Comparative Evaluation of Detection Rates for Clinically Significant Prostate Cancer Using MRI-Targeted Biopsy Alone Versus in Combination With Systematic Biopsies: Development of a Risk-Stratification Scoring System

OBJECTIVES

To compare the detection rates for clinically significant prostate cancer (csPCa; grade group 2 or higher disease) using MRI-targeted biopsy (MRI-TB) versus systematic biopsy (SB) or their combination, and identify risk factors for detecting csPCa in MRI-TB with systematic transrectal (TR)/transperineal (TP) biopsies (sTR/TP-bx) and MRI-TB with sTP-bx.

METHODS

We retrospectively analyzed 216 patients who underwent MRI-TB with SB at our hospital between September 2020 and December 2023 and compared clinical characteristics for patients with and without prostate cancer.

RESULTS

csPCa was detected in 132 (61.1%) patients by MRI-TB with sTR/TP-bx, in 121 (56.0%) patients using MRI-TB with sTP-bx, and in 101 (46.8%) patients using MRI-TB. Older age, higher PSA density (PSAD), smaller prostate volume, region of interest in the peripheral zone, higher Prostate Imaging-Reporting and Data System (PI-RADS), and administration of dutasteride were more common in csPCa cases. A scoring system was constructed based on odds ratios for PSAD, PI-RADS ≥ 4, and administration of dutasteride; accordingly, the detection rate of csPCa was 20.3% (14/69) in the low-risk group (RG) and 95.5% (42/44) in high RG for MRI-TB with sTR/TP-bx, and 16.7% (12/72) in the low RG and 97.8% (45/46) in high RG for MRI-TB with sTP-Bx.

CONCLUSIONS

The addition of SB increased the detection rate of csPCa compared with MRI-TB alone. PSAD, PI-RADS ≥ 4, and administration of dutasteride significantly affect the detection of csPCa using MRI-TB with SB and can be used for deciding whether to perform a biopsy or include sTR-bx with MRI-TB.

High-resolution Diffusion-weighted Imaging of the Prostate Using Multiplexed Sensitivity-encoding: Comparison with the Conventional and Reduced Field-of-view Techniques

PURPOSE

To compare objective and subjective image quality, lesion conspicuity, and apparent diffusion coefficient (ADC) of high-resolution multiplexed sensitivity-encoding diffusion-weighted imaging (MUSE-DWI) with conventional DWI (c-DWI) and reduced FOV DWI (rFOV-DWI) in prostate MRI.

METHODS

Forty-seven patients who underwent prostate MRI, including c-DWI, rFOV-DWI, and MUSE-DWI, were retrospectively evaluated. SNR and ADC of normal prostate tissue and contrast-to-noise ratio (CNR) and ADC of prostate cancer (PCa) were measured and compared between the three sequences. Image quality and lesion conspicuity were independently graded by two radiologists using a 5-point scale and compared between the three sequences.

RESULTS

The SNR of normal prostate tissue was significantly higher with rFOV-DWI than with the other two DWI techniques (P ≤ 0.01). The CNR of the PCa was significantly higher with rFOV-DWI than with MUSE-DWI (P < 0.05). The ADC of normal prostate tissue measured by rFOV-DWI was lower than that measured by MUSE-DWI and c-DWI (P < 0.01), while there was no difference in the ADC of cancers. In the qualitative analysis, MUSE-DWI showed significantly higher scores than rFOV-DWI and c-DWI for visibility of anatomy and overall image quality in both readers, and significantly higher scores for distortion in one of the two readers (P < 0.001). There was no difference in lesion conspicuity between the three sequences.

CONCLUSION

High-resolution MUSE-DWI showed higher image quality and reduced distortion compared to c-DWI, while maintaining a wide FOV and similar ADC quantification, although no difference in lesion conspicuity was observed.

Comparisons of three scoring systems based on biparametric magnetic resonance imaging for prediction of clinically significant prostate cancer

Purpose

In this study, we aimed to validate and compare three scoring systems based on biparametric magnetic resonance imaging (bpMRI) for the detection of clinically significant prostate cancer (csPCa) in biopsy-naïve patients.

Method

In this study, we included patients who underwent MRI examinations between January 2018 and December 2022, with MRI-targeted fusion biopsy (MRGB) as the reference standard. The MRI findings were categorized using three bpMRI-based scorings, in all of them the diffusion-weighted imaging (DWI) was the dominant sequence for peripheral zone (PZ) and T2-weighed imaging (T2WI) was the dominant sequence for transition zone (TZ). We also used the Prostate Imaging Reporting and Data System version (PI-RADS) v2.1 to evaluate each lesion. For each scoring, we calculated the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and area under the receiver operating characteristic (ROC) curves (AUC).

Results

The calculated AUC for three bpMRI-based scorings were 83.2% (95% CI 78.8%-87.6%), 85.0% (95% CI 80.8%-89.3%), 82.9% (95% CI 78.4%-87.5%), and 86.0% (95% CI 81.8%-90.1%), respectively. Scoring 2 exhibited significantly superior performance than scoring 1 (P = 0.01) and scoring 3 (P < 0.001). Moreover, the accuracy of scoring 2 was not decreased significantly as compared to PI-RADS v2.1 (P = 0.05). There was no significant difference between 3 bpMRI-based scorings and with PI-RADS in TZ. However, although scoring 2 yielded the highest AUC, it was still notably inferior to PI-RADS (P = 0.02).

