Imaging 2023; 36:486-496. [PMID: 36547859 PMCID: PMC10039205 DOI: 10.1007/s10278-022-00756-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
This study is to determine whether the volume and contact surface area (CSA) of a tumour with an adjacent prostate capsule on MRI in a three-dimensional (3D) model that can predict side-specific extraprostatic extension (EPE) at radical prostatectomy (RP). Patients with localised prostate cancer (PCa) who underwent robot-assisted RP between July 2015 and March 2021 were included in this retrospective study. MRI-based 3D prostate models incorporating the PCa volume and location were reconstructed. The tumour volume and surface variables were extracted. For the prostate-to-tumour and tumour-to-prostate CSAs, the areas in which the distances were ≤ 1, ≤ 2, ≤ 3, ≤ 4, and ≤ 5 mm were defined, and their surface (cm2) were determined. Differences in prostate sides with and without pathological EPE were analysed. Multivariable logistic regression analysis to find independent predictors of EPE. Overall, 75/302 (25%) prostate sides showed pathological EPE. Prostate sides with EPE had higher cT-stage, higher PSA density, higher percentage of positive biopsy cores, higher biopsy Gleason scores, higher radiological tumour stage, larger tumour volumes, larger prostate CSA, and larger tumour CSA (all p < 0.001). Multivariable logistic regression analysis showed that the radiological tumour stage (p = 0.001), tumour volume (p < 0.001), prostate CSA (p < 0.001), and tumour CSA (p ≤ 0.001) were independent predictors of pathological EPE. A 3D reconstruction of tumour locations in the prostate improves prediction of extraprostatic extension. Tumours with a higher 3D-reconstructed volume, a higher surface area of tumour in contact with the prostate capsule, and higher surface area of prostate capsule in contact with the tumour are at increased risk of side-specific extraprostatic extension.
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Affiliation(s)
- Hans Veerman
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands.
- Department of Urology, Amsterdam University Medical Centers Location Boelelaan, Amsterdam, Netherlands.
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands.
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066CX, Amsterdam, The Netherlands.
| | | | - Judith H Sluijter
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Verwelius 3D Lab, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Jari A van der Eijk
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Verwelius 3D Lab, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Thierry N Boellaard
- Department of Radiology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Ton A Roeleveld
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
- Department of Urology, Noord-West Ziekenhuisgroep, Alkmaar, Netherlands
| | - Tim M van der Sluis
- Department of Urology, Amsterdam University Medical Centers Location Boelelaan, Amsterdam, Netherlands
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Centers Location Boelelaan, Amsterdam, Netherlands
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
| | - Esther Wit
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
| | - Erik-Jan Rijkhorst
- Department of Clinical Physics and Instrumentation, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek Hospital, Alkmaar, Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers Location Boelelaan, Amsterdam, Netherlands
| | - Maarten J A van Alphen
- Verwelius 3D Lab, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Robert L P van Veen
- Verwelius 3D Lab, The Netherlands Cancer Institute - Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - André N Vis
- Department of Urology, Amsterdam University Medical Centers Location Boelelaan, Amsterdam, Netherlands
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
- Prostate Cancer Network the Netherlands, Amsterdam, Netherlands
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Singh D, Das CJ, Kumar V, Singh A, Mehndiratta A. Quantification of prostate tumour diameter and volume from MR images using 3D ellipsoid model and its impact on PI-RADS v2.1 assessment. Sci Rep 2022; 12:21501. [PMID: 36513800 PMCID: PMC9748032 DOI: 10.1038/s41598-022-26065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Maximum diameter and volume of the tumour provide important clinical information and are decision-making parameters for patients suspected with prostate cancer (PCa). The objectives of this study were to develop an automated method for 3D tumour measurement and compare it with the radiologist's manual assessment, as well as to investigate the impact of 3D tumour measurement on Prostate Imaging-Reporting and Data System version-2.1 (PI-RADS v2.1) scoring of prostate cancer. Tumour maximum diameter and volume were calculated using automated ellipsoid-fit method. For all PI-RADS scores, mean ± standard deviation range of tumour maximum diameter and volume measured using ellipsoid-fit method were 1.36 ± 0.28 to 1.97 ± 0.67 cm and 0.49 ± 0.31 to 1.05 ± 0.78 cc and manual assessment were in range of 0.73 ± 0.12 to 1.14 ± 0.25 cm and 0.36 ± 0.21 to 0.93 ± 0.39 cc, respectively. Ellipsoid-fit method showed significantly (p < 0.05) higher values for maximum diameter and volume than manual assessment. 3D measurement of tumour using ellipsoid-fit method was found to have higher maximum diameter and volume values (in 40-61% patients) compared to conventional assessment by radiologist, which may have an impact on PI-RADS v2.1 scoring system.
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Affiliation(s)
- Dharmesh Singh
- grid.417967.a0000 0004 0558 8755Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India
| | - Chandan J. Das
- grid.413618.90000 0004 1767 6103Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Virendra Kumar
- grid.413618.90000 0004 1767 6103Department of NMR, All India Institute of Medical Sciences, New Delhi, India
| | - Anup Singh
- grid.417967.a0000 0004 0558 8755Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India ,grid.413618.90000 0004 1767 6103Department of Biomedical Engineering, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Mehndiratta
- grid.417967.a0000 0004 0558 8755Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India ,grid.413618.90000 0004 1767 6103Department of Biomedical Engineering, All India Institute of Medical Sciences, New Delhi, India ,grid.417967.a0000 0004 0558 8755Centre for Biomedical Engineering, IIT Delhi Hauz-Khas, Room No-298, Block III, New Delhi, 110016 India
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Singh D, Kumar V, Das CJ, Singh A, Mehndiratta A. Machine learning-based analysis of a semi-automated PI-RADS v2.1 scoring for prostate cancer. Front Oncol 2022; 12:961985. [PMID: 36505875 PMCID: PMC9730331 DOI: 10.3389/fonc.2022.961985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
Abstract
Background Prostate Imaging-Reporting and Data System version 2.1 (PI-RADS v2.1) was developed to standardize the interpretation of multiparametric MRI (mpMRI) for prostate cancer (PCa) detection. However, a significant inter-reader variability among radiologists has been found in the PI-RADS assessment. The purpose of this study was to evaluate the diagnostic performance of an in-house developed semi-automated model for PI-RADS v2.1 scoring using machine learning methods. Methods The study cohort included an MRI dataset of 59 patients (PI-RADS v2.1 score 2 = 18, score 3 = 10, score 4 = 16, and score 5 = 15). The proposed semi-automated model involved prostate gland and zonal segmentation, 3D co-registration, lesion region of interest marking, and lesion measurement. PI-RADS v2.1 scores were assessed based on lesion measurements and compared with the radiologist PI-RADS assessment. Machine learning methods were used to evaluate the diagnostic accuracy of the proposed model by classification of PI-RADS v2.1 scores. Results The semi-automated PI-RADS assessment based on the proposed model correctly classified 50 out of 59 patients and showed a significant correlation (r = 0.94, p < 0.05) with the radiologist assessment. The proposed model achieved an accuracy of 88.00% ± 0.98% and an area under the receiver-operating characteristic curve (AUC) of 0.94 for score 2 vs. score 3 vs. score 4 vs. score 5 classification and accuracy of 93.20 ± 2.10% and AUC of 0.99 for low score vs. high score classification using fivefold cross-validation. Conclusion The proposed semi-automated PI-RADS v2.1 assessment system could minimize the inter-reader variability among radiologists and improve the objectivity of scoring.
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Affiliation(s)
- Dharmesh Singh
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India
| | - Virendra Kumar
- Department of Nuclear Magnetic Resonance (NMR), All India Institute of Medical Sciences, New Delhi, India
| | - Chandan J. Das
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Anup Singh
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India,Department of Biomedical Engineering, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Mehndiratta
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India,Department of Biomedical Engineering, All India Institute of Medical Sciences, New Delhi, India,*Correspondence: Amit Mehndiratta,
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A Comparative Study of Multiparametric MRI Sequences in Measuring Prostate Cancer Index Lesion Volume. J Belg Soc Radiol 2022; 106:105. [DOI: 10.5334/jbsr.2832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022] Open
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Concordance between biparametric MRI, transperineal targeted plus systematic MRI-ultrasound fusion prostate biopsy, and radical prostatectomy pathology. Sci Rep 2022; 12:6964. [PMID: 35484364 PMCID: PMC9051051 DOI: 10.1038/s41598-022-10672-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/08/2022] [Indexed: 12/03/2022] Open
Abstract
We aimed to confirm the reliability of the results of bi-parametric magnetic resolution imaging-ultrasound fusion targeted and systematic biopsies (bpMRI-US transperineal FTSB) compared to prostatectomy specimens. We retrospectively analyzed the records of 80 men who underwent bpMRI-US transperineal FTSB with region of interest (ROI) and subsequent robot-assisted radical prostatectomy. Changes in the grade group determined by MRI and biopsy versus surgical specimens were analyzed. Thirty-five patients with insignificant prostate cancer and 45 with significant cancer were diagnosed using bpMRI-US transperineal FTSB. Among those with insignificant PCa, 25 (71.4%) were upgraded to significant PCa in prostatectomy specimens: 9/12 (75.0%) with Prostate Imaging Reporting and Data System (PI-RADS) 3, 12/16 (75.0%) with PI-RADS 4, and 4/7 (57.1%) with PI-RADS 5. In the PI-RADS 3 group, the upgraded group showed higher prostate specific antigen (PSA) and PSA density (PSAD) than the concordance group; PSA 8.34(2.73) vs. 5.31(2.46) (p = 0.035) and PSAD 0.29(0.11) vs. 0.18(0.09) (p = 0.025). The results of prostate biopsy and prostatectomy specimens were inconsistent and underestimated in patients with MRI-visible lesions. Therefore, for precise and individualized treatment strategies for PCa with MRI-visible lesions, careful interpretation of biopsy result is required.
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Sood A, Jeong W, Palma-Zamora I, Abdollah F, Butaney M, Corsi N, Wurst H, Arora S, Kachroo N, Hassan O, Gupta N, Gorin MA, Menon M. Description of Surgical Technique and Oncologic and Functional Outcomes of the Precision Prostatectomy Procedure (IDEAL Stage 1-2b Study). Eur Urol 2021; 81:396-406. [PMID: 34872786 DOI: 10.1016/j.eururo.2021.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/23/2021] [Accepted: 10/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The existing treatment options for men with intermediate- or high-volume low-risk prostate cancer (PCa) are associated with a substantial risk of over- or undertreatment. The development of risk-adjusted therapies is an unmet need for these patients. OBJECTIVE To describe our novel technique of precision prostatectomy, a form of surgical focal therapy that allows radical excision of the index PCa lesion along with >90% prostatic tissue extirpation while preserving the prostatic capsule and seminal vesicle/vas deferens complex on the side contralateral to the dominant cancer lesion, and to report on medium-term functional and oncologic outcomes in the first 88 consecutive men who underwent this procedure between December 2016 and January 2020. DESIGN, SETTING, AND PARTICIPANTS Men with (1) prostate-specific antigen (PSA) ≤20 ng/ml, (2) clinical T stage ≤cT2, (3) a dominant unilateral lesion with Gleason ≤ 4 + 3 disease with any number or percentage of cores involved ipsilaterally on prostate biopsy, (4) no primary Gleason ≥4 lesion contralaterally, and (5) a preoperative Sexual Health Inventory of Men (SHIM) score of ≥17 (out of 25) with/without phosphodiesterase type-5 inhibitor use who consented to undergo precision prostatectomy were included in this single-arm, single-center, IDEAL stage 2b prospective development study. INTERVENTION Robotic precision prostatectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The safety and urinary, sexual, and oncologic outcomes of the precision prostatectomy technique were studied. Descriptive statistics and Kaplan-Meier analyses were used to assess 12-mo urinary continence (0-1 pad), 12-mo sexual potency (SHIM score ≥17), 36-mo freedom from clinically significant PCa (grade group ≥2), secondary treatments, metastatic disease, and mortality. RESULTS AND LIMITATIONS At study entry, the median age, PSA, and SHIM score were 60.0 yr (interquartile range [IQR] 54.2-65.9), 5.7 ng/ml (IQR 4.2-7.1), and 22 points (IQR 19-24), respectively. The median follow-up was 25 mo (IQR 14-38). At 12 mo, all patients were continent (0-1 pads), with 90.9% of patients using 0 pads. The median time to urinary continence was 1 mo (IQR 1-4). At 12 mo, 85% of all-comers and 90.2% of the preoperatively potent men were potent. The median time to sexual potency was 4 mo (IQR 4-12). From an oncologic standpoint, at 36 mo an estimated 93.4% of the patients were free from clinically significant residual PCa and 91.7% had not undergone any additional treatment. All patients were alive and free of metastatic disease at 36 mo. CONCLUSIONS Precision prostatectomy is technically safe and reproducible and offers excellent postoperative functional results. At 36-mo follow-up, the oncologic outcomes and secondary treatment rates appear to be superior to existing ablative focal therapy results. Pending long-term data, a risk-stratified surgical approach to PCa may avoid whole-gland therapy and preserve functional quality of life in men with localized PCa. PATIENT SUMMARY Precision prostatectomy is a new form of focal therapy for intermediate-risk prostate cancer in which a 5-10-mm rim of prostate capsule is left on the opposite side of the gland to where the dominant cancer is located. The technique appears to be safe and efficacious and adds to the growing armamentarium of risk-adapted therapies for treatment of localized prostate cancer that avoid the adverse effects on urinary and erectile function of whole-gland treatments.
