对比MRI-经直肠超声软件融合导航穿刺与认知融合导航穿刺检出前列腺癌效果

目的 对比MRI-经直肠超声（TRUS）软件融合导航穿刺与认知融合导航穿刺检出前列腺癌（PC）效果。方法 回顾性分析120例疑诊PC患者、共127个病灶,均接受2～3针靶向穿刺（TB）+10针系统穿刺方案经会阴前列腺穿刺活检,并根据TB引导方法将其中73例（78个结节）接受MRI-TRUS软件融合导航穿刺归为A组,47例（49个结节）接受认知融合穿刺归为B组;比较2组经TB检出PC及临床显著性PC（csPC）阳性率、不同大小病灶PC阳性率,以及穿刺2针与3针PC阳性率。结果 A组经TB检出PC阳性率及csPC阳性率分别为55.13%（43/78）及39.74%（31/78）,B组分别为53.06%（26/49）及34.69%（17/49）;组间差异均无统计学意义（P均＞0.05）。对于最大径≤10 mm病灶,A组TB检出PC阳性率高于B组（P＜0.05）;而对于最大径＞10 mm且＜15 mm、≥15 mm病灶,组间TB检出PC阳性率差异均无统计学意义（P均＞0.05）。A组2针与3针TB检出PC阳性率差异无统计学意义（P＞0.05）,而B组3针TB检出PC阳性率高于2针（P＜0.05）。结论 MRI-TRUS软件融合导航穿刺检出PC及csPC阳性率与认知融合导航穿刺相当,但有助于减少TB次数、提高最大径≤10 mm小病灶检出率。     

Impact of prebiopsy magnetic resonance imaging of the prostate on cancer detection and treatment patterns

Purpose

Though superior in clinical trial settings, outcomes following magnetic resonance image (MRI)-guided prostate biopsies have not been reported broadly. We compared prostate cancer detection rates for men who did and did not undergo prebiopsy MRI and evaluated treatment patterns based on biopsy approach, year of biopsy, and proximity to early adopters.

经直肠多模态超声与多模态MRI检查对前列腺癌诊断价值的对照研究

目的比较经直肠多模态超声与多模态MRI检查对前列腺癌的诊断价值。方法回顾性分析2016年4月至2018年5月解放军总医院第一医学中心收治的102例可疑前列腺癌患者的临床资料。平均年龄66.1(38.0~85.0)岁,PSA平均值30.1(0.4~227.0)ng/ml,PSA密度(PSAD)平均值0.67(0.02~4.27)ng/ml^2。102例均行经直肠多模态超声(经直肠常规超声、剪切波弹性成像和超声造影)、多模态MRI(T2加权成像、弥散加权成像和动态增强)以及实验室检查。以经直肠超声引导穿刺活检或手术病理结果作为金标准,对比经直肠多模态超声与多模态MRI检查诊断前列腺癌的敏感性、特异性、阳性预测值、阴性预测值、准确性和受试者工作特征(receiver operating characteristic,ROC)曲线的曲线下面积。结果102例中,病理诊断为前列腺癌62例,良性前列腺增生(BPH)40例。并联多模态经直肠超声(即经直肠常规超声、剪切波弹性成像和超声造影检查中任一项结果阳性诊断为前列腺癌)诊断前列腺癌63例,BPH 39例;诊断前列腺癌的敏感性、特异性和准确性分别为98.4%、70.0%和87.3%。多模态MRI检查诊断前列腺癌75例,BPH 27例;诊断前列腺癌的敏感性、特异性和准确性分别为95.2%、60.0%和81.4%。并联多模态经直肠超声和多模态MRI检查诊断前列腺癌ROC曲线的曲线下面积分别为0.842和0.776,差异无统计学意义(P=0.208)。结论并联多模态经直肠超声检查诊断前列腺癌的效能不亚于多模态MRI检查。     

The accuracy of prostate cancer diagnosis in biopsy-naive patients using combined magnetic resonance imaging and transrectal ultrasound fusion-targeted prostate biopsy