Conclusion

All three bpMRI-based scorings demonstrated favorite diagnostic accuracy, and scoring 2 performed significantly better than the other two bpMRI-based scorings. Notably, scoring 2 was not significantly inferior to the full-sequence PI-RADS v2.1 in terms of sensitivity and specificity.

Deep learning-accelerated T2WI of the prostate for transition zone lesion evaluation and extraprostatic extension assessment

This bicenter retrospective analysis included 162 patients who had undergone prostate biopsy following prebiopsy MRI, excluding those with PCa identified only in the peripheral zone (PZ). DLR T2WI achieved a 69% reduction in scan time relative to TSE T2WI. The intermethod agreement between the two T2WI sets in terms of the Prostate Imaging Reporting and Data System (PI-RADS) classification and extraprostatic extension (EPE) grade was measured using the intraclass correlation coefficient (ICC) and diagnostic performance was assessed with the area under the receiver operating characteristic curve (AUC). Clinically significant PCa (csPCa) was found in 74 (45.7%) patients. Both T2WI methods showed high intermethod agreement for the overall PI-RADS classification (ICC: 0.907-0.949), EPE assessment (ICC: 0.925-0.957) and lesion size measurement (ICC: 0.980-0.996). DLR T2WI and TSE T2WI showed similar AUCs (0.666-0.814 versus 0.684-0.832) for predicting EPE. The AUCs for detecting csPCa with DLR T2WI (0.834-0.935) and TSE T2WI (0.891-0.935) were comparable in 139 patients with TZ lesions with no significant differences (P > 0.05). The findings suggest that DLR T2WI is an efficient alternative for TZ lesion assessment, offering reduced scan times without compromising diagnostic accuracy.

ESR Essentials: using the right scoring system in prostate MRI-practice recommendations by ESUR

MRI has gained prominence in the diagnostic workup of prostate cancer (PCa) patients, with the Prostate Imaging Reporting and Data System (PI-RADS) being widely used for cancer detection. Beyond PI-RADS, other MRI-based scoring tools have emerged to address broader aspects within the PCa domain. However, the multitude of available MRI-based grading systems has led to inconsistencies in their application within clinical workflows. The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) assesses the likelihood of clinically significant radiological changes of PCa during active surveillance, and the Prostate Imaging for Local Recurrence Reporting (PI-RR) scoring system evaluates the risk of local recurrence after whole-gland therapies with curative intent. Underlying any system is the requirement to assess image quality using the Prostate Imaging Quality Scoring System (PI-QUAL). This article offers practicing radiologists a comprehensive overview of currently available scoring systems with clinical evidence supporting their use for managing PCa patients to enhance consistency in interpretation and facilitate effective communication with referring clinicians. KEY POINTS: Assessing image quality is essential for all prostate MRI interpretations and the PI-QUAL score represents  the standardized tool for this purpose. Current urological clinical guidelines for prostate cancer diagnosis and localization recommend adhering to the PI-RADS recommendations. The PRECISE and PI-RR scoring systems can be used for assessing radiological changes of prostate cancer during active surveillance and the likelihood of local recurrence after radical treatments respectively.

Diagnostic performance of MRI in detecting prostate cancer in patients with prostate-specific antigen levels of 4-10 ng/mL: a systematic review and meta-analysis

OBJECTIVE

To investigate the diagnostic performance of MRI in detecting clinically significant prostate cancer (csPCa) and prostate cancer (PCa) in patients with prostate-specific antigen (PSA) levels of 4-10 ng/mL.

METHODS

A computerized search of PubMed, Embase, Cochrane Library, Medline, and Web of Science was conducted from inception until October 31, 2023. We included articles on the use of MRI to detect csPCa or PCa at 4-10 ng/mL PSA. The primary and secondary outcomes were MRI performance in csPCa and PCa detection, respectively; the estimates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were pooled in a bivariate random-effects model.

RESULTS

Among the 19 studies (3879 patients), there were 10 (2205 patients) and 13 studies (2965 patients) that reported MRI for detecting csPCa or PCa, respectively. The pooled sensitivity and specificity for csPCa detection were 0.84 (95% confidence interval [CI], 0.79-0.88) and 0.76 (95%CI, 0.65-0.84), respectively, for PCa detection were 0.82 (95%CI, 0.75-0.87) and 0.74 (95%CI, 0.65-0.82), respectively. The pooled NPV for csPCa detection was 0.91 (0.87-0.93). Biparametric magnetic resonance imaging also showed a significantly higher sensitivity and specificity relative to multiparametric magnetic resonance imaging (both p < 0.01).

CONCLUSION

Prostate MRI enables the detection of csPCa and PCa with satisfactory performance in the PSA gray zone. The excellent NPV for csPCa detection indicates the possibility of biopsy decision-making in patients in the PSA gray zone, but substantial heterogeneity among the included studies should be taken into account.

CLINICAL RELEVANCE STATEMENT

Prostate MRI can be considered a reliable and satisfactory tool for detecting csPCa and PCa in patients with PSA in the "gray zone", allowing for reducing unnecessary biopsy and optimizing the overall examination process.

KEY POINTS

Prostate-specific antigen (PSA) is a common screening tool for prostate cancer but risks overdiagnosis. MRI demonstrated excellent negative predictive value for prostate cancer in the PSA gray zone. MRI can influence decision-making for these patients, and biparametric MRI should be further evaluated.