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Affiliation(s)
- Akshay Sood
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA; VCORE Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.
| | - Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | | | - Firas Abdollah
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA; VCORE Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Mohit Butaney
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Nicholas Corsi
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Hallie Wurst
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Sohrab Arora
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Naveen Kachroo
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Oudai Hassan
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - Nilesh Gupta
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - Michael A Gorin
- Urology Associates and UPMC Western Maryland, Cumberland, MD, USA; Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA; VCORE Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA; Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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10
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Veerman H, Boellaard TN, van Leeuwen PJ, Vis AN, Bekers E, Hoeks C, Schoots IG, van der Poel HG. The detection rate of apical tumour involvement on preoperative MRI and its impact on clinical outcomes in patients with localized prostate cancer. J Robot Surg 2021; 16:1047-1056. [PMID: 34783953 DOI: 10.1007/s11701-021-01333-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/29/2021] [Indexed: 12/01/2022]
Abstract
To determine the diagnostic performance of radiological apical tumour involvement (radATI) in preoperative prostate MRI, referenced to pathological ATI (pathATI) at radical prostatectomy specimens. To investigate risk factors for apical positive surgical margins (APSM). A retrospective cohort of consecutive patients with biopsy-proven PCa who underwent MRI and robot-assisted radical prostatectomy between July 2015 and March 2020 was studied (n = 177). Clinical, imaging, pathology, oncology and functional data were retrieved. The diagnostic accuracy of MRI to detect pathATI was analysed. Multivariate logistic regression was used to find independent predictors for APSM. radATI and pathATI was found in 121 (68%) and 161 (91%) patients, respectively. The diagnostic metrics of sensitivity, specificity, PPV, and NPV were 69, 38, 92, and 11%, respectively. APSM were present in 43 (24%) patients. Patients with radATI were more likely to have APSM (37/121 (31%)) than those without radATI (6/56 (11%)) (OR 3.67 [95% CI 1.45-9.31], p = 0.004). This was confirmed in multivariate analysis. Only 2/56 (4%) patients without radATI developed a biochemical recurrence compared to 25/120 (21%) patients with radATI (hazard ratio 6.68 [95% CI 3.03-14.8], p = 0.003). Prostate cancer extends into the apex in the majority of cases. Clinicians are advised to report on the presence or absence of radiological apical tumour involvement as it is an independent risk factor for apical positive surgical margins and is even associated with biochemical recurrence.
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Affiliation(s)
- Hans Veerman
- Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066CX, Amsterdam, The Netherlands. .,Location VU Medical Centre, Department of Urology, Amsterdam University Medical Centres, Amsterdam, The Netherlands. .,Prostate Cancer Network the Netherlands, Amsterdam, The Netherlands.
| | - Thierry N Boellaard
- Department of Radiology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066CX, Amsterdam, The Netherlands.,Prostate Cancer Network the Netherlands, Amsterdam, The Netherlands
| | - André N Vis
- Location VU Medical Centre, Department of Urology, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Prostate Cancer Network the Netherlands, Amsterdam, The Netherlands
| | - Elise Bekers
- Department of Pathology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Caroline Hoeks
- Department of Radiology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ivo G Schoots
- Department of Radiology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066CX, Amsterdam, The Netherlands.,Prostate Cancer Network the Netherlands, Amsterdam, The Netherlands
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11
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Sood A, Jeong W, Keeley J, Abdollah F, Hassan O, Gupta N, Menon M. Subtotal surgical therapy for localized prostate cancer: a single-center precision prostatectomy experience in 25 patients, and SEER-registry data analysis. Transl Androl Urol 2021; 10:3155-3166. [PMID: 34430418 PMCID: PMC8350248 DOI: 10.21037/tau-20-1476] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/18/2021] [Indexed: 11/22/2022] Open
Abstract
Background We recently described a novel form of focal therapy for prostate cancer (CaP)—the precision prostatectomy. Here we report on the first 25 consecutive patients. Further, utilizing Surveillance Epidemiology and End Results (SEER)-registry data, we assess long-term oncological efficacies of various focal therapy techniques. Methods Men who met the criteria: (I) PSA ≤15 ng/mL, (II) stage ≤cT2, (III) dominant unilateral lesion with Gleason ≤4+3 with any number or percentage (%) of cores involved ipsilaterally on biopsy, (IV) no primary Gleason ≥4 contralaterally, and (V) preoperative erectile function score (IIEF-5/SHIM) of ≥17 with/without PDE-5i were included in this prospective, single-arm, IDEAL stage 2b study (December 2016 to July 2017). Safety of the technique, and intermediate-term urinary, sexual and oncological outcomes were studied. Descriptive statistics and Kaplan-Meier (KM) analysis were used to assess 12-month urinary continence (0–1 pad), 12-month sexual potency (SHIM ≥17), and 36-month freedom from clinically-significant CaP (grade group ≥2), radical treatment, metastatic disease and mortality. SEER-registry was queried to evaluate CaP-specific survival in patients undergoing hyperthermia, cryotherapy, or segmental prostatectomy. Results At study entry, the median (IQR) age, PSA and SHIM score were 56.5 (53.1–62.3) years, 4.2 (3.8–5.9) ng/mL and 23 [20–25], respectively. Only 1 patient met the Epstein criteria for active surveillance. All patients were followed for a minimum of 2 years. At 12 months, from a functional standpoint, all patients were continent. Twenty-three (92%) patients were potent at 12 months. From an oncological standpoint, at 36 months, the KM analysis (95% CI) demonstrated a 96.2% (92.9–98.7) rate of freedom from clinically-significant CaP and a 92.7% (88.9–97.2) rate of freedom from radical treatment. All patients were alive and free of metastatic disease at the latest follow-up. Analysis of the SEER-registry data demonstrated 10-year CaP-specific survival rates of 91.6% to 97.7% among the 3 studied modalities, P=0.298. Conclusions Precision prostatectomy is feasible, technically safe, and offers excellent postoperative functional results. At 36 months of follow-up, the oncological outcomes and secondary procedure rates appear to be at-par with the ablative forms of focal therapy.
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Affiliation(s)
- Akshay Sood
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.,VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | - Jacob Keeley
- VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Firas Abdollah
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.,VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
| | - Oudai Hassan
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - Nilesh Gupta
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.,VCORE - Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA
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12
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Pilot study comparing dominant intraprostatic lesion volume using Ga-68 prostate-specific membrane antigen PET-computed tomography and multiparametric MRI. Nucl Med Commun 2021; 41:1291-1298. [PMID: 32941400 DOI: 10.1097/mnm.0000000000001283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The standard imaging used for delineation of dominant intraprostatic lesion (DIL) is multiparametric MRI (mpMRI). The use of biologic imaging such as Ga-68 prostate-specific membrane antigen (PSMA) PET-computed tomography (PET-CT) for this purpose is being explored in view of increased sensitivity of this modality and the associated ease of delineation. MATERIALS AND METHODS The primary objective of the study was to compare the autogenerated volumes of the DIL in Ga-68 PSMA PET-CT with the standard volume delineated in mpMRI. Twenty patients with biopsy-proven untreated prostatic adenocarcinoma were included. Multiple percentages of the maximum standardized uptake value (%SUVmax) were used to autogenerate DIL volumes in Ga-68 PSMA PET-CT and these volumes were numerically matched with the consensus DIL volume in mpMRI. PSMA tumor volume (PSMA-TV) and total lesion PSMA (TL-PSMA) were also calculated for each lesion. RESULTS Median volume of DIL in mpMRI was 4 cm (interquartile range, IQR = 2.5-7.6 cm). The IQR for interobserver variability was 0.5-2.5 cm. Median SUVmax of the DIL was 14.1 (IQR = 10.2-22.3). Median %SUVmax corresponding to mpMRI volume was 41% of SUVmax (IQR = 34-55%). There was a strong negative correlation between MRI volume and %SUVmax (r = -0.829, P < 0.001). There was a significant correlation between TL-PSMA and prostate-specific antigen (r = 0.609, P = 0.004). CONCLUSIONS The median DIL volume was 4 cm and median %SUVmax corresponding to MR volume of DIL was 41%. A strong inverse relationship is found between mpMRI-defined DIL volume and the %SUVmax which generates similar volume in Ga-68 PSMA PET-CT. TL-PSMA could be a quantitative biomarker for tumor load and prognosis.
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13
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Tumor volume and the dural tail sign enable the differentiation of intracranial solitary fibrous tumor/hemangiopericytoma from high-grade meningioma. Clin Neurol Neurosurg 2021; 207:106769. [PMID: 34171585 DOI: 10.1016/j.clineuro.2021.106769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare mesenchymal neoplasm with imaging features mimicking high-grade meningioma (HGM) and can easily be misdiagnosed. We sought to determine the value of routine preoperative data in differentiating these tumors. PATIENTS AND METHODS Patients with confirmed SFT/HPC or HGM between January 2012 and June 2020 were identified. A total of 28 preoperative variables (including age, sex, tumor location, tumor volume, 10 traditional MRI features, and 14 peripheral blood indices) were collected for each patient. The top features were selected sequentially based on the least absolute shrinkage and selection operator (LASSO) and support vector machines-recursive feature elimination (SVM-RFE) methods. Differentiation and calibration of the classifiers were assessed by receiver operating characteristic (ROC) curves and calibration curves, respectively. Nomograms were constructed based on multivariate analysis. RESULTS A total of 127 patients, including 29 with SFT/HPC and 98 with HGM, were analyzed. Three features were first selected using the LASSO and SVM-RFE methods, and corresponding models were developed. Although the area under the curve (AUC) of model 1 was the highest, a comprehensive analysis suggested the superiority of model 2, which consisted only of the features tumor volume (TV) and dural tail sign (DTS) (AUC: 0.942, sensitivity: 93.10%, p-value of H-L test: 0.734, Brier score: 0.07). A risk score formula and a nomogram were constructed. CONCLUSIONS TV can be used to effectively identify SFT/HPC and HGM, whereas adding DTS can improve the overall prediction accuracy. As these two variables are routinely available and are easy for clinicians to master, they can provide a powerful reference for clinical decision-making.