BackgroundThis study aimed to estimate whether multiparametric magnetic resonance imaging (mpMRI)-transrectal ultrasound (TRUS) fusion biopsy (FUS-TB) increases the detection rates of clinically significant prostate cancer (csPCa) compared with TRUS-guided systematic biopsy (TRUS-GB).MethodsThis retrospective study focused on patients who underwent mpMRI before prostate biopsy (PB) with Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) scores ≥3 and prostate-specific antigen (PSA) level between 2.5 and 20 ng/mL. Before FUS-TB, the biopsy needle position was checked virtually using three-dimensional mapping. After confirming the position of the target within the prostate, biopsy needle was inserted and PB was performed. Suspicious lesions were generally targeted with 2 to 4 cores. Subsequently, 10–12 cores were biopsied for TRUS-GB. The primary endpoint was the PCa detection rate (PCDR) for patients with PCa who underwent combined FUS-TB and TRUS-GB.ResultsAccording to PI-RADS v2, 76.7% of the patients with PI-RADS v2 score ≥3 were diagnosed with PCa. The PCDRs in patients with PI-RADS v2 score of 4 or 5 were significantly higher than those in patients with PI-RADS v2 score of 3 (3 vs. 4, P<0.001; 3 vs. 5, P<0.001; 4 vs. 5, P=0.073). According to PCDR, the detection rates of PCa and csPCa in the FUS-TB were significantly higher than that in the TRUS-GB.ConclusionsFollowing detection of suspicious tumor lesions on mpMRI, FUS-TB use detects a higher number of PCa cases compared with TRUS-GB.     

Multiparametric magnetic resonance imaging–targeted biopsy for the detection of prostate cancer in patients with prior negative biopsy results

PurposeWe aimed to determine the performance of multiparametric magnetic resonance imaging (mpMRI) in the detection of prostate cancer (PCa) in patients with prior negative transrectal ultrasound–guided prostate biopsy (TRUS-B) results.Materials and methodsBetween 2010 and 2013, 2,416 men underwent TRUS-B or an mpMRI or both at Vancouver General Hospital. Among these, 283 men had persistent suspicion of PCa despite prior negative TRUS-B finding. An MRI was obtained in 112, and a lesion (prostate imaging reporting and data system score ≥3) was identified in 88 cases (78%). A subsequent combined MRI-targeted and standard template biopsy was performed in 86 cases. A matching cohort of 86 patients was selected using a one-nearest neighbor method without replacement. The end points were the rate of diagnosis of PCa and significant PCa (sPCa) (Gleason>6, or>2 cores, or>50% of any core).ResultsMRI-targeted TRUS-B detected PCa and sPCa in 36 (41.9%) and 30 (34.9%) men when compared with 19 (22.1%) and 14 (16.3%), respectively, men without mpMRI (P = 0.005 for both). In 9 cases (10.4%), MRI-targeted TRUS-B detected sPCa that was missed on standard cores. sPCa was present in 6 cases (6.9%) on standard cores but not the targeted cores. Multivariate analysis revealed that prostate imaging reporting and data system score and prostate-specific antigen density>0.15 ng/ml² were statistically significant predictors of significant cancer detection (odds ratio = 14.93, P<0.001 and odds ratio = 6.19, P = 0.02, respectively).ConclusionIn patients with prior negative TRUS-B finding, MRI-targeted TRUS-B improves the detection rate of all PCa and sPCa.     

Three-tesla magnetic resonance-guided prostate biopsy in men with increased prostate-specific antigen and repeated, negative, random, systematic, transrectal ultrasound biopsies: detection of clinically significant prostate cancers

Background

Patients with elevated prostate-specific antigen (PSA) and one or more previous negative transrectal ultrasound (TRUS) biopsy sessions are subject to diagnostic uncertainty due to TRUS-biopsy undersampling. Magnetic resonance (MR)–guided biopsy (MRGB) has shown high prostate cancer (PCa)–detection rates in studies with limited patient numbers.

Objective

Determine the detection rate of (clinically significant) PCa for MRGB of cancer-suspicious regions (CSRs) on 3-T multiparametric MR imaging (MP-MRI) in patients with elevated PSA and one or more negative TRUS-biopsy sessions.

Design, setting, and participants

Of 844 patients who underwent 3-T MP-MRI in our referral centre between March 2008 and February 2011, 438 consecutive patients with a PSA >4.0 ng/ml and one negative TRUS-biopsy session or more were included. MRGB was performed in 265 patients. Exclusion criteria were existent PCa, endorectal coil use, and MP-MRI for indications other than cancer detection.

Intervention

Patients underwent MRGB of MP-MRI CSRs.