Prostate MRI for the detection of clinically significant prostate cancer: Update and future directions

PURPOSE OF REVIEW

In recent decades, there has been an increasing role for magnetic resonance imaging (MRI) in the detection of clinically significant prostate cancer (csPC). The purpose of this review is to provide an update and outline future directions for the role of MRI in the detection of csPC.

RECENT FINDINGS

In diagnosing clinically significant prostate cancer pre-biopsy, advances include our understanding of MRI-targeted biopsy, the role of biparametric MRI (non-contrast) and changing indications, for example the role of MRI in screening for prostate cancer. Furthermore, the role of MRI in identifying csPC is maturing, with emphasis on standardization of MRI reporting in active surveillance (PRECISE), clinical staging (EPE grading, MET-RADS-P) and recurrent disease (PI-RR, PI-FAB). Future directions of prostate MRI in detecting csPC include quality improvement, artificial intelligence and radiomics, positron emission tomography (PET)/MRI and MRI-directed therapy.

SUMMARY

The utility of MRI in detecting csPC has been demonstrated in many clinical scenarios, initially from simply diagnosing csPC pre-biopsy, now to screening, active surveillance, clinical staging, and detection of recurrent disease. Continued efforts should be undertaken not only to emphasize the reporting of prostate MRI quality, but to standardize reporting according to the appropriate clinical setting.

Bi-parametric prostate MRI with a recall system for contrast enhanced imaging: Improving accessibility while maintaining quality

PURPOSE

To review the efficacy of a recall system for bi-parametric non-contrast prostate MRI (bp-MRI).

METHODS

A bi-parametric protocol was instituted in July 2020 for all patients who had a prostate MRI requested, excluding those after treatment of prostate cancer, patients with hip prosthesis or pacemaker, and those who lived out-of-town. The protocol consisted of tri-planar T2-weighted and diffusion weighted images (DWI) (b = 50, 800 s/mm2 for ADC map; b = 1,500 s/mm2 acquired separately) in accordance with the Prostate Imaging Reporting & Data system (PI-RADS) v2.1 guidelines. After interpretation of bp-MRI exams, patients with equivocal (PI-RADS 3) lesions in peripheral zone (PZ) or any technical limitations were recalled for contrast administration.

RESULTS

Out of 909 bp-MRI scans performed from July 2020 to April 2021, only 52 (5.7 %) were recalled, of which 46 (88.5 %) attended. Amongst these, 41/52 (78.8 %) were recalled for PZ PI-RADS 3 lesions, while the rest of 11 (21.2 %) cases were recalled for technical reasons. Mean time to subsequent recall scan was 11.6 days. On assessment of post-contrast imaging, 29/46 (63 %) cases were upgraded to PI-RADS 4 while 17/46 (37 %) remained PI-RADS 3. This system avoided contrast-agent use in 857 patients, with contrast cost savings of €64,620 (US$68,560) and 214 hours 15 minutes of scanner time was saved. This allowed 255 additional bp-MRI scans to be performed, reducing the waitlist from 1 year to 2-3 weeks.

CONCLUSION

A bi-parametric prostate MRI protocol with a robust recall system for contrast administration not only saved time eliminating the marked backlog but was also more cost efficient without compromising the quality of patient care.

Comparison of a Deep Learning-Accelerated vs. Conventional T2-Weighted Sequence in Biparametric MRI of the Prostate

BACKGROUND

Demand for prostate MRI is increasing, but scan times remain long even in abbreviated biparametric MRIs (bpMRI). Deep learning can be leveraged to accelerate T2-weighted imaging (T2WI).

PURPOSE

To compare conventional bpMRIs (CL-bpMRI) with bpMRIs including a deep learning-accelerated T2WI (DL-bpMRI) in diagnosing prostate cancer.

STUDY TYPE

Retrospective.

POPULATION

Eighty consecutive men, mean age 66 years (47-84) with suspected prostate cancer or prostate cancer on active surveillance who had a prostate MRI from December 28, 2020 to April 28, 2021 were included. Follow-up included prostate biopsy or stability of prostate-specific antigen (PSA) for 1 year.

FIELD STRENGTH AND SEQUENCES

A 3 T MRI. Conventional axial and coronal T2 turbo spin echo (CL-T2), 3-fold deep learning-accelerated axial and coronal T2-weighted sequence (DL-T2), diffusion weighted imaging (DWI) with b = 50 sec/mm2 , 1000 sec/mm2 , calculated b = 1500 sec/mm2 .

ASSESSMENT

CL-bpMRI and DL-bpMRI including the same conventional diffusion-weighted imaging (DWI) were presented to three radiologists (blinded to acquisition method) and to a deep learning computer-assisted detection algorithm (DL-CAD). The readers evaluated image quality using a 4-point Likert scale (1 = nondiagnostic, 4 = excellent) and graded lesions using Prostate Imaging Reporting and Data System (PI-RADS) v2.1. DL-CAD identified and assigned lesions of PI-RADS 3 or greater.

STATISTICAL TESTS

Quality metrics were compared using Wilcoxon signed rank test, and area under the receiver operating characteristic curve (AUC) were compared using Delong's test.

SIGNIFICANCE

P = 0.05.