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14
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Gaffney C, Liu D, Cooley V, Ma X, Angulo C, Robinson B, Khani F, Cai P, Salami S, Nallandhighal S, Shoag J, Barbieri C. Tumor size and genomic risk in localized prostate cancer. Urol Oncol 2021; 39:434.e17-434.e22. [PMID: 33563537 DOI: 10.1016/j.urolonc.2021.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Unlike many other cancers, measurement of primary prostate tumor size has no defined role in the management of localized prostate cancer. Here, we assess whether prostate tumor size is associated with aggressive tumor biology using biomarkers of genomic risk. MATERIALS AND METHODS We abstracted or imputed tumor size from the primary pathology reports of prostate cancers incorporated in The Cancer Genome Atlas. We used transcriptomic data to estimate the Cell Cycle Progression Score (CCPS, Prolaris), the Genomic Classifier Score (GCS, Decipher) and the Genomic Prostate Score (GPS, OncotypeDx), SChLaP1 expression, and copy number alteration percentage (%CNA) as well as hallmark gene set enrichment analysis. RESULTS Tumor size and gene expression data was available for 267 men. On multivariable regression adjusted for Gleason Grade Group and tumor purity, tumor size was independently associated with the calculated (c)GCS, cGPS, SChLaP1 expression, and %CNA (P< 0.05), but not cCCPS. Gene set enrichment analysis demonstrated that tumors <5 cc, when adjusting for Gleason grade group, were enriched for androgen response genes, while tumors >5 cc were enriched for MYC targets and genes associated with epithelial mesenchymal transition. CONCLUSIONS Prostate tumor size is independently associated with established markers of genomic risk. This study nominates the size of a primary prostate cancer as candidate for inclusion in future novel risk scores seeking to quantify cancer aggressiveness.
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Affiliation(s)
- Christopher Gaffney
- Department of Urology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Deli Liu
- Department of Urology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Victoria Cooley
- Department of Healthcare Policy and Research, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Xiayoue Ma
- Department of Healthcare Policy and Research, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Cynthia Angulo
- Department of Urology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Brian Robinson
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Francesca Khani
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Peter Cai
- Department of Urology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
| | - Simpa Salami
- Department of Urology, University of Michigan, Ann Arbor, MI
| | | | - Jonathan Shoag
- Department of Urology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY; Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Christopher Barbieri
- Department of Urology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY
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15
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Mayer R, Simone CB, Turkbey B, Choyke P. Algorithms applied to spatially registered multi-parametric MRI for prostate tumor volume measurement. Quant Imaging Med Surg 2021; 11:119-132. [PMID: 33392016 DOI: 10.21037/qims-20-137a] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Prostate tumor volume correlates with critical components of cancer staging such as Gleason score (GS) grade, predicted disease progression, and metastasis. Therefore, non-invasive tumor volume measurement may elevate clinical management. Radiology assessments of multi-parametric MRI (MP-MRI) commonly visually examine individual images to determine possible tumor presence. This study combines registered MP-MRI into a single image that display normal tissue and possible lesions. This study tests and exploits the vector nature of spatially registered MP-MRI by using supervised target detection algorithms (STDA) and color display and psychovisual analysis (CIELAB) to non-invasively estimate prostate tumor volume. Methods MRI, including T1, T2, diffusion [apparent diffusion coefficient (ADC)], dynamic contrast enhanced (DCE) images, were resampled, rescaled, translated, and stitched to form spatially registered Multi-parametric cubes. The multi-parametric or multi-spectral signatures (7-component or T1, T2, ADC, etc.) that characterize the prostate tumors were inserted into target detection algorithms with conical decision surfaces (adaptive cosine estimator, ACE). Various detection thresholds were applied to discriminate tumor from normal tissue. In addition, tumor appeared as yellow in color images that were created by assigning red to washout from DCE, green to high B from diffusion, and blue to autonomous diffusion image. The yellow voxels in the three-channel hypercube were visually identified by a reader and recording voxels that exceed a threshold in the b* component of the CIELAB algorithm. The number of reported tumor voxels were converted to volume based on spatial resolution and slice separation. The tumor volume measurements were quantitatively validated by comparing the tumor volume computations to the pathologist's assessment of the histology of sectioned whole mount prostates from 26 consecutive patients with prostate adenocarcinoma who underwent radical prostatectomy. This study analyzed tumors exceeding 1 cc and that also took up contrast material (18 patients). Results High correlation coefficients for tumor volume measurements using supervised target detection and color analysis vs. histology from wholemount prostatectomy were computed (R=0.83 and 0.91, respectively). A linear fit for tumor volume measurements using for supervised target detection and color analysis vs. tumor measurements from radical prostatectomy (after correcting for shrinkage from the radical prostatectomy) results in a slope of 1.02 and 3.02, respectively. A polynomial fit for the color analysis to the histology found (R=0.95). Voxels exceeding a threshold in the b* part of the CIELAB algorithm yielded correlation coefficients (0.71, 0.80) offsets (0.01 cc, -0.63 cc) and slopes (1.99, 0.89) against the wholemount prostatectomy and color analysis, respectively. Conclusions Supervised target detection and color display and analysis applied to registered MP-MRI non-invasively estimates prostate tumor volumes >1 cc and displaying angiogenesis.
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Affiliation(s)
- Rulon Mayer
- Oncoscore, Garrett Park, MD, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Peter Choyke
- National Institutes of Health, Bethesda, MD, USA
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16
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Kalapara AA, Nzenza T, Pan HYC, Ballok Z, Ramdave S, O'Sullivan R, Ryan A, Cherk M, Hofman MS, Konety BR, Lawrentschuk N, Bolton D, Murphy DG, Grummet JP, Frydenberg M. Detection and localisation of primary prostate cancer using 68 gallium prostate-specific membrane antigen positron emission tomography/computed tomography compared with multiparametric magnetic resonance imaging and radical prostatectomy specimen pathology. BJU Int 2020; 126:83-90. [PMID: 31260602 DOI: 10.1111/bju.14858] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare the accuracy of 68 gallium prostate-specific membrane antigen positron emission tomography/computed tomography (68 Ga-PSMA PET/CT) with multiparametric MRI (mpMRI) in detecting and localising primary prostate cancer when compared with radical prostatectomy (RP) specimen pathology. PATIENTS AND METHODS Retrospective review of men who underwent 68 Ga-PSMA PET/CT and mpMRI for primary prostate cancer before RP across four centres between 2015 and 2018. Patients undergoing imaging for recurrent disease or before non-surgical treatment were excluded. We defined pathological index tumour as the lesion with highest International Society of Urological Pathology Grade Group (GG) on RP specimen pathology. Our primary outcomes were rates of accurate detection and localisation of RP specimen pathology index tumour using 68 Ga-PSMA PET/CT or mpMRI. We defined tumour detection as imaging lesion corresponding with RP specimen tumour on any imaging plane, and localisation as imaging lesion matching RP specimen index tumour in all sagittal, axial, and coronal planes. Secondary outcomes included localisation of clinically significant and transition zone (TZ) index tumours. We defined clinically significant disease as GG 3-5. We used descriptive statistics and the Mann-Whitney U-test to define and compare demographic and pathological characteristics between detected, missed and localised tumours using either imaging modality. We used the McNemar test to compare detection and localisation rates using 68 Ga-PSMA PET/CT and mpMRI. RESULTS In all, 205 men were included in our analysis, including 133 with clinically significant disease. There was no significant difference between 68 Ga-PSMA PET/CT and mpMRI in the detection of any tumour (94% vs 95%, P > 0.9). There was also no significant difference between localisation of all index tumours (91% vs 89%, P = 0.47), clinically significant index tumours (96% vs 91%, P = 0.15) or TZ tumours (85% vs 80%, P > 0.9) using 68 Ga-PSMA PET/CT and mpMRI. Limitations include retrospective study design and non-central review of imaging and pathology. CONCLUSION We found no significant difference in the detection or localisation of primary prostate cancer between 68 Ga-PSMA PET/CT and mpMRI. Further prospective studies are required to evaluate a combined PET/MRI model in minimising tumours missed by either modality.
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Affiliation(s)
- Arveen A Kalapara
- Department of Surgery, Monash University, Melbourne, VIC, Australia.,Australian Urology Associates, Malvern, VIC, Australia
| | - Tatenda Nzenza
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Henry Y C Pan
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Zita Ballok
- Healthcare Imaging Services, Richmond, VIC, Australia.,Department of Nuclear Medicine and PET, Monash Medical Centre, Bentleigh East, VIC, Australia
| | - Shakher Ramdave
- Department of Nuclear Medicine and PET, Monash Medical Centre, Bentleigh East, VIC, Australia
| | - Richard O'Sullivan
- Healthcare Imaging Services, Richmond, VIC, Australia.,Department of Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Martin Cherk
- Department of Nuclear Medicine and PET, Alfred Hospital, Melbourne, VIC, Australia
| | - Michael S Hofman
- Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Nathan Lawrentschuk
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Damien Bolton
- Department of Urology, Austin Hospital, Heidelberg, VIC, Australia
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum, Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Jeremy P Grummet
- Department of Surgery, Monash University, Melbourne, VIC, Australia.,Department of Urology, Alfred Hospital, Melbourne, VIC, Australia
| | - Mark Frydenberg
- Department of Surgery, Monash University, Melbourne, VIC, Australia.,Australian Urology Associates, Malvern, VIC, Australia
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17
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Wake N, Rosenkrantz AB, Sodickson DK, Chandarana H, Wysock JS. MRI guided procedure planning and 3D simulation for partial gland cryoablation of the prostate: a pilot study. 3D Print Med 2020; 6:33. [PMID: 33141272 PMCID: PMC7607830 DOI: 10.1186/s41205-020-00085-2] [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: 02/11/2020] [Accepted: 10/25/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE This study reports on the development of a novel 3D procedure planning technique to provide pre-ablation treatment planning for partial gland prostate cryoablation (cPGA). METHODS Twenty men scheduled for partial gland cryoablation (cPGA) underwent pre-operative image segmentation and 3D modeling of the prostatic capsule, index lesion, urethra, rectum, and neurovascular bundles based upon multi-parametric MRI data. Pre-treatment 3D planning models were designed including virtual 3D cryotherapy probes to predict and plan cryotherapy probe configuration needed to achieve confluent treatment volume. Treatment efficacy was measured with 6 month post-operative MRI, serum prostate specific antigen (PSA) at 3 and 6 months, and treatment zone biopsy results at 6 months. Outcomes from 3D planning were compared to outcomes from a series of 20 patients undergoing cPGA using traditional 2D planning techniques. RESULTS Forty men underwent cPGA. The median age of the cohort undergoing 3D treatment planning was 64.8 years with a median pretreatment PSA of 6.97 ng/mL. The Gleason grade group (GGG) of treated index lesions in this cohort included 1 (5%) GGG1, 11 (55%) GGG2, 7 (35%) GGG3, and 1 (5%) GGG4. Two (10%) of these treatments were post-radiation salvage therapies. The 2D treatment cohort included 20 men with a median age of 68.5 yrs., median pretreatment PSA of 6.76 ng/mL. The Gleason grade group (GGG) of treated index lesions in this cohort included 3 (15%) GGG1, 8 (40%) GGG2, 8 (40%) GGG3, 1 (5%) GGG4. Two (10%) of these treatments were post-radiation salvage therapies. 3D planning predicted the same number of cryoprobes for each group, however a greater number of cryoprobes was used in the procedure for the prospective 3D group as compared to that with 2D planning (4.10 ± 1.37 and 3.25 ± 0.44 respectively, p = 0.01). At 6 months post cPGA, the median PSA was 1.68 ng/mL and 2.38 ng/mL in the 3D and 2D cohorts respectively, with a larger decrease noted in the 3D cohort (75.9% reduction noted in 3D cohort and 64.8% reduction 2D cohort, p 0.48). In-field disease detection was 1/14 (7.1%) on surveillance biopsy in the 3D cohort and 3/14 (21.4%) in the 2D cohort, p = 0.056) In the 3D cohort, 6 month biopsy was not performed in 4 patients (20%) due to undetectable PSA, negative MRI, and negative MRI Axumin PET. For the group with traditional 2D planning, treatment zone biopsy was positive in 3/14 (21.4%) of the patients, p = 0.056. CONCLUSIONS 3D prostate cancer models derived from mpMRI data provide novel guidance for planning confluent treatment volumes for cPGA and predicted a greater number of treatment probes than traditional 2D planning methods. This study prompts further investigation into the use of 3D treatment planning techniques as the increase of partial gland ablation treatment protocols develop.