Measurements

(Clinically significant) MRGB cancer-detection rates were determined. Clinically significant cancer was defined by accepted (i.a. Epstein and d’Amico) criteria based on PSA, Gleason score, stage, and tumour volume. Follow-up PSA and histopathology were collected. Sensitivity analysis was performed for patients with MP-MRI CSRs without MRGB.

Results and limitations

In a total of 117 patients, cancer was detected with MRGB (n = 108) or after negative MRGB (n = 9). PCa was detected in 108 of 438 patients (25%) and in 41% (108 of 265) of MRGB patients. The majority of detected cancers (87%) were clinically significant. Clinically significant cancers were detected in seven of nine (78%) negative MRGB patients in whom PCa was detected during follow-up. Sensitivity analysis resulted in increased cancer detection (47–56%). Complications occurred in 0.2% of patients (5 of 265).

Conclusions

In patients with elevated PSA and one or more negative TRUS-biopsy sessions, MRGB of MP-MRI CSRs had a PCa-detection rate of 41%. The majority of detected cancers were clinically significant (87%).     

Magnetic Resonance Imaging/Ultrasound–Fusion Biopsy Significantly Upgrades Prostate Cancer Versus Systematic 12-core Transrectal Ultrasound Biopsy

Background

Gleason scores from standard, 12-core prostate biopsies are upgraded historically in 25−33% of patients. Multiparametric prostate magnetic resonance imaging (MP-MRI) with ultrasound (US)-targeted fusion biopsy may better sample the true gland pathology.

Objective

The rate of Gleason score upgrading from an MRI/US-fusion-guided prostate-biopsy platform is compared with a standard 12-core biopsy regimen alone.

Design, setting, and participants

There were 582 subjects enrolled from August 2007 through August 2012 in a prospective trial comparing systematic, extended 12-core transrectal ultrasound biopsies to targeted MRI/US-fusion-guided prostate biopsies performed during the same biopsy session.

Outcome measurements and statistical analysis

The highest Gleason score from each biopsy method was compared.

Interventions

An MRI/US-fusion-guided platform with electromagnetic tracking was used for the performance of the fusion-guided biopsies.

Results and limitations

A diagnosis of prostate cancer (PCa) was made in 315 (54%) of the patients. Addition of targeted biopsy led to Gleason upgrading in 81 (32%) cases. Targeted biopsy detected 67% more Gleason ≥4 + 3 tumors than 12-core biopsy alone and missed 36% of Gleason ≤3 + 4 tumors, thus mitigating the detection of lower-grade disease. Conversely, 12-core biopsy led to upgrading in 67 (26%) cases over targeted biopsy alone but only detected 8% more Gleason ≥4 + 3 tumors. On multivariate analysis, MP-MRI suspicion was associated with Gleason score upgrading in the targeted lesions (p < 0.001). The main limitation of this study was that definitive pathology from radical prostatectomy was not available.

Conclusions

MRI/US-fusion-guided biopsy upgrades and detects PCa of higher Gleason score in 32% of patients compared with traditional 12-core biopsy alone. Targeted biopsy technique preferentially detects higher-grade PCa while missing lower-grade tumors.     

Preoperative prostate biopsy and multiparametric magnetic resonance imaging: reliability in detecting prostate cancer

Purpose

The aim of the study was to analyse and compare the ability of multiparametric magnetic resonance imaging (mp–MRI) and prostate biopsy (PB) to correctly identify tumor foci in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa).

Materials and Methods

157 patients with clinically localised PCa with a PSA <10 ng/mL and a negative DRE diagnosed on the first (12 samples, Group A) or second (18 samples, Group B) PB were enrolled at our institution. All patients underwent mp-MRI with T2-weighted images, diffusion-weighted imaging, dynamic contrast enhanced-MRI prior to RP. A map of comparison describing each positive biopsy sample was created for each patient, with each tumor focus shown on the MRI and each lesion present on the definitive histological examination in order to compare tumor detection and location. The sensitivity of mp-MRI and PB for diagnosis was compared using Student’s t-test. The ability of the two exams to detect the prevalence of Gleason pattern 4 in the identified lesions was compared using a chi-square test.