RESULTS

Eighty men were included (age: 66 ± 9 years; 17/80 clinically significant prostate cancer). Overall image quality results by the three readers (CL-T2, DL-T2) are reader 1: 3.72 ± 0.53, 3.89 ± 0.39 (P = 0.99); reader 2: 3.33 ± 0.82, 3.31 ± 0.74 (P = 0.49); reader 3: 3.67 ± 0.63, 3.51 ± 0.62. In the patient-based analysis, the reader results of AUC are (CL-bpMRI, DL-bpMRI): reader 1: 0.77, 0.78 (P = 0.98), reader 2: 0.65, 0.66 (P = 0.99), reader 3: 0.57, 0.60 (P = 0.52). Diagnostic statistics from DL-CAD (CL-bpMRI, DL-bpMRI) are sensitivity (0.71, 0.71, P = 1.00), specificity (0.59, 0.44, P = 0.05), positive predictive value (0.23, 0.24, P = 0.25), negative predictive value (0.88, 0.88, P = 0.48).

CONCLUSION

Deep learning-accelerated T2-weighted imaging may potentially be used to decrease acquisition time for bpMRI.

EVIDENCE LEVEL

3.

TECHNICAL EFFICACY

Stage 2.

Emerging Role of Nuclear Medicine in Prostate Cancer: Current State and Future Perspectives

Prostate cancer is the most frequent epithelial neoplasia after skin cancer in men starting from 50 years and prostate-specific antigen (PSA) dosage can be used as an early screening tool. Prostate cancer imaging includes several radiological modalities, ranging from ultrasonography, computed tomography (CT), and magnetic resonance to nuclear medicine hybrid techniques such as single-photon emission computed tomography (SPECT)/CT and positron emission tomography (PET)/CT. Innovation in radiopharmaceutical compounds has introduced specific tracers with diagnostic and therapeutic indications, opening the horizons to targeted and very effective clinical care for patients with prostate cancer. The aim of the present review is to illustrate the current knowledge and future perspectives of nuclear medicine, including stand-alone diagnostic techniques and theragnostic approaches, in the clinical management of patients with prostate cancer from initial staging to advanced disease.

Extraprostatic incidental findings on prostate mpMRI: A pictorial review from the ESUR junior network

The role of multiparametric MRI (mpMRI) in prostate cancer setting is increasingly consolidated and, as a result, its usage in clinical practice is in exponential growth. However, beyond the prostate gland, several key structures are included in the field of view of mpMRI scans. Consequently, various extra-prostatic incidental findings (IFs) belonging to different anatomical systems can be accidentally recognized. Therefore, it is mandatory for a radiologist to be familiar with the wide range of pathologies potentially encountered, to guide management and avoid patient anxiety and costs due to additional work-up prompted by clinically insignificant extra-prostatic findings. With this pictorial review, we aim to illustrate a wide range of IFs that can be detected when performing mpMRI of the prostate, focusing on their imaging characteristics, differential diagnosis, and clinical relevance. Additionally, we propose the CheckDEEP, the Checklist for DEtection of ExtraProstatic findings, to be used for a thorough evaluation of target areas within each anatomical system.

MR image quality in local staging of prostate cancer: Role of PI-QUAL in the detection of extraprostatic extension

PURPOSE

To assess the impact of prostate MRI image quality by means of the Prostate Imaging Quality (PI-QUAL) score, on the identification of extraprostatic extension of disease (EPE), predicted using the EPE Grade Score, Likert Scale Score (LSS) and a clinical nomogram (MSKCCn).

METHODS

We retrospectively included 105 patients with multiparametric prostate MRI prior to prostatectomy. Two radiologists evaluated image quality using PI-QUAL (≥4 was considered high quality) in consensus. All cases were also scored using the EPE Grade, the LSS, and the MSKCCn (dichotomized). Inter-rater reproducibility for each score was also assessed. Accuracy was calculated for the entire population and by image quality, considering two thresholds for EPE Grade (≥2 and = 3) and LSS (≥3 and ≥ 4) and using McNemar's test for comparison.

RESULTS

Overall, 66 scans achieved high quality. The accuracy of EPE Grade ranged from 0.695 to 0.743, while LSS achieved values between 0.705 and 0.733. Overall sensitivity for the radiological scores (range = 0.235-0.529) was low irrespective of the PI-QUAL score, while specificity was higher (0.775-0.986). The MSKCCn achieved an AUC of 0.76, outperforming EPE Grade (=3 threshold) in studies with suboptimal image quality (0.821 vs 0.564, p = 0.016). EPE Grade (=3 threshold) accuracy was also better in high image quality studies (0.849 vs 0.564, p = 0.001). Reproducibility was good to excellent overall (95 % Confidence Interval range = 0.782-0.924).

CONCLUSION

Assessing image quality by means of PI-QUAL is helpful in the evaluation of EPE, as a scan of low quality makes its performance drop compared to clinical staging tools.