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Affiliation(s)
- Nicole Wake
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA. .,Center for Advanced Imaging Innovation and Research (CAI2R) and Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA.
| | - Andrew B Rosenkrantz
- Center for Advanced Imaging Innovation and Research (CAI2R) and Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel K Sodickson
- Center for Advanced Imaging Innovation and Research (CAI2R) and Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Hersh Chandarana
- Center for Advanced Imaging Innovation and Research (CAI2R) and Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
| | - James S Wysock
- Division of Urologic Oncology, Department of Urology, NYU Langone Health, NYU Grossman School of Medicine, New York, NY, USA
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18
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Kim TH, Woo S, Han S, Suh CH, Ghafoor S, Hricak H, Vargas HA. The Diagnostic Performance of the Length of Tumor Capsular Contact on MRI for Detecting Prostate Cancer Extraprostatic Extension: A Systematic Review and Meta-Analysis. Korean J Radiol 2020; 21:684-694. [PMID: 32410407 PMCID: PMC7231615 DOI: 10.3348/kjr.2019.0842] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/06/2020] [Accepted: 02/09/2020] [Indexed: 01/23/2023] Open
Affiliation(s)
- Tae Hyung Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Department of Radiology, Naval Pohang Hospital, Pohang, Korea
| | - Sungmin Woo
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| | - Sangwon Han
- Department of Nuclear Medicine, Armed Forces Daejeon Hospital, Daejeon, Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Soleen Ghafoor
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Hedvig Hricak
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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19
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Giganti F, Stavrinides V, Stabile A, Osinibi E, Orczyk C, Radtke JP, Freeman A, Haider A, Punwani S, Allen C, Emberton M, Kirkham A, Moore CM. Prostate cancer measurements on serial MRI during active surveillance: it's time to be PRECISE. Br J Radiol 2020; 93:20200819. [PMID: 32955923 DOI: 10.1259/bjr.20200819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The PRECISE criteria for reporting multiparametric MRI in patients on active surveillance (AS) for prostate cancer (PCa) score the likelihood of clinically significant change over time using a 1-5 scale, where 4 or 5 indicates radiological progression. According to the PRECISE recommendations, the index lesion size can be reported using different definitions of volume (planimetry or ellipsoid formula) or by measuring one or two diameters. We compared different measurements using planimetry as the reference standard and stratified changes according to the PRECISE scores. METHODS We retrospectively analysed 196 patients on AS with PCa confirmed by targeted biopsy who had two MR scans (baseline and follow-up). Lesions were measured on T2 weighted imaging (T2WI) according to all definitions. A PRECISE score was assessed for each patient. RESULTS The ellipsoid formula exhibited the highest correlation with planimetry at baseline (ρ = 0.97) and follow-up (ρ = 0.98) imaging, compared to the biaxial measurement and single maximum diameter. There was a significant difference (p < 0.001) in the yearly percentage volume change between radiological regression/stability (PRECISE 2-3) and progression (PRECISE 4-5) for planimetry (39.64%) and for the ellipsoid formula (46.78%). CONCLUSION The ellipsoid formula could be used to monitor tumour growth during AS. Evidence of a significant yearly percentage volume change between radiological regression/stability (PRECISE 2-3) and progression (PRECISE 4-5) has been also observed. ADVANCES IN KNOWLEDGE The ellipsoid formula is a reasonable surrogate for planimetry in capturing tumour volume changes on T2WI in patients on imaging-led AS. This is also associated with radiological changes using the PRECISE recommendations.
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Affiliation(s)
- Francesco Giganti
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Vasilis Stavrinides
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Armando Stabile
- Department of Urology and Division of Experimental Oncology, Vita-Salute San Raffaele University, Milan, Italy
| | - Elizabeth Osinibi
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Clement Orczyk
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | | | - Alex Freeman
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Aiman Haider
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK.,Centre for Medical Imaging, University College London, London, UK
| | - Clare Allen
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Alex Kirkham
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Caroline M Moore
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
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20
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Abstract
PURPOSE OF REVIEW Rapid advances in imaging of the prostate have facilitated the development of focal therapy and provided a non-invasive method of estimating tumour volume. Focal therapy relies on an accurate estimate of tumour volume for patient selection and treatment planning so that the optimal energy dose can be delivered to the target area(s) of the prostate while minimising toxicity to surrounding structures. This review provides an overview of different imaging modalities which may be used to optimise tumour volume assessment and critically evaluates the published evidence for each modality. RECENT FINDINGS Multi-parametric MRI (mp-MRI) has become the standard tool for patient selection and guiding focal therapy treatment. The current evidence suggests that mp-MRI may underestimate tumour volume, although there is a large variability in results. There remain significant methodological challenges associated with pathological processing and accurate co-registration of histopathological data with mp-MRI. Advances in different ultrasound modalities are showing promise but there has been limited research into tumour volume estimation. The role of PSMA PET/CT is still evolving and further investigation is needed to establish if this is a viable technique for prostate tumour volumetric assessment. mp-MRI provides the necessary tumour volume information required for selecting patients and guiding focal therapy treatment. The potential for underestimation of tumour volume should be taken into account and an additional margin applied to ensure adequate treatment coverage. At present, there are no other viable image-based alternatives although advances in new technologies may refine volume estimations in the future.
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21
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Martell K, Roy S, Meyer T, Stosky J, Jiang W, Thind K, Roumeliotis M, Bosch J, Angyalfi S, Quon H, Husain S. Analysis of outcomes after non-contour-based dose painting of dominant intra-epithelial lesion in intra-operative low-dose rate brachytherapy. Heliyon 2020; 6:e04092. [PMID: 32548323 PMCID: PMC7286970 DOI: 10.1016/j.heliyon.2020.e04092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To compare the outcomes of patients with intermediate risk prostate cancer (IR-PCa) treated with low-dose rate I-125 seed brachytherapy (LDR-BT) and targeted dose painting of a histologic dominant intra-epithelial lesion (DIL) to those without a DIL. Methods 455 patients with IR-PCa were treated at a single center with intra-operatively planned LDR-BT, each following the same in-house dose constraints. Patients with a DIL on pathology had hot spots localized to that region but no specific contouring during the procedure. Results 396 (87%) patients had a DIL. Baseline tumor characteristics and overall prostate dosimetry were similar between patients with and without DIL except the median number of biopsy cores taken: 10 (10–12) vs 12 (10–12) (p = 0.002). 19 (5%) and 18 (5%) of patients with and 1 (2%) and 0 (0%) of those without DIL experienced CTCAE grade 2 and 3 toxicity respectively. Overall, toxicity grade did not significantly correlate with presence of DIL (p = 0.10). Estimated 7-year freedom from biochemical failure (FFBF) was 84% (95% confidence interval: 79–89) and 70% (54–89) in patients with and without a DIL (log-rank p = 0.315). In DIL patients, cox regression revealed location of DIL (“Base” vs “Apex” HR: 1.03; 1.00–1.06; p = 0.03) and older age (70 vs 60 HR: 1.62; 1.06–2.49; p = 0.03) was associated with poor FFBF. Conclusions Targeting DIL through dose painting during intraoperatively planned LDR-BT provided no statistically significant change in FFBF. Patients with DILs in the prostate base had slightly lower FFBF despite DIL boost.
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Affiliation(s)
- Kevin Martell
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Soumyajit Roy
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada.,Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tyler Meyer
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Jordan Stosky
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Will Jiang
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Kundan Thind
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Michael Roumeliotis
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - John Bosch
- Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Steve Angyalfi
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Harvey Quon
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
| | - Siraj Husain
- University of Calgary, Department of Oncology, Calgary, AB, Canada.,Alberta Health Services, Calgary Zone, Calgary, AB, Canada
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22
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Christie DRH, Sharpley CF. How accurately can multiparametric magnetic resonance imaging measure the tumour volume of a prostate cancer? Results of a systematic review. J Med Imaging Radiat Oncol 2020; 64:398-407. [PMID: 32363735 DOI: 10.1111/1754-9485.13035] [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: 02/22/2020] [Revised: 03/22/2020] [Accepted: 03/23/2020] [Indexed: 12/15/2022]
Abstract
The tumour volume of a cancer within the prostate gland is commonly measured with multiparametric MRI. The measurement has a role in many clinical scenarios including focal therapy, but the accuracy of it has never been systematically reviewed. We included articles if they compared tumour volume measurements obtained by mpMRI with a reference volume measurement obtained after radical prostatectomy. Correlation and concordance statistics were summarised. A simple accuracy score was derived by dividing the given mean or median mpMRI volume by the histopathological reference volume. Factors affecting the accuracy were noted. Scores for potential bias and quality were calculated for each article. A total of 18 articles describing 1438 patients were identified. Nine articles gave Pearson's correlation scores, with a median value of 0.75 but the range was wide (0.42-0.97). A total of 11 articles reported mean values for volume while 9 reported median values. For all 18 articles, the mean or median values for MRI volumes were lower than the corresponding reference values suggesting consistent underestimation. For articles reporting mean and median values for volume, the median accuracy scores were 0.83 and 0.80, respectively. The accuracy was higher for tumours of greater volume, higher grade and when an endorectal coil was used. Accuracy did not seem to improve over time, with a 3 Tesla magnet or by applying a shrinkage factor to the reference measurement. Most studies showed evidence of at least moderate bias, and their quality was highly variable, but neither of these appeared to affect accuracy.
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Affiliation(s)
- David R H Christie
- Genesiscare, Inland Drive, Gold Coast, Queensland, Australia.,Brain-Behaviour Research Group, University of New England, Armidale, New South Wales, Australia
| | - Christopher F Sharpley
- Brain-Behaviour Research Group, University of New England, Armidale, New South Wales, Australia
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23
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The Precision Prostatectomy: “Waiting for Godot”. Eur Urol Focus 2020; 6:227-230. [DOI: 10.1016/j.euf.2020.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/05/2020] [Accepted: 01/16/2020] [Indexed: 11/22/2022]
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24
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Reply to “Prostate Cancer Index Lesion Detection and Volume Estimation: Is Dynamic Contrast-Enhanced MRI Really Reliable?”. AJR Am J Roentgenol 2019; 213:W290. [DOI: 10.2214/ajr.19.21950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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25
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Elfatairy KK, Filson CP, Sanda MG, Osunkoya AO, Nour SG. In-Bore MRI-guided Prostate Biopsies: Retrospective Observational Study of Complementary Nontargeted Sampling of Normal-appearing Areas at Multiparametric MRI. Radiol Imaging Cancer 2019; 1:e190016. [PMID: 33778681 DOI: 10.1148/rycan.2019190016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/23/2019] [Accepted: 09/03/2019] [Indexed: 11/11/2022]
Abstract
Purpose To investigate the pathologic outcomes of additional random biopsies from areas with no visible MR targets in the setting of targeted in-bore MRI-guided biopsy and to assess the negative predictive value (NPV) of areas with no visible MR targets stratified according to patients' different biopsy statuses. Materials and Methods A retrospective analysis of patients who underwent in-bore MRI-guided biopsy with additional random biopsies in areas with no visible MR targets (Prostate Imaging-Reporting and Data System, version 2 category 1 or 2) was conducted in this study. Diagnostic scans and in-bore MRI-guided biopsy were performed with a 3-T MRI scanner. Areas with no visible MR targets were biopsied in a random fashion whenever a zone or side did not have a visible focal target. Clinically significant cancers (CSCs) were defined as a Gleason score of 7 or greater. NPVs were stratified based on patient's prior biopsy status. Descriptive analysis was performed. Results A total of 59 consecutive patients were included, with a median age of 65 years (interquartile range [IQR], 59-71 years). The median prostate-specific antigen level was 7 ng/mL (IQR, 4.9-10.8 ng/mL). Of the 59 patients, 16 (27.1%) were biopsy naive, 24 (40.7%) had prior negative transrectal US-guided biopsy findings, and 19 (32.2%) had prior positive transrectal US-guided biopsy findings. Forty-two (71.2%) biopsies revealed prostate cancer. A total of 112 areas with no visible MR targets were biopsied, of which 20 (17.9%) were cancers and 11 (9.8%) were CSCs. The NPV of areas with no visible MR targets was approximately 78% for all cancers and was 88.1% for CSCs. NPVs in biopsy-naive patients, patients with prior negative transrectal US-guided biopsy findings, and patients with prior positive transrectal US-guided biopsy findings were 62.5%, 83.3%, and 84.2%, respectively, for all cancers and 75.0%, 91.7%, and 94.7%, respectively, for CSCs. Conclusion Areas with no visible MR targets in patients with MR-suspicious foci may still harbor CSCs that may significantly affect management plans. Additional biopsies from areas with no visible MR targets are warranted in this population.Keywords: Biopsy/Needle Aspiration, Interventional-Body, MR-Imaging, Prostate, Urinary© RSNA, 2019.