Results

Overall sensitivity of PB and mp-MRI to identify tumor lesion was 59.4% and 78.9%, respectively (p<0.0001). PB missed 144/355 lesions, 59 of which (16.6%) were significant. mp-MRI missed 75/355 lesions, 12 of which (3.4%) were significant. No lesions with a GS≥8 were missed. Sensitivity of PB and mp-MRI to detect the prevalence of Gleason pattern 4 was 88.2% and 97.4%, respectively.

Conclusions

mp-MRI seems to identify more tumor lesions than PB and to provide more information concerning tumor characteristics.     

MR弥散加权成像在前列腺癌诊断中的应用价值

目的 探讨MR弥散加权成像(MRDWI)在前列腺癌(PCa)诊断中的应用价值. 方法 临床怀疑PCa患者57例行MRDWI与T_2 WI检查,通过表观弥散系数(ADC)图对可疑病灶进行良恶性评判.并与穿刺或手术病理结果 进行比较,利用曲线下面积(ROC)分析比较MRDWI与T_2 WI在PCa病灶检出中的价值.同时对30例直肠指检无结节,前列腺穿刺活检阴性患者行MRDWI检查,通过ADC值将可疑病灶按照Ⅰ(良性)～Ⅴ(恶性)级标准划分,在经直肠超声横断面上对异常区域进行定位穿刺.评价以MRDWI定位再次穿刺的价值. 结果 57例患者MRDWI与T_2WI的ROC分别为0.830和0.742,MRDWI诊断敏感性为85%、特异性为82%、阳性预测值80%、阴性预测值86%、准确率为83%;T_2 WI的敏感性为77%、特异性为71%、阳性预测值69%、阴性预测值79%、准确率为74%.MRDWI诊断准确性优于TzWl(P<0.05).30例穿刺定位患者中ADC图诊断为PCa 24例(≥Ⅳ级),BPH 6例(Ⅰ～Ⅲ级).穿刺病理证实为PCa 17例(85%),以Ⅳ级为界划分良恶性,诊断敏感性100%、特异性46%、阳性预测值71%、阴性预测值100%、准确率77%.如果以至少有1个区域为V级划为恶性,则17例PCa患者中DWI诊断恶性13例,敏感性77%、特异性85%、阳性预测值87%、阴性预测值73%、准确率80%. 结论 MR弥散加权成像诊断PCa准确性优于T2加权成像,能有效提高PSA持续升高患者前列腺再次穿刺活检的检出率.     

MRI引导下乳腺病灶真空辅助穿刺活检术的应用

目的探讨MRI引导真空辅助穿刺活检术在BI-RADS 4类乳腺病变中的应用价值。方法对9例MRI诊断为BI-RADS 4类乳腺病变的患者行MR引导真空辅助穿刺活检术。采用1.5T MR仪,8通道专用乳腺MR活检线圈,乳腺适度加压后固定于定位装置内;定位扫描采用矢状位3D动态增强扫描,将数据传至乳腺活检专用定位工作站,由工作站自动计算活检位置及进针深度。以14.5cm、8G真空辅助活检针进行穿刺。结果 9例中,8例病灶准确定位,并成功取得组织病理结果;1例因病灶位置表浅、工作站不能定位而终止活检。每例取组织6~20条,共取96条;每例操作时间为30~65min。组织病理学结果:乳腺浸润性导管癌2例,腺病3例,导管内乳头状瘤1例,硬化性腺病合并导管扩张1例,腺病伴不典型增生1例。结论 MR引导下乳腺病变真空抽吸活检术用于BI-RADS 4类乳腺病变安全可行,能够取得足够的组织用于病理学评估。     

Decision analysis model comparing cost of multiparametric magnetic resonance imaging vs. repeat biopsy for detection of prostate cancer in men with prior negative findings on biopsy