MR imaging features to predict the type of bone metastasis in prostate cancer

Bone metastases (BMs) of prostate cancer (PCa) have been considered predominantly osteoblastic, but non-osteoblastic (osteolytic or mixed osteoblastic and osteolytic) BMs can occur. We investigated the differences in prostate MRI and clinical findings between patients with osteoblastic and non-osteoblastic BMs. Between 2014 and 2021, patients with pathologically proven PCa without a history of other malignancies were included in this study. Age, Gleason score, prostate-specific antigen (PSA) density, normalized mean apparent diffusion coefficient and normalized T2 signal intensity (nT2SI) of PCa, and Prostate Imaging Reporting and Data System category on MRI were compared between groups. A multivariate logistic regression analysis using factors with P-values < 0.2 was performed to detect the independent parameters for predicting non-osteoblastic BM group. Twenty-five (mean 73 ± 6.6 years) and seven (69 ± 13.1 years) patients were classified into the osteoblastic and non-osteoblastic groups, respectively. PSA density and nT2SI were significantly higher in the non-osteoblastic group than in the osteoblastic group. nT2SI was an independent predictive factor for non-osteoblastic BMs in the multivariate logistic regression analysis. These results indicated that PCa patients with high nT2SI and PSA density should be examined for osteolytic BMs.

Screening for prostate cancer: evidence, ongoing trials, policies and knowledge gaps

Long-term screening with serum prostate-specific antigen (PSA) and systematic prostate biopsies can reduce prostate cancer mortality but leads to unacceptable overdiagnosis. Over the past decade, diagnostic methods have improved and the indolent nature of low-grade prostate cancer has been established. These advances now enable more selective detection of potentially lethal prostate cancer. This non-systematic review summarises relevant diagnostic advances, previous and ongoing screening trials, healthcare policies and important remaining knowledge gaps. Evidence synthesis and conclusions: The strong association between low serum PSA values and minimal long-term risk of prostate cancer death allows for adjusting screening intervals. Use of risk calculators, biomarkers and MRI to select men with a raised PSA value for biopsy and lesion-targeting rather than systematic prostate biopsies reduce the detection of low-grade cancer and thereby overdiagnosis. These improvements recently led the European Union to recommend its member states to evaluate the feasibility and effectiveness of organised screening programmes for prostate cancer. Nonetheless, important knowledge gaps remain such as the performance of modern diagnostic methods in long-term screening programmes and their impact on mortality. The knowledge gaps are currently being addressed in three large randomised screening trials. Population-based pilot programmes will contribute critical practical experience.

[Common errors, pitfalls, and management of complications of prostate biopsy : The most common diagnostic and procedural challenges of transrectal fusion prostate biopsy in the initial diagnosis of clinically significant prostate cancer]

BACKGROUND

Transrectal (TR) prostate biopsy is the gold standard in diagnosis of prostate cancer (PC). It requires a precise and safe technique for sample acquisition.

OBJECTIVE

Several approaches will be discussed to avoid overdiagnosis, false-negative results, and complications of the procedure.

MATERIALS AND METHODS

We analyzed national and European guidelines, systematic reviews, meta-analyses, as well as prospective and retrospective studies to describe current trends in indication and performance of biopsies.

RESULTS

Incorporation of risk calculators and magnetic resonance imaging (MRI) into daily routine reduces biopsy rates and results in a more precise diagnosis of clinically significant prostate cancer (csPC). Combination of random- and MRI-fusion guided biopsy-but also extending the radius of sampling by 10 mm beyond the MRI lesion and a transperineal (TP) sampling approach - lead to a higher tumor-detection rate. Bleeding is the most common complication after prostate biopsy and is usually self-limiting. Postbiopsy infection rates can be reduced through TP biopsy.

CONCLUSION

TR MRI-fusion guided biopsy is a widely acknowledged tool in primary diagnostics of csPC. Higher detection rates and safety can be achieved through a TP sampling approach.

Biparametric MR signal characteristics can predict histopathological measures of prostate cancer

OBJECTIVES

The aim of this study was to establish a new data-driven metric from MRI signal intensity that can quantify histopathological characteristics of prostate cancer.

METHODS

This retrospective study was conducted on 488 patients who underwent biparametric MRI (bp-MRI), including T2-weighted imaging (T2W) and apparent diffusion coefficient (ADC) of diffusion-weighted imaging, and having biopsy-proven prostate cancer between August 2011 and July 2015. Forty-two of the patients who underwent radical prostatectomy and the rest of 446 patients constitute the labeled and unlabeled datasets, respectively. A deep learning model was built to predict the density of epithelium, epithelial nuclei, stroma, and lumen from bp-MRI, called MR-driven tissue density. On both the labeled validation set and the whole unlabeled dataset, the quality of MR-driven tissue density and its relation to bp-MRI signal intensity were examined with respect to different histopathologic and radiologic conditions using different statistical analyses.

RESULTS

MR-driven tissue density and bp-MRI of 446 patients were evaluated. MR-driven tissue density was significantly related to bp-MRI (p < 0.05). The relationship was generally stronger in cancer regions than in benign regions. Regarding cancer grades, significant differences were found in the intensity of bp-MRI and MR-driven tissue density of epithelium, epithelial nuclei, and stroma (p < 0.05). Comparing MR true-negative to MR false-positive regions, MR-driven lumen density was significantly different, similar to the intensity of bp-MRI (p < 0.001).

CONCLUSIONS

MR-driven tissue density could serve as a reliable histopathological measure of the prostate on bp-MRI, leading to an improved understanding of prostate cancer and cancer progression.

KEY POINTS

• Semi-supervised deep learning enables non-invasive and quantitative histopathology in the prostate from biparametric MRI. • Tissue density derived from biparametric MRI demonstrates similar characteristics to the direct estimation of tissue density from histopathology images. • The analysis of MR-driven tissue density reveals significantly different tissue compositions among different cancer grades as well as between MR-positive and MR-negative benign.