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Affiliation(s)
- Kareem K Elfatairy
- Department of Radiology and Imaging Sciences (K.K.E., S.G.N.), Interventional MRI Program (K.K.E., S.G.N.), Department of Urology (C.P.F., M.G.S., A.O.O.), and Department of Pathology (A.O.O.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Atlanta Veterans Affairs Medical Center, Decatur, Ga (C.P.F., M.G.S.); Emory Winship Cancer Institute, Atlanta, Ga (C.P.F., M.G.S., A.O.O., S.G.N.); Department of Pathology, Veterans Affairs Medical Center, Atlanta, Ga (A.O.O.); and Department of Radiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt (K.K.E.)
| | - Christopher P Filson
- Department of Radiology and Imaging Sciences (K.K.E., S.G.N.), Interventional MRI Program (K.K.E., S.G.N.), Department of Urology (C.P.F., M.G.S., A.O.O.), and Department of Pathology (A.O.O.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Atlanta Veterans Affairs Medical Center, Decatur, Ga (C.P.F., M.G.S.); Emory Winship Cancer Institute, Atlanta, Ga (C.P.F., M.G.S., A.O.O., S.G.N.); Department of Pathology, Veterans Affairs Medical Center, Atlanta, Ga (A.O.O.); and Department of Radiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt (K.K.E.)
| | - Martin G Sanda
- Department of Radiology and Imaging Sciences (K.K.E., S.G.N.), Interventional MRI Program (K.K.E., S.G.N.), Department of Urology (C.P.F., M.G.S., A.O.O.), and Department of Pathology (A.O.O.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Atlanta Veterans Affairs Medical Center, Decatur, Ga (C.P.F., M.G.S.); Emory Winship Cancer Institute, Atlanta, Ga (C.P.F., M.G.S., A.O.O., S.G.N.); Department of Pathology, Veterans Affairs Medical Center, Atlanta, Ga (A.O.O.); and Department of Radiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt (K.K.E.)
| | - Adeboye O Osunkoya
- Department of Radiology and Imaging Sciences (K.K.E., S.G.N.), Interventional MRI Program (K.K.E., S.G.N.), Department of Urology (C.P.F., M.G.S., A.O.O.), and Department of Pathology (A.O.O.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Atlanta Veterans Affairs Medical Center, Decatur, Ga (C.P.F., M.G.S.); Emory Winship Cancer Institute, Atlanta, Ga (C.P.F., M.G.S., A.O.O., S.G.N.); Department of Pathology, Veterans Affairs Medical Center, Atlanta, Ga (A.O.O.); and Department of Radiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt (K.K.E.)
| | - Sherif G Nour
- Department of Radiology and Imaging Sciences (K.K.E., S.G.N.), Interventional MRI Program (K.K.E., S.G.N.), Department of Urology (C.P.F., M.G.S., A.O.O.), and Department of Pathology (A.O.O.), Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322; Atlanta Veterans Affairs Medical Center, Decatur, Ga (C.P.F., M.G.S.); Emory Winship Cancer Institute, Atlanta, Ga (C.P.F., M.G.S., A.O.O., S.G.N.); Department of Pathology, Veterans Affairs Medical Center, Atlanta, Ga (A.O.O.); and Department of Radiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt (K.K.E.)
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26
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Can Extraprostatic Extension Be Predicted by Tumor-Capsule Contact Length in Prostate Cancer? Relationship With International Society of Urological Pathology Grade Groups. AJR Am J Roentgenol 2019; 214:588-596. [PMID: 31670596 DOI: 10.2214/ajr.19.21828] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE. The objective of our study was to evaluate the relationship between the tumor-capsule contact length, defined as tumor contact length (TCL), and extraprostatic extension (EPE) using the MRI-based TCL measurements and the real TCL measurements from pathology and to determine whether the International Society of Urological Pathology (ISUP) grade group of the tumors influenced this relationship. MATERIALS AND METHODS. In this retrospective study, we reviewed prostate multiparametric MRI (mpMRI) studies performed between 2012 and 2018 of 1576 patients and found that 134 patients also underwent radical prostatectomy (RP) after mpMRI. Finally, 86 patients with index lesions in contact with the prostate capsule in RP specimens were enrolled in the study. ROC analysis was used to evaluate the cutoff values of TCLs measured at pathology and TCLs measured on MRI in terms of EPE according to ISUP grade groups. RESULTS. There was no statistically significant cutoff value for pathology-based TCL measurements in individual ISUP grade groups and subgroups. Although not statistically significant, pathology-based TCL cutoff values decreased (from 21.0 to 11.0 mm) as ISUP grade group increased in terms of EPE positivity. When the relationship between MRI-based TCL measurements and EPE was considered, statistically significant cutoff values (range, 14.5-16.6 mm) could be determined in many groups and subgroups with low ISUP grades (sensitivity, 66.7-100%; specificity, 52.8-93.0%; p = 0.006-0.042). However, no statistically significant cutoff value was found for high ISUP grades. CONCLUSION. ISUP grade groups may have an effect on the TCL-EPE relationship. When the MRI-based TCL and EPE relationship is evaluated independent of ISUP grade group, a cutoff value around 15-16 mm may be usable to predict EPE.
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27
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Houdt PJ, Ghobadi G, Schoots IG, Heijmink SW, Jong J, Poel HG, Pos FJ, Rylander S, Bentzen L, Haustermans K, Heide UA. Histopathological Features of MRI‐Invisible Regions of Prostate Cancer Lesions. J Magn Reson Imaging 2019; 51:1235-1246. [DOI: 10.1002/jmri.26933] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022] Open
Affiliation(s)
- Petra J. Houdt
- Department of Radiation Oncologythe Netherlands Cancer Institute Amsterdam The Netherlands
| | - Ghazaleh Ghobadi
- Department of Radiation Oncologythe Netherlands Cancer Institute Amsterdam The Netherlands
| | - Ivo G. Schoots
- Department of Radiologythe Netherlands Cancer Institute Amsterdam The Netherlands
- Department of Radiology and Nuclear MedicineErasmus University Medical Center Rotterdam The Netherlands
| | | | - Jeroen Jong
- Department of Pathologythe Netherlands Cancer Institute Amsterdam The Netherlands
| | - Henk G. Poel
- Department of Urologythe Netherlands Cancer Institute Amsterdam The Netherlands
| | - Floris J. Pos
- Department of Radiation Oncologythe Netherlands Cancer Institute Amsterdam The Netherlands
| | - Susanne Rylander
- Department of Medical PhysicsAarhus University Hospital Aarhus Denmark
| | - Lise Bentzen
- Department of OncologyAarhus University Hospital Aarhus Denmark
| | - Karin Haustermans
- Department of Radiation OncologyUniversity Hospitals Leuven Leuven Belgium
| | - Uulke A. Heide
- Department of Radiation Oncologythe Netherlands Cancer Institute Amsterdam The Netherlands
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28
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Sood A, Jeong W, Taneja K, Abdollah F, Palma-Zamora I, Arora S, Gupta N, Menon M. The Precision Prostatectomy: an IDEAL Stage 0, 1 and 2a Study. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2019; 1:e000002. [PMID: 35047770 PMCID: PMC8647607 DOI: 10.1136/bmjsit-2019-000002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/17/2019] [Accepted: 07/17/2019] [Indexed: 11/28/2022] Open
Abstract
Objective This study aimed to develop a preclinical model of prostate cancer (CaP) for studying focal/hemiablation of the prostate (IDEAL stage 0), and to use the information from the stage 0 investigation to design a novel focal surgical treatment approach—the precision prostatectomy (IDEAL stage 1/2a). Methods The IDEAL stage 0 study included simulation of focal/hemiablation in whole-mount prostate specimens obtained from 100 men who had undergone radical prostatectomies, but met the criteria for focal/hemiablation. The IDEAL stage 1/2a was a prospective, single-arm, Institutional Review Board-approved study of precision prostatectomy undertaken in eight men, who met the predetermined criteria. Criteria for both stages included (1) prostate-specific antigen (PSA) ≤15 ng/mL, (2) stage ≤cT2, (3) dominant unilateral lesion with Gleason ≤4+3 with any number of cores or % cores involved ipsilaterally on transrectal biopsy, (4) no primary Gleason ≥4 contralaterally on transrectal biopsy, and (5) preoperative erectile function score (International Index of Erectile Function (IIEF)-5) of ≥17 (out of 25) without PDE-5i (applicable only to the stage 1/2a study participants). Feasibility and safety of the precision prostatectomy technique, and short-term urinary, sexual and oncological outcomes were studied. Results Analysis of whole-mount specimens in the 100 men showed an index lesion (>1 cm in diameter) in all. Ninety-eight men had satellite lesions smaller than 0.5 cm∧3 in volume—46 on the side of the dominant lesions and 52 in the contralateral lobe. If the men in this modeling cohort had undergone focal ablation with a 5–10 mm untreated margin, all except one would have had at least Gleason 6 residual cancer. If they had undergone hemiablation with no untreated tissue on the ablated side, 56 men would have had residual cancer on the contralateral side, of whom 21 would have had clinically significant cancer (Gleason 7 or higher). If these men had undergone precision prostatectomy, with preservation of 5–10 mm of tissue on the non-dominant side, 10% and 4% would have had Gleason 3+4 and Gleason 4+3 disease left behind, respectively. For the stage 1/2a study, the median (IQR) age, PSA and IIEF-5 scores at the time of surgery were 54 (52–57) years, 4.4 (3.8–6.1) ng/mL and 24 (23-25), respectively. All eight patients were continent and sexually active at 12 months with a median IIEF-5 score of 21 (out of 25). At 24–30 months from surgery, the median PSA was 0.2 (range 0.1–0.7) ng/mL. Six men had undergone follow-up protocol biopsies, two, with undetectable PSA, had refused. Two men had residual Gleason 3+3 cancer, with PSA of 0.7 and 0.4 ng/mL, and remain on active surveillance. No man has undergone secondary whole-gland therapy. Conclusions Examination of whole-mount radical prostatectomy specimens in men who fit the conventional criteria of focal/hemiablation showed that approximately 21%–68% of men would have clinically significant CaP in the untreated tissue. In a small development cohort, precision prostatectomy was technically feasible, with excellent postoperative functional recovery. At 30 months of follow-up, no patient had clinically significant residual cancer or required secondary treatment. Pending long-term follow-up, a risk-stratified surgical approach may avoid whole-gland therapy and preserve erectile function in the majority of men with intermediate-risk CaP.