PurposeWe compared cost of multiparametric magnetic resonance imaging (MP-MRI) vs. repeat biopsy in detection of prostate cancer (PCa) in men with prior negative findings on biopsy.MethodsA decision tree model compared the strategy of office-based transrectal ultrasound–guided biopsy (TRUS) for men with prior negative findings on biopsy with a strategy of initial MP-MRI with TRUS performed only in cases of abnormal results on imaging. Study end points were cost, number of biopsies, and cancers detected. Cost was based on Medicare reimbursement. Cost of sepsis and minor complications were incorporated into analysis. Sensitivity analyses were performed by varying model assumptions.ResultsThe baseline model with 24% PCa found that the overall cost for 100 men was $90,400 and $87,700 for TRUS and MP-MRI arms, respectively. The MP-MRI arm resulted in 73 fewer biopsies per 100 men but detected 4 fewer cancers (16 vs. 20.4) than the TRUS arm did. A lower risk of PCa resulted in lower costs for the MP-MRI arm and a small difference in detected cancers. At lower cancer rates, MP-MRI is superior to TRUS over a wide range of sensitivity and specificity of MRI. A lower sensitivity of MP-MRI decreases the cost of the MP-MRI, as fewer biopsies are performed, but this also reduces the number of cancers detected.ConclusionsThe use of MP-MRI to select patients for repeat biopsy reduced the number of biopsies needed by 73% but resulted in a few cancers being missed at lower cost when compared with the TRUS arm. Further studies are required to determine whether cancers missed represent clinically significant tumors.     

Differences in biopsy features between prostate cancers located in the transition and peripheral zone

OBJECTIVE: To identify the zonal location of prostate cancers before surgery, by analysing the mapping of ultrasonography-guided systematic sextant biopsies for differences between cancers located in the transition zone (TZ) and peripheral zone (PZ); and to compare the correlation between Gleason scores of needle biopsies and those of radical prostatectomy (RP) specimens. PATIENTS AND METHODS: In all, 186 patients with TZ (46) and PZ cancers (140) underwent ultrasonography-guided systematic sextant biopsy and RP at the same institution. The clinical and pathological characteristics, and the anatomical location of positive biopsies, were determined and compared using t-tests and chi-square tests. Differences between Gleason scores of needle biopsies and those of RP specimens were evaluated and compared by Cohen kappa testing. RESULTS: TZ cancers had a significantly lower rate of positive biopsies in the middle (63% vs 80%) and base (50% vs 80%) of the prostate than had PZ cancers. Positive biopsies were exclusively obtained from the apex in 19.6% of TZ and 5% of PZ cancers (P = 0.002). There was exact agreement between Gleason scores of needle biopsies and those of RP specimens in 15.2% of TZ (kappa = 0.02) and 55% of PZ cancers (kappa = 0.25), respectively. CONCLUSION: Compared with PZ cancers, TZ cancers had a different anatomical pattern of positive biopsies, with lower rates in the middle and base of the prostate. The finding of positive biopsies exclusively in the apex favoured prostate cancer located in the TZ. Furthermore, the correlation between needle biopsy Gleason scores and those of the RP specimens was clearly lower in TZ cancers.     

Computer-aided diagnosis system for characterizing ISUP grade ≥ 2 prostate cancers at multiparametric MRI: A cross-vendor evaluation

PurposeTo assess the performance of a computer-aided diagnosis (CADx) system trained at characterizing International Society of Urological Pathology (ISUP) grade ≥ 2 peripheral zone (PZ) prostate cancers on multiparametric magnetic resonance imaging (mpMRI) examinations from a different institution and acquired on different scanners than those used for the training database.Patients and methodsPreoperative mpMRIs of 74 men (median age, 65.7 years) treated by prostatectomy between 2014 and 2017 were retrospectively selected. One radiologist outlined suspicious lesions and scored them using Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2); their CADx score was calculated using a classifier trained on an independent database of 106 patients treated by prostatectomy in another institution. The lesions’ nature was assessed by comparison with prostatectomy whole-mounts. Diagnostic accuracy was estimated with areas under receiver operating characteristic curves (AUCs). Sensitivity and specificity were calculated using a CADx threshold (≥0.21) that yielded 95% sensitivity in the training database, and a PI-RADSv2 ≥ 3 threshold.ResultsA total of 127 lesions (PZ, n = 104; transition zone [TZ], n = 23) were described. In PZ, CADx and PI-RADSv2 scores had similar AUCs for characterizing ISUP grade ≥ 2 cancers (0.78 [95% confidence interval (CI): 0.69–0.87] vs. 0.74 [95%CI: 0.62–0.82], respectively) (P = 0.59). Sensitivity and specificity were respectively 89% (95%CI: 82–97%) and 42% (95%CI: 26–58%) for the CADx score, and 97% (95%CI: 93–100%) and 37% (95%CI: 22–52%) for the PI-RADSv2 score. In TZ, both scores showed poor specificity.ConclusionIn this external cohort, the CADx and PI-RADSv2 scores showed similar performances in characterizing ISUP grade ≥ 2 cancers.