Comparison of single-shot EPI and multi-shot EPI in prostate DWI at 3.0 T

In prostate MRI, single-shot EPI (ssEPI) DWI still suffers from distortion and blurring. Multi-shot EPI (msEPI) overcomes the drawbacks of ssEPI DWI. The aim of this article was to compare the image quality and diagnostic performance for clinically significant prostate cancer (csPC) between ssEPI DWI and msEPI DWI. This retrospective study included 134 patients with suspected PC who underwent 3.0 T MRI and subsequent MRI-guided biopsy. Three radiologists independently assessed anatomical distortion, prostate edge clarity, and lesion conspicuity score for pathologically confirmed csPC. Lesion apparent diffusion coefficient (ADC) and benign ADC were also calculated. In 17 PC patients who underwent prostatectomy, three radiologists independently assessed eight prostate regions by DWI score in PI-RADS v 2.1. Anatomical distortion and prostate edge clarity were significantly higher in msEPI DWI than in ssEPI DWI in the three readers. Lesion conspicuity score was significantly higher in msEPI DWI than in ssEPI DWI in reader 1 and reader 3. Regarding discrimination ability between PC with GS ≤ 3 + 4 and PC with GS ≥ 4 + 3 using lesion ADC, AUC was comparable between ssEPI DWI and msEPI DWI. For diagnostic performance of csPC using DWI score, AUC was comparable between msEPI DWI and ssEPI DWI in all readers. Compared with ssEPI DWI, msEPI DWI had improved image quality and similar or higher diagnostic performance.

Head-to-head comparison of biparametric versus multiparametric MRI of the prostate before robot-assisted transperineal fusion prostate biopsy

Purpose

Prostate biparametric magnetic resonance imaging (bpMRI) including T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) might be an alternative to multiparametric MRI (mpMRI, including dynamic contrast imaging, DCE) to detect and guide targeted biopsy in patients with suspected prostate cancer (PCa). However, there is no upgrading peripheral zone PI-RADS 3 to PI-RADS 4 without DCE in bpMRI. The aim of this study was to evaluate bpMRI against mpMRI in biopsy-naïve men with elevated prostate-specific antigen (PSA) scheduled for robot-assisted-transperineal fusion-prostate biopsy (RA-TB).

Methods

Retrospective single-center-study of 563 biopsy-naïve men (from 01/2015 to 09/2018, mean PSA 9.7 ± 6.5 ng/mL) with PI-RADSv2.1 conform mpMRI at 3 T before RA-TB. Clinically significant prostate cancer (csPCa) was defined as ISUP grade ≥ 2 in any core. Two experienced readers independently evaluated images according to PI-RADSv2.1 criteria (separate readings for bpMRI and mpMRI sequences, 6-month interval). Reference standard was histology from RA-TB.

Results

PI-RADS 2 was scored in 5.1% of cases (3.4% cancer/3.4% csPCa), PI-RADS 3 in 16.9% (32.6%/3.2%), PI-RADS 4 in 57.6% (66.1%/58.3%) and PI-RADS 5 in 20.4% of cases (79.1%/74.8%). For mpMRI/bpMRI test comparison, sensitivity was 99.0%/97.1% (p < 0.001), specificity 47.5%/61.2% (p < 0.001), PPV 69.5%/75.1% (p < 0.001) and NPV 97.6%/94.6% (n.s.). csPCa was considered gold standard. 35 cases without cancer were upgraded to PI-RADS 4 (mpMRI) and six PI-RADS 3 cases with csPCa were not upgraded (bpMRI).

Conclusion

In patients planned for RA-TB with elevated PSA and clinical suspicion for PCa, specificity was higher in bpMRI vs. mpMRI, which could solve constrains regarding time and contrast agent.

Noninferiority of Monoparametric MRI Versus Multiparametric MRI for the Detection of Prostate Cancer: Diagnostic Accuracy of ADC Ratios Based on Advanced "Zoomed" Diffusion-Weighted Imaging

OBJECTIVES

The aim of this study was to compare the diagnostic accuracy of apparent diffusion coefficient (ADC) ratios as a monoparametric magnetic resonance imaging (MRI) protocol for the detection of prostate cancer (PCa) with the established multiparametric (mp) MRI at 3.0 T.

MATERIALS AND METHODS

According to power analysis, 52 male patients were included in this monocenter study with prospective data collection and retrospective, blinded multireader image analysis. The study was approved by the local ethics committee. Patients were recruited from January to December 2020. Based on mpMRI findings, patients underwent in-bore MR biopsy or prostatectomy for histopathologic correlation of suspicious lesions. Three readers, blinded to the histopathologic results and images of mpMRI, independently evaluated ADC maps for the detection of PCa. The ADC ratio was defined as the lowest signal intensity (SI) of lesions divided by the SI of normal tissue in the zone of origin. Predictive accuracy of multiparametric and monoparametric MRI were compared using logistic regression analysis. Moreover, both protocols were compared applying goodness-of-fit analysis with the Hosmer-Lemeshow test for continuous ADC ratios and Pearson χ2 test for binary decision calls, correlation analysis with Spearman ρ and intraclass correlation coefficients, as well as noninferiority assessment with a TOST ("two one-sided test").