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Affiliation(s)
- Akshay Sood
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kanika Taneja
- Department of Pathology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Firas Abdollah
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - Isaac Palma-Zamora
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sohrab Arora
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
| | - Nilesh Gupta
- Department of Pathology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
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29
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Gupta RT, Mehta KA, Turkbey B, Verma S. PI‐RADS: Past, present, and future. J Magn Reson Imaging 2019; 52:33-53. [DOI: 10.1002/jmri.26896] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 12/25/2022] Open
Affiliation(s)
- Rajan T. Gupta
- Department of RadiologyDuke University Medical Center Durham North Carolina USA
- Department of Surgery, Division of Urologic SurgeryDuke University Medical Center Durham North Carolina USA
- Duke Cancer Institute Center for Prostate and Urologic Cancers Durham North Carolina USA
| | - Kurren A. Mehta
- Department of RadiologyDuke University Medical Center Durham North Carolina USA
| | - Baris Turkbey
- National Cancer Institute, Center for Cancer Research Bethesda Maryland USA
| | - Sadhna Verma
- Cincinnati Veterans Hospital, University of Cincinnati Cancer InstituteUniversity of Cincinnati Medical Center Cincinnati Ohio USA
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30
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Richenberg J, Løgager V, Panebianco V, Rouviere O, Villeirs G, Schoots IG. The primacy of multiparametric MRI in men with suspected prostate cancer. Eur Radiol 2019; 29:6940-6952. [PMID: 31172275 PMCID: PMC6828624 DOI: 10.1007/s00330-019-06166-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 12/14/2022]
Abstract
Background Multiparametric MRI (mpMRI) became recognised in investigating those with suspected prostate cancer between 2010 and 2012; in the USA, the preventative task force moratorium on PSA screening was a strong catalyst. In a few short years, it has been adopted into daily urological and oncological practice. The pace of clinical uptake, born along by countless papers proclaiming high accuracy in detecting clinically significant prostate cancer, has sparked much debate about the timing of mpMRI within the traditional biopsy-driven clinical pathways. There are strongly held opposing views on using mpMRI as a triage test regarding the need for biopsy and/or guiding the biopsy pattern. Objective To review the evidence base and present a position paper on the role of mpMRI in the diagnosis and management of prostate cancer. Methods A subgroup of experts from the ESUR Prostate MRI Working Group conducted literature review and face to face and electronic exchanges to draw up a position statement. Results This paper considers diagnostic strategies for clinically significant prostate cancer; current national and international guidance; the impact of pre-biopsy mpMRI in detection of clinically significant and clinically insignificant neoplasms; the impact of pre-biopsy mpMRI on biopsy strategies and targeting; the notion of mpMRI within a wider risk evaluation on a patient by patient basis; the problems that beset mpMRI including inter-observer variability. Conclusions The paper concludes with a set of suggestions for using mpMRI to influence who to biopsy and who not to biopsy at diagnosis. Key Points • Adopt mpMRI as the first, and primary, investigation in the workup of men with suspected prostate cancer. • PI-RADS assessment categories 1 and 2 have a high negative predictive value in excluding significant disease, and systematic biopsy may be postponed, especially in men with low-risk of disease following additional risk stratification. • PI-RADS assessment category lesions 4 and 5 should be targeted; PI-RADS assessment category lesion 3 may be biopsied as a target, as part of systematic biopsies or may be observed depending on risk stratification. Electronic supplementary material The online version of this article (10.1007/s00330-019-06166-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonathan Richenberg
- Department of Imaging, Brighton & Sussex University Hospitals NHS Trust and Brighton and Sussex Medical School, Brighton, BN2 5BE, UK.
| | - Vibeke Løgager
- Department of Radiology, Herlev University Hospital Copenhagen University, Herlev, Denmark
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza, University of Rome, Rome, Italy
| | - Olivier Rouviere
- Hospices civils de Lyon, Department of Urinary and Vascular Radiology, hôpital Édouard-Herriot, 69437, Lyon, France.,Faculté de médecine Lyon Est, Université Lyon 1, 69003, Lyon, France
| | - Geert Villeirs
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
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Investigating the role of DCE-MRI, over T2 and DWI, in accurate PI-RADS v2 assessment of clinically significant peripheral zone prostate lesions as defined at radical prostatectomy. Abdom Radiol (NY) 2019; 44:1520-1527. [PMID: 30361870 DOI: 10.1007/s00261-018-1807-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE PI-RADS v2 dictates that dynamic contrast-enhanced (DCE) imaging be used to further classify peripheral zone (PZ) cases that receive a diffusion-weighted imaging equivocal score of three (DWI3), a positive DCE resulting in an increase in overall assessment score to a four, indicative of clinically significant prostate cancer (csPCa). However, the accuracy of DCE in predicting csPCa in DWI3 PZ cases is unknown. This study sought to determine the frequency with which DCE changes the PI-RADS v2 DWI3 assessment category, and to determine the overall accuracy of DCE-MRI in equivocal PZ DWI3 lesions. MATERIALS AND METHODS This is a retrospective study of patients with pathologically proven PCa who underwent prostate mpMRI at 3T and subsequent radical prostatectomy. PI-RADS v2 assessment categories were determined by a radiologist, aware of a diagnosis of PCa, but blinded to final pathology. csPCa was defined as a Gleason score ≥ 7 or extra prostatic extension at pathology review. Performance characteristics and diagnostic accuracy of DCE in assigning a csPCa assessment in PZ lesions were calculated. RESULTS A total of 271 men with mean age of 59 ± 6 years mean PSA 6.7 ng/mL were included. csPCa was found in 212/271 (78.2%) cases at pathology, 209 of which were localized in the PZ. DCE was necessary to further classify (45/209) of patients who received a score of DWI3. DCE was positive in 29/45 cases, increasing the final PI-RADS v2 assessment category to a category 4, with 16/45 having a negative DCE. When compared with final pathology, DCE was correct in increasing the assessment category in 68.9% ± 7% (31/45) of DWI3 cases. CONCLUSION DCE increases the accuracy of detection of csPCa in the majority of PZ lesions that receive an equivocal PI-RADS v2 assessment category using DWI.
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Comparison of T2-Weighted Imaging, DWI, and Dynamic Contrast-Enhanced MRI for Calculation of Prostate Cancer Index Lesion Volume: Correlation With Whole-Mount Pathology. AJR Am J Roentgenol 2018; 212:351-356. [PMID: 30540213 DOI: 10.2214/ajr.18.20147] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of our study was to investigate the comparative effectiveness of different MRI sequences for the estimation of index lesion volume in patients with prostate cancer (PCa) compared with ground truth volume measured on whole-mount pathology. MATERIALS AND METHODS Patients with PCa underwent multiparametric MRI (mpMRI) on a 3-T MRI scanner before radical prostatectomy. Forty PCa index lesions were identified and outlined on histology by a pathologist. Two radiologists who were informed about the presence of PCa but were not aware of lesion outlines on histology worked in consensus to delineate PCa lesions on T2-weighted imaging, apparent diffusion coefficient (ADC) maps, and early-phase dynamic contrast-enhanced MRI (DCE-MRI). The lesion volumes from different mpMRI sequences and the percentage of volume underestimation compared with pathology were calculated and correlated with volume at pathology. The repeated-measures ANOVA with the posthoc Bonferroni test was performed to evaluate whether the difference between the estimated tumor volumes was statistically significant. RESULTS The mean PCa lesion volume estimated from pathology, T2-weighted imaging, DWI (ADC maps), and DCE-MRI were 4.61 ± 4.99 (SD) cm3, 2.03 ± 2.96 cm3, 1.81 ± 2.76 cm3, and 3.48 ± 4.06 cm3, respectively. The lesion volumes on T2-weighted images (p = 0.000002), ADC maps (p = 0.000003), and DCE-MR images (p = 0.004412) were significantly lower than those from pathology. PCa lesion volume was significantly underestimated on T2-weighted images, ADC maps, and DCE-MR images compared with pathology by 54.98% ± 22.60% (mean ± SD), 58.59% ± 18.58%, and 18.33% ± 30.11%, respectively; underestimation using T2-weighted imaging (p = 1.01 × 10-11) and DWI (p = 2.94 × 10-11) was significantly higher than underestimation using DCE-MRI. Correlations between lesion volume estimated on T2-weighted images, ADC maps, and DCE-MR images with pathology were 0.91 (p = 9.03 × 10-16), 0.86 (p = 7.32 × 10-13), and 0.93 (p = 8.22 × 10-18), respectively. CONCLUSION DCE-MRI performed better than T2-weighted imaging and DWI for estimation of index PCa volume and therefore can be preferred over these other two sequences for volume estimation.
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Gennaro KH, Porter KK, Gordetsky JB, Galgano SJ, Rais-Bahrami S. Imaging as a Personalized Biomarker for Prostate Cancer Risk Stratification. Diagnostics (Basel) 2018; 8:diagnostics8040080. [PMID: 30513602 PMCID: PMC6316045 DOI: 10.3390/diagnostics8040080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 02/07/2023] Open
Abstract
Biomarkers provide objective data to guide clinicians in disease management. Prostate-specific antigen serves as a biomarker for screening of prostate cancer but has come under scrutiny for detection of clinically indolent disease. Multiple imaging techniques demonstrate promising results for diagnosing, staging, and determining definitive management of prostate cancer. One such modality, multiparametric magnetic resonance imaging (mpMRI), detects more clinically significant disease while missing lower volume and clinically insignificant disease. It also provides valuable information regarding tumor characteristics such as location and extraprostatic extension to guide surgical planning. Information from mpMRI may also help patients avoid unnecessary biopsies in the future. It can also be incorporated into targeted biopsies as well as following patients on active surveillance. Other novel techniques have also been developed to detect metastatic disease with advantages over traditional computer tomography and magnetic resonance imaging, which primarily rely on defined size criteria. These new techniques take advantage of underlying biological changes in prostate cancer tissue to identify metastatic disease. The purpose of this review is to present literature on imaging as a personalized biomarker for prostate cancer risk stratification.
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Affiliation(s)
- Kyle H Gennaro
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Kristin K Porter
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Jennifer B Gordetsky
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Samuel J Galgano
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Soroush Rais-Bahrami
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Dinis Fernandes C, Ghobadi G, van der Poel HG, de Jong J, Heijmink SWTPJ, Schoots I, Walraven I, van Houdt PJ, Smolic M, Pos FJ, van der Heide UA. Quantitative 3-T multi-parametric MRI and step-section pathology of recurrent prostate cancer patients after radiation therapy. Eur Radiol 2018; 29:4160-4168. [PMID: 30421016 PMCID: PMC6610274 DOI: 10.1007/s00330-018-5819-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/30/2018] [Accepted: 10/02/2018] [Indexed: 12/21/2022]
Abstract
Objectives Diagnosis of radio-recurrent prostate cancer using multi-parametric MRI (mp-MRI) can be challenging due to the presence of radiation effects. We aim to characterize imaging of prostate tissue after radiation therapy (RT), using histopathology as ground truth, and to investigate the visibility of tumor lesions on mp-MRI. Methods Tumor delineated histopathology slides from salvage radical prostatectomy patients, primarily treated with RT, were registered to MRI. Median T2-weighted, ADC, Ktrans, and kep values in tumor and other regions were calculated. Two radiologists independently performed mp-MRI-based tumor delineations which were compared with the true pathological extent. General linear mixed-effect modeling was used to establish the contribution of each imaging modality and combinations thereof in distinguishing tumor and benign voxels. Results Nineteen of the 21 included patients had tumor in the available histopathology slides. Recurrence was predominantly multifocal with large tumor foci seen after external beam radiotherapy, whereas these were small and sparse after low-dose-rate brachytherapy. MRI-based delineations missed small foci and slightly underestimated tumor extent. The combination of T2-weighted, ADC, Ktrans, and kep had the best performance in distinguishing tumor and benign voxels. Conclusions Using high-resolution histopathology delineations, the real tumor extent and size were found to be underestimated on MRI. mp-MRI obtained the best performance in identifying tumor voxels. Appropriate margins around the visible tumor-suspected region should be included when designing focal salvage strategies. Recurrent tumor delineation guidelines are warranted. Key Points • Compared to the use of individual sequences, multi-parametric MRI obtained the best performance in distinguishing recurrent tumor from benign voxels. • Delineations based on mp-MRI miss smaller foci and slightly underestimate tumor volume of local recurrent prostate cancer. • Focal salvage strategies should include appropriate margins around the visible tumor. Electronic supplementary material The online version of this article (10.1007/s00330-018-5819-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catarina Dinis Fernandes
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Ghazaleh Ghobadi
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jeroen de Jong
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Ivo Schoots
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Walraven
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Petra J van Houdt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Milena Smolic
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Floris J Pos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Giganti F, Moore CM, Punwani S, Allen C, Emberton M, Kirkham A. The natural history of prostate cancer on MRI: lessons from an active surveillance cohort. Prostate Cancer Prostatic Dis 2018; 21:556-563. [PMID: 30038388 DOI: 10.1038/s41391-018-0058-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/08/2018] [Accepted: 04/17/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) is being used increasingly in the setting of active surveillance (AS) for prostate cancer. We investigated changes in the mpMRI appearance of lesions on AS, to show the variability of volume measurements in visible lesions and assess change in lesion size according to grade. METHODS We retrospectively retrieved 86 men on AS (NICE guidelines) with more than one mpMRI (the first before 2013). Two radiologists, in consensus, were blinded to patient demographics and date of scan. The scans were randomly reported to reduce any bias. For visible lesions, we measured volume by planimetry on the sequence best showing the most conspicuous (index) tumour and attributed a 5-point Likert score. RESULTS 43/86 men did not have a visible lesion on the initial mpMRI (≤2/5). Of these, 5/43 had developed a lesion scoring ≥3/5 at a median of 3.6 years of follow up. 40/86 had a lesion scoring ≥3/5 on two or more scans. There was a significant increase in volume over 3.6 years by a median of 10% (p < 0.01)-by a median of 6% for Gleason 3+3 and 18% for 3+4 (p = 0.058). Thirty-five men had a visible lesion on two scans separated by <2 years; of these, 21/35 showed a 78% median increase in tumour size between the two scans and 11/35 showed an apparent 25% median decrease in lesion size. CONCLUSIONS A total of 17% of men with no visible lesion developed a visible lesion at a median follow up of 3.6 years. It is possible to show significant growth in patients with a visible lesion, but variability in volume measurements between scans means that it is difficult to reliably detect increases of this order. This variability may inform the design of mpMRI protocols in AS and the time between follow up scans.
