Systematic sampling during MRI-US fusion prostate biopsy can overcome errors of targeting—prospective single center experience after 300 cases in first biopsy setting

BackgroundMultiparametric magnetic resonance imaging (mpMRI) and targeted biopsy have become an integral part of the diagnosis of prostate cancer (PCa), as recommended by the European Association of Urology Guidelines. The aim of the current study was to evaluate the performance of MRI and MRI-transrectal ultrasound (TRUS) fusion prostate biopsy as first biopsy setting in a tertiary center.MethodsA cohort of 300 patients was included in the current analysis. All patients presented with clinical or biochemical suspicion of PCa and harbored at least one suspect lesion on mpMRI. MRI-TRUS fusion prostate biopsy, followed by 12 core systematic prostate biopsy were performed by the same operator using a rigid registration system.ResultsThe mean age of the patients was 64 years (IQR: 58–68.5 years) and the mean PSA was 6.35 ng/mL (IQR: 4.84–9.46 ng/mL). Overall cancer and csPCa diagnosis rates were 47% and 40.66%. Overall PCa/csPCa detection rates were 20.4%/11.1%, 52%/45% and 68.5%/66.7% for PI-RADS lesions 3, 4 and 5 (P<0.001/P<0.0001). Larger lesion diameter and lesion volume were associated with PCa diagnosis (P=0.006 and P=0.001, respectively). MRI-TRUS fusion biopsy missed PCa diagnosis in 37 cases (of whom 48.6% ISUP 1) in comparison with 9 patients missed by systematic biopsy (of whom 11.1% ISUP 1). In terms of csPCa, systematic biopsy missed 77.7% of the tumors located in the anterior and transitional areas. The rate of csPCa was highest when targeted biopsy was associated with systematic biopsy: 86.52% vs. 68.79% for targeted biopsy vs. 80.14% for systematic biopsy, P=0.0004. In 60.6% of cases, systematic biopsy was positive for PCa at the same site as the targeted lesion. Of these patients, eight harbored csPCa and were diagnosed exclusively on systematic biopsy.ConclusionsMRI-TRUS fusion prostate biopsy improves the diagnosis of csPCa. The main advantage of an MRI-guided approach is the diagnosis of anterior and transitional area tumors. The best results in terms of csPCa diagnosis are obtained by the combination of MRI-TRUS fusion with systematic biopsy. The systematic biopsy performed during MRI-targeted biopsy could have an important role in overcoming errors of MRI-TRUS fusion systems.     

Which men with non-malignant pathology at magnetic resonance imaging-targeted prostate biopsy and persistent PI-RADS 3-5 lesions should repeat biopsy?

PurposeTo assess predictors of clinically significant (cs) prostate cancer (PCa) in men who had a non-malignant Multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy and persistent Prostate Imaging-Reporting Data System (PI-RADS) 3 to 5 lesions in subsequent mpMRI.Materials and MethodsWe retrospectively analyzed MRI-targeted biopsy database in three centers. Inclusion criteria: persistence of at least one PI-RADS ≥3 lesion found negative for cancer in a previous MRI-targeted plus systemic biopsy (baseline biopsy). Exclusion criteria: downgrading to PI-RADS 1-2. A logistic regression analysis was performed to estimate the predictors of csPCa.ResultsFifty-seven patients were included. Median interval between biopsies was 12.9(2.43) months. Median age was 68.0(12) years. Median PSA was 7.0(5.45) ng/ml. At follow-up, 24.6%, 54.4%, and 21% of patients had a PI-RADS score 3, 4, and 5 index lesion (IL), respectively. At re-biopsy, 28/57(49.1%) men were found to harbor PCa. Among these, 22(78.6%) had csPCa. csPCa was found outside the IL in only 2 patients. Eleven, 13, and 5 patients with PI-RADS 3, 4, and 5, respectively, had no cancer. Three patients with a PI-RADS 3 lesion had cancer (2 with Gleason score 3+3, 1 with Gleason score 3+4). 14/43 men with a PI-RADS 4/5 lesion harbored Gleason score ≥3+4 PCa. Logistic regression analysis found that PSA (HR 1.281, 95% CI: 1.013–1.619, P = 0.039) and IL size (HR 1.146, 95% CI: 1.018–1.268, P = 0.041) were the predictors of csPCa at re-biopsy.ConclusionsPatients with non-malignant pathology from PI-RADS ≥3 lesions targeted biopsy should be follow-up with mpMRI, and those with persistent PI-RADS 4 to 5 lesions should repeat MRI-targeted and systematic biopsy.     

Evaluación de la biopsia de fusión elástica vs. biopsia sistemática para la detección del cáncer de próstata: resultados de un estudio multicéntrico en 1.119 pacientes

ObjectivesTo assess the accuracy of targeted and systematic biopsies for the detection of prostate cancer (PCa) and clinically significant PCa (csPCa) in the everyday practice, evaluating the need for additional systematic biopsies at the time of targeted biopsy.Patients and methodsFrom our multicentric database gathering data on 2,115 patients who underwent fusion biopsy with Koelis™ system between 2010 and 2017, we selected 1,119 patients who received targeted biopsies (a median of 3 for each target), followed by systematic sampling of the prostate (12 to 14 cores). Overall and clinically significant cancer detection rate (CDR) of Koelis™ fusion biopsies were assessed, comparing target and systematic biopsies. Secondary endpoint was the identification of predictors of PCa detection.ResultsThe CDR of targeted biopsies only was 48% for all cancers and 33% for csPCa. The performance of additional, systematic prostate sampling improved the CDR of 15% for all cancers and of 12% for csPCa. PCa was detected in 35%, 69%, and 92% of patients with lesions scored as PI-RADS 3, 4 and 5, respectively. Elevated PI-RADS score and positive digital rectal examination were predictors of PCa, whereas biopsy-naïve status was associated with csPCa.ConclusionIn the everyday practice target biopsy with Koelis™ achieves a good CDR for all PCa and csPCa, which is significantly improved by subsequent systematic sampling of the prostate. The outstanding outcomes of fusion biopsy are confirmed also in biopsy-naïve patients. Elevated PI-RADS score and positive digital rectal examination are strongly associated with presence of PCa.     