RESULTS

Eighty-one histopathologically proven, unique PCa lesions (Gleason score [GS] ≥ 3 + 3) in 52 patients could be unequivocally correlated, with 57 clinically significant (cs) PCa lesions (GS ≥ 3 + 4). Multiparametric MRI detected 95%, and monoparametric ADC detected ratios 91% to 93% of csPCa. Noninferiority of monoparametric MRI was confirmed by TOST (P < 0.05 for all comparisons). Logistic regression analysis revealed comparable predictive diagnostic accuracy of ADC ratios (73.7%-87.8%) versus mpMRI (72.2%-84.7%). Spearman rank correlation coefficient for PCa aggressiveness revealed satisfactory correlation of ADC ratios (P < 0.013 for all correlations). The Hosmer-Lemeshow test for the logistic regression analysis for continuous ADC ratios indicated adequate predictive accuracy (P = 0.55-0.87), and the Pearson χ2 test showed satisfactory goodness of fit (P = 0.35-0.69, χ2 = 0.16-0.87).

CONCLUSIONS

Normalized ADC ratios based on advanced DWI are noninferior to mpMRI at 3.0 T for the detection of csPCa in a preselected patient cohort and proved a fast and accurate assessment tool, thus showing a potential prospect of easing the development of future screening methods for PCa.

Synthetic magnetic resonance imaging for primary prostate cancer evaluation: Diagnostic potential of a non-contrast-enhanced bi-parametric approach enhanced with relaxometry measurements

Purpose

Bi-parametric magnetic resonance imaging (bpMRI) with diffusion-weighted images has wide utility in diagnosing clinically significant prostate cancer (csPCa). However, bpMRI yields more false-negatives for PI-RADS category 3 lesions than multiparametric (mp)MRI with dynamic-contrast-enhanced (DCE)-MRI. We investigated the utility of synthetic MRI with relaxometry maps for bpMRI-based diagnosis of csPCa.

Methods

One hundred and five treatment-naïve patients who underwent mpMRI and synthetic MRI before prostate biopsy for suspected PCa between August 2019 and December 2020 were prospectively included. Three experts and three basic prostate radiologists evaluated the diagnostic performance of conventional bpMRI and synthetic bpMRI for csPCa. PI-RADS version 2.1 category 3 lesions were identified by consensus, and relaxometry measurements (T1-value, T2-value, and proton density [PD]) were performed. The diagnostic performance of relaxometry measurements for PI-RADS category 3 lesions in peripheral zone was compared with that of DCE-MRI. Histopathological evaluation results were used as the reference standard. Statistical analysis was performed using the areas under the receiver operating characteristic curve (AUC) and McNemar test.

Results

In 102 patients without significant MRI artefacts, the diagnostic performance of conventional bpMRI was not significantly different from that of synthetic bpMRI for all readers (p = 0.11–0.79). The AUCs of the combination of T1-value, T2-value, and PD (T1 + T2 + PD) for csPCa in peripheral zone for PI-RADS category 3 lesions were 0.85 for expert and 0.86 for basic radiologists, with no significant difference between T1 + T2 + PD and DCE-MRI for both expert and basic radiologists (p = 0.29–0.45).

Conclusion

Synthetic MRI with relaxometry maps shows promise for contrast media-free evaluation of csPCa.

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Diagnostic performances of synthetic bpMRI and conventional bpMRI are comparable for primary PCa

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Diagnostic performance of synthetic MRI variables are similar to that of DCE-MRI for csPCa in PZ

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Synthetic bpMRI shows potential as a contrast agent-free method for primary PCa

A narrative review of biparametric MRI (bpMRI) implementation on screening, detection, and the overall accuracy for prostate cancer

Prostate cancer is the most common malignancy in American men following skin cancer, with approximately one in eight men being diagnosed during their lifetime. Over the past several decades, the treatment of prostate cancer has evolved rapidly, so too has screening. Since the mid-2010s, magnetic resonance imaging (MRI)-guided biopsies or 'targeted biopsies' has been a rapidly growing topic of clinical research within the field of urologic oncology. The aim of this publication is to provide a review of biparametric MRI (bpMRI) utilization for the diagnosis of prostate cancer and a comparison to multiparametric MRI (mpMRI). Through single-centered studies and meta-analysis across all identified pertinent published literature, bpMRI is an effective tool for the screening and diagnosis of prostate cancer. When compared with the diagnostic accuracy of mpMRI, bpMRI identifies prostate cancer at comparable rates. In addition, when omitting dynamic contrast-enhanced (DCE) protocol to the MRI, patients incur reduced costs and shorter imaging time while providers can offer more tests to their patient population.

A Combined Radiomics and Machine Learning Approach to Distinguish Clinically Significant Prostate Lesions on a Publicly Available MRI Dataset

Although prostate cancer is one of the most common causes of mortality and morbidity in advancing-age males, early diagnosis improves prognosis and modifies the therapy of choice. The aim of this study was the evaluation of a combined radiomics and machine learning approach on a publicly available dataset in order to distinguish a clinically significant from a clinically non-significant prostate lesion. A total of 299 prostate lesions were included in the analysis. A univariate statistical analysis was performed to prove the goodness of the 60 extracted radiomic features in distinguishing prostate lesions. Then, a 10-fold cross-validation was used to train and test some models and the evaluation metrics were calculated; finally, a hold-out was performed and a wrapper feature selection was applied. The employed algorithms were Naïve bayes, K nearest neighbour and some tree-based ones. The tree-based algorithms achieved the highest evaluation metrics, with accuracies over 80%, and area-under-the-curve receiver-operating characteristics below 0.80. Combined machine learning algorithms and radiomics based on clinical, routine, multiparametric, magnetic-resonance imaging were demonstrated to be a useful tool in prostate cancer stratification.