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Affiliation(s)
- Francesco Giganti
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK.
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Caroline M Moore
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
- Centre for Medical Imaging, University College London, London, UK
| | - Clare Allen
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Alex Kirkham
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
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36
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Histopathological to multiparametric MRI spatial mapping of extended systematic sextant and MR/TRUS-fusion-targeted biopsy of the prostate. Eur Radiol 2018; 29:1820-1830. [DOI: 10.1007/s00330-018-5751-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/15/2018] [Accepted: 09/11/2018] [Indexed: 01/08/2023]
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Lovegrove CE, Matanhelia M, Randeva J, Eldred-Evans D, Tam H, Miah S, Winkler M, Ahmed HU, Shah TT. Prostate imaging features that indicate benign or malignant pathology on biopsy. Transl Androl Urol 2018; 7:S420-S435. [PMID: 30363462 PMCID: PMC6178322 DOI: 10.21037/tau.2018.07.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Accurate diagnosis of clinically significant prostate cancer is essential in identifying patients who should be offered treatment with curative intent. Modifications to the Gleason grading system in recent years show that accurate grading and reporting at needle biopsy can improve identification of clinically significant prostate cancers. Extracapsular extension of prostate cancer has been demonstrated to be an adverse prognostic factor with greater risk of metastatic spread than organ-confined disease. Tumor volume may be an independent prognostic factor and should be considered in conjunction with other factors. Multi-parametric magnetic resonance imaging (MP-MRI) has become an increasingly important tool in the diagnosis and characterization of prostate cancer. MP-MRI allows T2-weighted (T2W) anatomical imaging to be combined with functional and physiological assessment. Diffusion-weighted imaging (DWI) has shown greater sensitivity, specificity and negative predictive value compared to prostate specific antigen (PSA) testing and T2W imaging alone and has a more positive correlation with Gleason score and tumour volume. Dynamic gadolinium contrast-enhanced (DCE) imaging can exhibit difficulties in distinguishing prostatitis from malignancy in the peripheral zone, and between benign prostatic hyperplasia (BPH) and malignancies in the transition zone (TZ). Computer aided diagnosis utilizes software to aid radiologists in detecting and diagnosing abnormalities from diagnostic imaging. New techniques of quantitative MRI, such as VERDICT MRI use tissue-specific factors to delineate different cellular and microstructural phenotypes, characterizing tissue properties with greater detail. Proton MR spectroscopic imaging (MRSI) is a more technically challenging imaging modality than DCE and DWI MRI. Over the last decade, choline and prostate-specific membrane antigen (PSMA) positron emission tomography (PET) have developed as better tools for staging than conventional imaging. While hyperpolarized MRI shows promise in improving the imaging and differentiation of benign and malignant lesions there is further work required. Accurate reading and interpretation of diagnostic investigations is key to accurate identification of abnormal areas requiring biopsy, sparing those in whom benign or indolent disease can be managed by non-invasive means. Embracing and advancing existing technologies is essential in furthering this process.
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Affiliation(s)
- Catherine Elizabeth Lovegrove
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mudit Matanhelia
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jagpal Randeva
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - David Eldred-Evans
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Henry Tam
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Saiful Miah
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mathias Winkler
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Hashim U Ahmed
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Taimur T Shah
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
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Golan S, Nidam M, Bernstine H, Baniel J, Groshar D. Dynamic 11C-Choline PET / CT for the primary diagnosis of prostate cancer. Int Braz J Urol 2018; 44:900-905. [PMID: 30088719 PMCID: PMC6237539 DOI: 10.1590/s1677-5538.ibju.2018.0035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/31/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To test the ability of dynamic 11C-PET / CT to discriminate cancerous tissue from background tissue in patients with localized prostate cancer. MATERIALS AND METHODS Twenty-four consecutive patients with prostate cancer were prospectively evaluated with dynamic 11C-choline PET / CT prior to radical prostatectomy. The PET / CT scan was divided into 18 sequences of 5 seconds each, followed by 9 sequences of 60 seconds each. Whole-mount sections of harvested prostates served as reference standards. Volumes of interest were positioned on the dynamic PET / CT images and the following quantitative variables were calculated: perfusion coefficient (K1), washout constant (K2), area under the curve (AUC) at 175 and 630 seconds, and average and maximum standardized uptake values (SUVavg, and SUVmax). Wilcoxon signed-ranks test was used to compare benign and cancerous areas of the prostate. RESULTS Areas of cancerous tissue were characterized by higher SUVavg and SUVmax than areas of benign tissue (3.67 ± 2.7 vs. 2.08 ± 1.3 and 5.91 ± 4.4 vs. 3.71 ± 3.7, respectively, P < 0.001), in addition to a higher K1 (0.95 ± 0.58 vs. 0.43 ± 0.24, P < 0.001) and greater cumulative tracer uptake, represented by the AUC at 175 and 630 seconds (P <0.001). No associations were found between dynamic parameters and preoperative prostate specific antigen level or Gleason score. CONCLUSIONS In this pilot study, 11C-choline PET / CT demonstrated increased tracer uptake with higher values of static and dynamic parameters in areas of prostate cancer compared to areas of benign tissue. Larger studies are warranted to validate these results and examine the potential applicability of 11C-choline dynamic PET / CT for the diagnosis of prostate cancer.
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Affiliation(s)
- Shay Golan
- Institute of Urology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Sackler Faculty of Medicine, Israel
| | - Meital Nidam
- Department of Nuclear Medicine, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Sackler Faculty of Medicine, Israel
| | - Hanna Bernstine
- Department of Nuclear Medicine, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Sackler Faculty of Medicine, Israel
| | - Jack Baniel
- Institute of Urology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Sackler Faculty of Medicine, Israel
| | - David Groshar
- Department of Nuclear Medicine, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Sackler Faculty of Medicine, Israel
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Duvnjak P, Schulman AA, Holtz JN, Huang J, Polascik TJ, Gupta RT. Multiparametric Prostate MR Imaging: Impact on Clinical Staging and Decision Making. Urol Clin North Am 2018; 45:455-466. [DOI: 10.1016/j.ucl.2018.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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40
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Update on the ICUD-SIU consultation on multi-parametric magnetic resonance imaging in localised prostate cancer. World J Urol 2018; 37:429-436. [DOI: 10.1007/s00345-018-2395-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 06/28/2018] [Indexed: 11/26/2022] Open
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41
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Multiparametric Prostate MR Imaging: Impact on Clinical Staging and Decision Making. Radiol Clin North Am 2018; 56:239-250. [DOI: 10.1016/j.rcl.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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42
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A prospective study evaluating indirect MRI-signs for the prediction of extraprostatic disease in patients with prostate cancer: tumor volume, tumor contact length and tumor apparent diffusion coefficient. World J Urol 2018; 36:629-637. [PMID: 29349572 DOI: 10.1007/s00345-018-2171-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate three indirect MRI signs for predicting extraprostatic disease in patients referred to radical prostatectomy: index tumor volume (MTV), apparent diffusion coefficient (ADC) and tumor contact length (TCL). MATERIALS AND METHODS This prospective study included 183 patients with biopsy proven prostate cancer. In all patients the MTV (ml), ADC (× 10-5 mm2/s) and TCL (mm) of the index tumor were registered at the preoperative MRI. Whole-mounted microscopical examination classified each patient as having either localized- or extraprostatic disease. The Youden index was used to identify the optimal cut-off values for predicting extraprostatic disease. Univariate regression analyses were conducted to estimate the odds ratio (OR) with 95% confidence intervals (CI). Results were stratified upon zonal location of the index tumor. RESULTS Extraprostatic disease was identified in 103 (56%) patients. The risk of extraprostatic disease was nine times higher in peripheral zone tumors with ADC ≤ 89 (OR 9.1, 95% CI 4.2-19.6), five times higher in MTV ≥ 0.9 ml (OR 5.5, 95% CI 2.6-11.4) and five times higher in case of TCL ≥ 14 mm (OR 4.9, 95% CI 2.3-10.2). None of the indirect MRI signs could predict extraprostatic disease for transition zone tumors. CONCLUSION The MTV, ADC and TCL are all significant predictors of extraprostatic disease for peripheral zone tumors, while none of the indirect signs were useful for transition zone tumors.
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Orczyk C, Rosenkrantz AB, Mikheev A, Villers A, Bernaudin M, Taneja SS, Valable S, Rusinek H. 3D Registration of mpMRI for Assessment of Prostate Cancer Focal Therapy. Acad Radiol 2017; 24:1544-1555. [PMID: 29122471 PMCID: PMC6025844 DOI: 10.1016/j.acra.2017.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/25/2017] [Accepted: 06/09/2017] [Indexed: 01/16/2023]
Abstract
RATIONALE AND OBJECTIVES This study aimed to assess a novel method of three-dimensional (3D) co-registration of prostate magnetic resonance imaging (MRI) examinations performed before and after prostate cancer focal therapy. MATERIALS AND METHODS We developed a software platform for automatic 3D deformable co-registration of prostate MRI at different time points and applied this method to 10 patients who underwent focal ablative therapy. MRI examinations were performed preoperatively, as well as 1 week and 6 months post treatment. Rigid registration served as reference for assessing co-registration accuracy and precision. RESULTS Segmentation of preoperative and postoperative prostate revealed a significant postoperative volume decrease of the gland that averaged 6.49 cc (P = .017). Applying deformable transformation based on mutual information from 120 pairs of MRI slices, we refined by 2.9 mm (max. 6.25 mm) the alignment of the ablation zone, segmented from contrast-enhanced images on the 1-week postoperative examination, to the 6-month postoperative T2-weighted images. This represented a 500% improvement over the rigid approach (P = .001), corrected by volume. The dissimilarity by Dice index of the mapped ablation zone using deformable transformation vs rigid control was significantly (P = .04) higher at the ablation site than in the whole gland. CONCLUSIONS Our findings illustrate our method's ability to correct for deformation at the ablation site. The preliminary analysis suggests that deformable transformation computed from mutual information of preoperative and follow-up MRI is accurate in co-registration of MRI examinations performed before and after focal therapy. The ability to localize the previously ablated tissue in 3D space may improve targeting for image-guided follow-up biopsy within focal therapy protocols.
