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Pecoraro M, Catanzaro G, Conte F, Besharat ZM, Messina E, Laschena L, Trocchianesi S, Splendiani E, Sciarra A, Catalano C, Paci P, Ferretti E, Panebianco V. Prospective Validation Study of a Novel Integrated Pathway Based on Clinical Features, Magnetic Resonance Imaging Biomarkers, and MicroRNAs for Early Detection of Prostate Cancer. Eur Urol Oncol 2024; 7:73-82. [PMID: 37270379 DOI: 10.1016/j.euo.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/03/2023] [Accepted: 05/19/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Prostate cancer (PCa) is the most diagnosed cancer in men, with an increasing need to integrate noninvasive imaging and circulating microRNAs beyond prostate-specific antigen for screening and early detection. OBJECTIVE To validate magnetic resonance imaging (MRI) biomarkers and circulating microRNAs as triage tests for patients directed to prostate biopsy, and to test different diagnostic pathways to compare their performance on patients' outcome, in terms of unnecessary biopsy avoidance. DESIGN, SETTING, AND PARTICIPANTS A prospective single-center cohort study, enrolling patients with PCa suspicion who underwent MRI, MRI-directed fusion biopsy (MRDB), and circulating microRNAs, was conducted. A network-based analysis was used to identify MRI biomarkers and microRNA drivers of clinically significant PCa. INTERVENTION MRI, MRDB, and blood sampling. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The decision curve analysis was exploited to assess the performance of the proposed diagnostic pathways and to quantify their benefit in terms of biopsy avoidance. RESULTS AND LIMITATIONS Overall, 261 men were enrolled and underwent MRDB for PCa detection. A total of 178 patients represented the entire cohort: 55 (30.9%) were negative for PCa, 39 (21.9%) had grade group (GG) 1 PCa, and 84 (47.2%) had GG >1 PCa. The proposed integrated pathway, including clinical data, MRI biomarkers, and microRNAs, provided the best net benefit with a biopsy avoidance rate of about 20% at a low disease probability. The main limitation is the monocentric design in a referral center. CONCLUSIONS The integrated pathway represents a validated model that sees MRI biomarkers and microRNAs as a prebiopsy triage of patients at a risk for clinically significant PCa. The proposed pathway showed the highest net benefit in terms of unnecessary biopsy avoidance. PATIENT SUMMARY The proposed integrated pathway for early detection of prostate cancer (PCa) allows accurate patient allocation to biopsy and patients' stratification into risk group categories, reducing overdiagnosis and overtreatment of clinically insignificant PCa.
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Affiliation(s)
- Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Giuseppina Catanzaro
- Department of Experimental Medicine, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Federica Conte
- Institute for Systems Analysis and Computer Science "A. Ruberti" (IASI), National Research Council (CNR), Rome, Italy
| | - Zein Mersini Besharat
- Department of Experimental Medicine, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Emanuele Messina
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Ludovica Laschena
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Sofia Trocchianesi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Elena Splendiani
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Sciarra
- Department of Maternal Infant and Urologic Sciences, Sapienza University of Rome, Rome, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Paola Paci
- Department of Computer, Control and Management Engineering, Sapienza University, Rome, Italy
| | - Elisabetta Ferretti
- Department of Experimental Medicine, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, Policlinico Umberto I, Rome, Italy.