Diffusion-weighted imaging in prostate cancer

Diffusion-weighted imaging (DWI), a key component in multiparametric MRI (mpMRI), is useful for tumor detection and localization in clinically significant prostate cancer (csPCa). The Prostate Imaging Reporting and Data System versions 2 and 2.1 (PI-RADS v2 and PI-RADS v2.1) emphasize the role of DWI in determining PIRADS Assessment Category in each of the transition and peripheral zones. In addition, several recent studies have demonstrated comparable performance of abbreviated biparametric MRI (bpMRI), which incorporates only T2-weighted imaging and DWI, compared with mpMRI with dynamic contrast-enhanced MRI. Therefore, further optimization of DWI is essential to achieve clinical application of bpMRI for efficient detection of csPC in patients with elevated PSA levels. Although DWI acquisition is routinely performed using single-shot echo-planar imaging, this method suffers from such as susceptibility artifact and anatomic distortion, which remain to be solved. In this review article, we will outline existing problems in standard DWI using the single-shot echo-planar imaging sequence; discuss solutions that employ newly developed imaging techniques, state-of-the-art technologies, and sequences in DWI; and evaluate the current status of quantitative DWI for assessment of tumor aggressiveness in PC.

Comparison of biparametric versus multiparametric prostate MRI for the detection of extracapsular extension and seminal vesicle invasion in biopsy naïve patients

PURPOSE

To compare biparametric MRI (bpMRI) with multiparametric MRI (mpMRI) staging accuracy in assessing extracapsular extension (ECE) and seminal vesicle invasion (SVI).

METHOD

Biopsy-naïve patients undergoing 3 T-MRI before radical prostatectomy for clinically significant prostate cancer were included in this single-centre retrospective study. Two uroradiologists separately evaluated bpMRI and mpMRI for presence of ECE and SVI using a 5-point Likert scale (1: ECE/SVI highly unlikely, 5: ECE/SVI highly likely).

RESULTS

110 men of median age 63 years and PSA 8.5 ng/mL were included. ECE and SVI was confirmed histologically in 71/110 (64.5 %) and 18/110 (16.4 %) patients, respectively. Sensitivity and specificity of bpMRI versus mpMRI for predicting ECE was 59.1 % and 87.2 % versus 66.2 % and 84.6 %, respectively. For SVI detection, the sensitivity and specificity for bpMRI versus mpMRI was 66.7 % and 92.4 % versus 83.3 % and 97.8 %, respectively. At an optimal cut-off Likert score ≥3 for ECE prediction, mpMRI area under the receiver operating curve (AUC) was 0.80 (95 % confidence interval (CI) 0.72-0.87) versus 0.78 (95 % CI 0.69-0.86) for bpMRI (p = 0.52) and for SVI, mpMRI AUC was 0.91 (95 % CI 0.84-0.96) versus 0.86 (95 % CI 0.78-0.92) for bpMRI (p = 0.02), respectively. Inter-reader agreement for both ECE and SVI prediction was substantial, with a marginally higher k-value for mpMRI (k range, 0.67-0.75) than bpMRI (k range, 0.65-0.69).

CONCLUSIONS

Diagnostic performance of bpMRI and mpMRI was comparable for detection of ECE, however, mpMRI with contrast was superior for SVI detection and improved the inter-reader agreement.

The future direction of imaging in prostate cancer: MRI with or without contrast injection

BACKGROUND

Multiparametric MRI (mpMRI) is the "state of the art" management tool for patients with suspicion of prostate cancer (PCa). The role of non-contrast MRI is investigated to move toward a more personalized, less invasive, and highly cost-effective PCa diagnostic workup.

OBJECTIVE

To perform a non-systematic review of the existing literature to highlight strength and flaws of performing non-contrast MRI, and to provide a critical overview of the international scientific production on the topic.

MATERIALS AND METHODS

Online databases (Medline, PubMed, and Web of Science) were searched for original articles, systematic review and meta-analysis, and expert opinion papers.

RESULTS

Several investigations have shown comparable diagnostic accuracy of biparametric (bpMRI) and mpMRI for the detection of PCa. The advantage of abandoning contrast-enhanced sequences improves operational logistics, lowering costs, acquisition time, and side effects. The main limitations of bpMRI are that most studies comparing non-contrast with contrast MRI come from centers with high expertise that might not be reproducible in the general community setting; besides, reduced protocols might be insufficient for estimation of the intra- and extra-prostatic extension and regional disease. The mentioned observations suggest that low-quality mpMRI for the general population might represent the main shortage to overcome.

DISCUSSION

Non-contrast MRI future trends are likely represented by PCa screening and the application of artificial intelligence (AI) tools. PCa screening is still a controversial topic; bpMRI has become one of the most promising diagnostic applications, as it is a more sensitive test for PCa early detection, compared to serum PSA level test. Also, AI applications and radiomic have been the object of several studies investigating PCa detection using bpMRI, showing encouraging results.

CONCLUSION

Today, the accessibility to MRI for early detection of PCa is a priority. Results from prospective, multicenter, multireader, and paired validation studies are needed to provide evidence supporting its role in the clinical practice.