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Affiliation(s)
- Clément Orczyk
- The Prostate Unit, Department of Urology, University College London Hospitals, London, United Kingdom; Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, NY; Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, 14000Caen, France; Department of Urology, University Hospital of Caen, Caen, France.
| | - Andrew B Rosenkrantz
- Department of Radiology, New York University Langone Medical Center, New York, NY
| | - Artem Mikheev
- Department of Radiology, New York University Langone Medical Center, New York, NY
| | - Arnauld Villers
- Department of Urology, Université Lille Nord de France, Lille, France
| | - Myriam Bernaudin
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, 14000Caen, France
| | - Samir S Taneja
- Division of Urologic Oncology, Department of Urology, New York University Langone Medical Center, New York, NY; Department of Radiology, New York University Langone Medical Center, New York, NY
| | - Samuel Valable
- Normandie Université, UNICAEN, CEA, CNRS, ISTCT/CERVOxy Group, 14000Caen, France
| | - Henry Rusinek
- Department of Radiology, New York University Langone Medical Center, New York, NY
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Diffusion-weighted imaging of the prostate: should we use quantitative metrics to better characterize focal lesions originating in the peripheral zone? Eur Radiol 2017; 28:2236-2245. [DOI: 10.1007/s00330-017-5107-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 09/05/2017] [Accepted: 09/28/2017] [Indexed: 02/05/2023]
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Borofsky S, George AK, Gaur S, Bernardo M, Greer MD, Mertan FV, Taffel M, Moreno V, Merino MJ, Wood BJ, Pinto PA, Choyke PL, Turkbey B. What Are We Missing? False-Negative Cancers at Multiparametric MR Imaging of the Prostate. Radiology 2017; 286:186-195. [PMID: 29053402 DOI: 10.1148/radiol.2017152877] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose To characterize clinically important prostate cancers missed at multiparametric (MP) magnetic resonance (MR) imaging. Materials and Methods The local institutional review board approved this HIPAA-compliant retrospective single-center study, which included 100 consecutive patients who had undergone MP MR imaging and subsequent radical prostatectomy. A genitourinary pathologist blinded to MP MR findings outlined prostate cancers on whole-mount pathology slices. Two readers correlated mapped lesions with reports of prospectively read MP MR images. Readers were blinded to histopathology results during prospective reading. At histopathologic examination, 80 clinically unimportant lesions (<5 mm; Gleason score, 3+3) were excluded. The same two readers, who were not blinded to histopathologic findings, retrospectively reviewed cancers missed at MP MR imaging and assigned a Prostate Imaging Reporting and Data System (PI-RADS) version 2 score to better understand false-negative lesion characteristics. Descriptive statistics were used to define patient characteristics, including age, prostate-specific antigen (PSA) level, PSA density, race, digital rectal examination results, and biopsy results before MR imaging. Student t test was used to determine any demographic differences between patients with false-negative MP MR imaging findings and those with correct prospective identification of all lesions. Results Of the 162 lesions, 136 (84%) were correctly identified with MP MR imaging. Size of eight lesions was underestimated. Among the 26 (16%) lesions missed at MP MR imaging, Gleason score was 3+4 in 17 (65%), 4+3 in one (4%), 4+4 in seven (27%), and 4+5 in one (4%). Retrospective PI-RADS version 2 scores were assigned (PI-RADS 1, n = 8; PI-RADS 2, n = 7; PI-RADS 3, n = 6; and PI-RADS 4, n = 5). On a per-patient basis, MP MR imaging depicted clinically important prostate cancer in 99 of 100 patients. At least one clinically important tumor was missed in 26 (26%) patients, and lesion size was underestimated in eight (8%). Conclusion Clinically important lesions can be missed or their size can be underestimated at MP MR imaging. Of missed lesions, 58% were not seen or were characterized as benign findings at second-look analysis. Recognition of the limitations of MP MR imaging is important, and new approaches to reduce this false-negative rate are needed. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Samuel Borofsky
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Arvin K George
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Sonia Gaur
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Marcelino Bernardo
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Matthew D Greer
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Francesca V Mertan
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Myles Taffel
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Vanesa Moreno
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Maria J Merino
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Bradford J Wood
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Peter A Pinto
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Peter L Choyke
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
| | - Baris Turkbey
- From the Molecular Imaging Program (S.B., S.G., M.B., M.D.G., F.V.M., P.L.C., B.T.), Urologic Oncology Branch (A.K.G.), and Laboratory of Pathology (V.M., M.J.M.), National Cancer Institute, National Institutes of Health, 10 Center Dr, Room B3B85, Bethesda, MD 20892; Department of Radiology, George Washington University Hospital, Washington, DC (S.B., M.T., P.A.P.); and Center for Interventional Oncology, National Cancer Institute, and Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Md (B.J.W.)
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[Indications and limits of ablative therapies in prostate cancer]. Prog Urol 2017; 27:865-886. [PMID: 28918871 DOI: 10.1016/j.purol.2017.08.004] [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: 07/17/2017] [Accepted: 08/04/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To perform a state of the art about indications and limits of ablative therapies for localized prostate cancer. METHODS A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 107 articles were analysed. RESULTS The objective to combine reduction of side effects and oncological control has induced recent development of several ablative therapies. Beyond this heterogeneity, some preferential indications appear: unilateral cancer of low risk (but with significant volume, excluding active surveillance) or intermediate risk (excluding majority of grade 4); treatment targeted the index lesion, by quarter or hemi-ablation, based on biopsy and mpMRI. In addition, indications must considered specific limits of each energy, such as gland volume and tumor localization. CONCLUSION Based on new imaging and biopsy, ablative therapies will probably increased its role in the future in management of localize prostate cancer. The multiple ongoing trials will certainly be helpful to better define their indications and limits.
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Re: Magnetic Resonance Imaging Underestimation of Prostate Cancer Geometry: Use of Patient Specific Molds to Correlate Images with Whole Mount Pathology: A. Priester, S. Natarajan, P. Khoshnoodi, D. J. Margolis, S. S. Raman, R. E. Reiter, J. Huang, W. Grundfest and L. S. Marks J Urol 2017;197:320-326. J Urol 2017; 198:1436-1437. [PMID: 28888772 DOI: 10.1016/j.juro.2017.07.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 11/24/2022]
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The performance of PI-RADSv2 and quantitative apparent diffusion coefficient for predicting confirmatory prostate biopsy findings in patients considered for active surveillance of prostate cancer. Abdom Radiol (NY) 2017; 42:1968-1974. [PMID: 28258355 DOI: 10.1007/s00261-017-1086-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To assess the performance of the updated Prostate Imaging Reporting and Data System (PI-RADSv2) and the apparent diffusion coefficient (ADC) for predicting confirmatory biopsy results in patients considered for active surveillance of prostate cancer (PCA). METHODS IRB-approved, retrospective study of 371 consecutive men with clinically low-risk PCA (initial biopsy Gleason score ≤6, prostate-specific antigen <10 ng/ml, clinical stage ≤T2a) who underwent 3T-prostate MRI before confirmatory biopsy. Two independent radiologists recorded the PI-RADSv2 scores and measured the corresponding ADC values in each patient. A composite score was generated to assess the performance of combining PI-RADSv2 + ADC. RESULTS PCA was upgraded on confirmatory biopsy in 107/371 (29%) patients. Inter-reader agreement was substantial (PI-RADSv2: k = 0.73; 95% CI [0.66-0.80]; ADC: r = 0.74; 95% CI [0.69-0.79]). Accuracies, sensitivities, specificities, positive predicted value and negative predicted value of PI-RADSv2 were 85, 89, 83, 68, 95 and 78, 82, 76, 58, 91% for ADC. PI-RADSv2 accuracy was significantly higher than that of ADC for predicting biopsy upgrade (p = 0.014). The combined PI-RADSv2 + ADC composite score did not perform better than PI-RADSv2 alone. Obviating biopsy in patients with PI-RADSv2 score ≤3 would have missed Gleason Score upgrade in 12/232 (5%) of patients. CONCLUSION PI-RADSv2 was superior to ADC measurements for predicting PCA upgrading on confirmatory biopsy.
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Rouvière O, Dagonneau T, Cros F, Bratan F, Roche L, Mège-Lechevallier F, Ruffion A, Crouzet S, Colombel M, Rabilloud M. Diagnostic value and relative weight of sequence-specific magnetic resonance features in characterizing clinically significant prostate cancers. PLoS One 2017; 12:e0178901. [PMID: 28599001 PMCID: PMC5466299 DOI: 10.1371/journal.pone.0178901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 05/19/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose To assess the diagnostic weight of sequence-specific magnetic resonance features in characterizing clinically significant prostate cancers (csPCa). Materials and methods We used a prospective database of 262 patients who underwent T2-weighted, diffusion-weighted, and dynamic contrast-enhanced (DCE) imaging before prostatectomy. For each lesion, two independent readers (R1, R2) prospectively defined nine features: shape, volume (V_Max), signal abnormality on each pulse sequence, number of pulse sequences with a marked (S_Max) and non-visible (S_Min) abnormality, likelihood of extracapsular extension (ECE) and PSA density (dPSA). Overall likelihood of malignancy was assessed using a 5-level Likert score. Features were evaluated using the area under the receiver operating characteristic curve (AUC). csPCa was defined as Gleason ≥7 cancer (csPCa-A), Gleason ≥7(4+3) cancer (csPCa-B) or Gleason ≥7 cancer with histological extraprostatic extension (csPCa-C), Results For csPCa-A, the Signal1 model (S_Max+S_Min) provided the best combination of signal-related variables, for both readers. The performance was improved by adding V_Max, ECE and/or dPSA, but not shape. All models performed better with DCE findings than without. When moving from csPCa-A to csPCa-B and csPCa-C definitions, the added value of V_Max, dPSA and ECE increased as compared to signal-related variables, and the added value of DCE decreased. For R1, the best models were Signal1+ECE+dPSA (AUC = 0,805 [95%CI:0,757–0,866]), Signal1+V_Max+dPSA (AUC = 0.823 [95%CI:0.760–0.893]) and Signal1+ECE+dPSA [AUC = 0.840 (95%CI:0.774–0.907)] for csPCa-A, csPCA-B and csPCA-C respectively. The AUCs of the corresponding Likert scores were 0.844 [95%CI:0.806–0.877, p = 0.11], 0.841 [95%CI:0.799–0.876, p = 0.52]) and 0.849 [95%CI:0.811–0.884, p = 0.49], respectively. For R2, the best models were Signal1+V_Max+dPSA (AUC = 0,790 [95%CI:0,731–0,857]), Signal1+V_Max (AUC = 0.813 [95%CI:0.746–0.882]) and Signal1+ECE+V_Max (AUC = 0.843 [95%CI: 0.781–0.907]) for csPCa-A, csPCA-B and csPCA-C respectively. The AUCs of the corresponding Likert scores were 0. 829 [95%CI:0.791–0.868, p = 0.13], 0.790 [95%CI:0.742–0.841, p = 0.12]) and 0.808 [95%CI:0.764–0.845, p = 0.006]), respectively. Conclusion Combination of simple variables can match the Likert score’s results. The optimal combination depends on the definition of csPCa.
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Affiliation(s)
- Olivier Rouvière
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
- Université de Lyon, Lyon, France; Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
- Inserm, U1032, LabTau, Lyon, France
- * E-mail:
| | - Tristan Dagonneau
- Hospices Civils de Lyon, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biotatistique-Santé, Villeurbanne, France
| | - Fanny Cros
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - Flavie Bratan
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Lyon, France
| | - Laurent Roche
- Hospices Civils de Lyon, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biotatistique-Santé, Villeurbanne, France
| | | | - Alain Ruffion
- Hospices Civils de Lyon, Department of Urology, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Sébastien Crouzet
- Université de Lyon, Lyon, France; Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
- Inserm, U1032, LabTau, Lyon, France
- Hospices Civils de Lyon, Department of Urology, Hôpital Edouard Herriot, Lyon, France
| | - Marc Colombel
- Université de Lyon, Lyon, France; Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
- Hospices Civils de Lyon, Department of Urology, Hôpital Edouard Herriot, Lyon, France
| | - Muriel Rabilloud
- Université de Lyon, Lyon, France; Université Lyon 1, faculté de médecine Lyon Est, Lyon, France
- Hospices Civils de Lyon, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biotatistique-Santé, Villeurbanne, France
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