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Messina E, Proietti F, Laschena L, Flammia RS, Pecoraro M, Cipollari S, Simone G, Catalano C, Leonardo C, Panebianco V. MRI for risk stratification of muscle invasion by upper tract urothelial carcinoma: a feasibility study. Eur Radiol Exp 2024; 8:9. [PMID: 38238523 PMCID: PMC10796856 DOI: 10.1186/s41747-023-00403-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/03/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is recommended in patients with upper tract urothelial carcinoma (UTUC) only when computed tomography (CT) is contraindicated. However, CT does not allow distinguishing ureter wall layers, making impossible to assess muscle invasion, a factor contributing to differentiate high- from low-risk UTUCs, which require different therapeutic approaches. We investigated the feasibility of MRI assessment of UTUC muscle invasion. METHODS From June 2022 to March 2023, we prospectively enrolled patients suspected of UTUC, i.e., with positive urinary tract ultrasound and/or ureteroscopy, or positive urinary cytology and/or hematuria but negative cystoscopy and bladder ultrasound at two Italian centers. They underwent CT followed by MRI (≤ 24 h apart), independently reported by two experienced radiologists, blinded from histopathology results. After imaging confirmation, they all underwent nephroureterectomy and histopathology analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the receiver operating characteristic curve (AUC) were calculated. RESULTS Thirty-nine lesions were detected in 30 patients on both CT and MRI. Muscle-invasive UTUC prevalence was 81% (21/26) among patients with MRI suspicion and 8% (1/13) among those without MRI suspicion (p < 0.001). Considering the assessment of muscle-layer invasion, the more experienced reader achieved 95% sensitivity (95% confidence interval 82-100), 71% specificity (47-88), 81% PPV (63-93), 92% NPV (70-100), 85% accuracy (67-96), and 0.84 AUC (0.70-0.98). Inter-reader agreement was substantial (κ = 0.73). CONCLUSIONS MRI showed a promising diagnostic performance for the assessment of UTUC risk of muscle invasion. RELEVANCE STATEMENT Resulting feasible both in technical and clinical terms, MRI could be helpful for upper tract urothelial carcinomas pre-operative risk stratification, to allow a personalized patients' management. These results play in favor of promoting preoperative MRI for UTUC, as already proven for bladder cancer. KEY POINTS • Muscle invasion is a crucial information for tailored treatments of upper tract urothelial carcinomas. • CT does not distinguish ureter wall layers, making muscle invasion risk assessment not feasible. • MRI was shown to reliably diagnose muscle-layer invasion by upper tract urothelial carcinomas (sensitivity 95%, specificity 71%).
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Affiliation(s)
- Emanuele Messina
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
| | - Flavia Proietti
- Department of Maternal-Infant and Urological Sciences, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Ludovica Laschena
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
| | - Rocco Simone Flammia
- Department of Maternal-Infant and Urological Sciences, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
| | - Stefano Cipollari
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
| | - Costantino Leonardo
- Department of Maternal-Infant and Urological Sciences, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, Rome, 00185, Italy.
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale Regina Elena 324, Rome, 00161, Italy.
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Messina E, Pecoraro M, Laschena L, Bicchetti M, Proietti F, Ciardi A, Leonardo C, Sciarra A, Girometti R, Catalano C, Panebianco V. Low cancer yield in PI-RADS 3 upgraded to 4 by dynamic contrast-enhanced MRI: is it time to reconsider scoring categorization? Eur Radiol 2023; 33:5828-5839. [PMID: 37045981 PMCID: PMC10326099 DOI: 10.1007/s00330-023-09605-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To evaluate MRI diagnostic performance in detecting clinically significant prostate cancer (csPCa) in peripheral-zone PI-RADS 4 lesions, comparing those with clearly restricted diffusion (DWI-score 4), and those with equivocal diffusion pattern (DWI-score 3) and positive dynamic contrast-enhanced (DCE) MRI. METHODS This observational prospective study enrolled 389 men referred to MRI and, if positive (PI-RADS 3 with PSA-density [PSAD] ≥ 0.15 ng/mL/mL, 4 and 5), to MRI-directed biopsy. Lesions with DWI-score 3 and positive DCE were classified as "PI-RADS 3up," instead of PI-RADS 4. Univariable and multivariable analyses were implemented to determine features correlated to csPCa detection. RESULTS Prevalence of csPCa was 14.5% and 53.3% in PI-RADS categories 3up and 4, respectively (p < 0.001). MRI showed a sensitivity of 100.0%, specificity 40.9%, PPV 46.5%, NPV 100.0%, and accuracy 60.9% for csPCa detection. Modifying the threshold to consider MRI positive and to indicate biopsy (same as previously described, but PI-RADS 3up only when associated with elevated PSAD), the sensitivity changed to 93.9%, specificity 57.2%, PPV 53.0%, NPV 94.8%, and accuracy 69.7%. Age (p < 0.001), PSAD (p < 0.001), positive DWI (p < 0.001), and PI-RADS score (p = 0.04) resulted in independent predictors of csPCa. CONCLUSIONS Most cases of PI-RADS 3up were false-positives, suggesting that upgrading peripheral lesions with DWI-score 3 to PI-RADS 4 because of positive DCE has a detrimental effect on MRI accuracy, decreasing the true prevalence of csPCa in the PI-RADS 4 category. PI-RADS 3up should not be upgraded and directed to biopsy only if associated with increased PSAD. KEY POINTS • As per PI-RADS v2.1 recommendations, in case of a peripheral zone lesion with equivocal diffusion-weighted imaging (DWI score 3), but positive dynamic contrast-enhanced (DCE) MRI, the overall PI-RADS score should be upgraded to 4. • The current PI-RADS recommendation of upgrading PI-RADS 3 lesions of the peripheral zone to PI-RADS 4 because of positive DCE decreased clinically significant prostate cancer detection rate in our series. • According to our results, the most accurate threshold for setting indication to prostate biopsy is PI-RADS 3 or PI-RADS 3 with positive DCE both associated with increased PSA density.
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Affiliation(s)
- Emanuele Messina
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Ludovica Laschena
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Marco Bicchetti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Flavia Proietti
- Department of Maternal-Infant and Urological Sciences, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Antonio Ciardi
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Costantino Leonardo
- Department of Maternal-Infant and Urological Sciences, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Alessandro Sciarra
- Department of Maternal-Infant and Urological Sciences, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, University of Udine, University Hospital S, Maria Della Misericordia; P.Le S. Maria Della Misericordia 15, 33100, Udine, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Viale del Policlinico 155, 00185, Rome, Italy.
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Messina E, Pecoraro M, Pisciotti ML, Del Giudice F, Lucciola S, Bicchetti M, Laschena L, Roberto M, De Berardinis E, Franco G, Panebianco V. Seeing is Believing: State of the Art Imaging of Bladder Cancer. Semin Radiat Oncol 2023; 33:12-20. [PMID: 36517189 DOI: 10.1016/j.semradonc.2022.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Imaging plays an important role in bladder cancer (BCa) diagnostic work-up. Ultrasound achieves an intermediate sensitivity in detecting urinary tract alterations and is considered a suboptimal imaging technique in diagnosis of BCa. CT urography accurately detects BCa in patients presenting with hematuria Multiparametric MRI achieves a very high rate of BCa detection and helps with accurate staging of patients; however, this modality is still not widely supported by international guidelines. The main applications of MRI are local tumor staging and differentiation between non-muscle-invasive BCa and muscle-invasive BCa. These applications led to development of Vesical Imaging-Reporting and Data System (VI-RADS) scoring system. The VI-RADS scoring system was developed in the setting of post-resection of primary bladder tumor and instillation of intravesical Bacillus Calmette-Guerin therapy; however validation of this system in the post-treatment setting showed promising results. The high risk of BCa recurrence leads to its application in the assessment of response to therapy and for disease surveillance after treatment. MRI is rapidly becoming a leading imaging modality in BCa diagnostic workup, assessment of response to therapies and for longitudinal surveillance, and plays an important role in BCa surgical and radiation therapy treatment planning.
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Affiliation(s)
- Emanuele Messina
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Martina Lucia Pisciotti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Francesco Del Giudice
- Department of Maternal-Infant and Urological Sciences, Sapienza University of Rome, Italy
| | - Sara Lucciola
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Marco Bicchetti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Ludovica Laschena
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Michela Roberto
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy
| | - Ettore De Berardinis
- Department of Maternal-Infant and Urological Sciences, Sapienza University of Rome, Italy
| | - Giorgio Franco
- Department of Maternal-Infant and Urological Sciences, Sapienza University of Rome, Italy
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy..
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