Predictive model containing PI-RADS v2 score for postoperative seminal vesicle invasion among prostate cancer patients

BackgroundSeminal vesicle invasion (SVI) is considered to be one of most adverse prognostic findings in prostate cancer, affecting the biochemical progression-free survival and disease-specific survival. Multiparametric magnetic resonance imaging (mpMRI) has shown excellent specificity in diagnosis of SVI, but with poor sensitivity. The aim of this study is to create a model that includes the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) score to predict postoperative SVI in patients without SVI on preoperative mpMRI.MethodsA total of 262 prostate cancer patients without SVI on preoperative mpMRI who underwent radical prostatectomy (RP) at our institution from January 2012 to July 2019 were enrolled retrospectively. The prostate-specific antigen levels in all patients were <10 ng/mL. Univariate and multivariate logistic regression analyses were used to assess factors associated with SVI, including the PI-RADS v2 score. A regression coefficient-based model was built for predicting SVI. The receiver operating characteristic curve was used to assess the performance of the model.ResultsSVI was reported on the RP specimens in 30 patients (11.5%). The univariate and multivariate analyses revealed that biopsy Gleason grade group (GGG) and the PI-RADS v2 score were significant independent predictors of SVI (all P<0.05). The area under the curve of the model was 0.746 (P<0.001). The PI-RADS v2 score <4 and Gleason grade <8 yielded only a 1.8% incidence of SVI with a high negative predictive value of 98.2% (95% CI, 93.0–99.6%).ConclusionsThe PI-RADS v2 score <4 in prostate cancer patients with prostate-specific antigen level <10 ng/mL is associated with a very low risk of SVI. A model based on biopsy Gleason grade and PI-RADS v2 score may help to predict SVI and serve as a tool for the urologists to make surgical plans.     

Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know. Part 2: Interpretation

BackgroundThere is large variability among radiologists in their detection of clinically significant (cs) prostate cancer (PCa) on multiparametric magnetic resonance imaging (mpMRI).ObjectiveTo reduce the interpretation variability and achieve optimal accuracy in assessing prostate mpMRI.Design, setting, and participantsHow the interpretation of mpMRI can be optimized is demonstrated here. Whereas part 1 of the “surgery-in-motion” paper focused on acquisition, this paper shows the correlation between (ab)normal prostate anatomical structures and image characteristics on mpMRI, and how standardized interpretation according to Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) should be performed. This will be shown in individual patients.Surgical procedureTo detect csPCa, three mpMRI “components” are used: “anatomic” T2-weighted imaging, “cellular-density” diffusion-weighted imaging, and “vascularity” dynamic contrast-enhanced MRI.MeasurementsBased on PI-RADS v2, the accompanying video shows how mpMRI interpretation is performed. Finally, the role of mpMRI in detecting csPCa is briefly discussed and the main features of the recently introduced PI-RADS v2.1 are evaluated.Results and limitationsWith PI-RADS v2, it is possible to quantify normal and abnormal anatomical structures within the prostate based on its imaging features of the three mpMRI “components.” With this knowledge, a more objective evaluation of the presence of a csPCa can be performed. However, there still remains quite some space to reduce interobserver variability.ConclusionsFor understanding the interpretation of mpMRI according to PI-RADS v2, knowledge of the correlation between imaging and (ab)normal anatomical structures on the three mpMRI components is needed.Patient summaryThis second surgery-in-motion contribution shows what structures can be recognized on prostate magnetic resonance imaging (MRI). How a radiologist performs his reading according to the so-called Prostate Imaging Reporting and Data System criteria is shown here. The main features of these criteria are summarized, and the role of prostate MRI in detecting clinically significant prostate cancer is discussed briefly.     

Evidence-based guideline recommendations on multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer: A Cancer Care Ontario updated clinical practice guideline

IntroductionThis clinical practice guideline is based on a systematic review to assess the use of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis of clinically significant prostate cancer (csPCa) for biopsy-naive men and men with a prior negative transrectal ultrasound-guided systematic biopsy (TRUS-SB) at elevated risk.MethodsThe methods of the clinical practice guideline included searches to September of 2020 of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Internal and external reviews were conducted.ResultsThe recommendations are:Recommendation 1: For biopsy-naive patients at elevated risk of csPCa, mpMRI is recommended prior to biopsy in patients who are candidates for curative management with suspected clinically localized prostate cancer.

• – If the mpMRI is positive, mpMRI-targeted biopsy (TB) and TRUS-SB should be performed together to maximize detection of csPCa.
• – If the mpMRI is negative, consider forgoing any biopsy after discussion of the risks and benefits with the patient as part of shared decision-making and ongoing followup.

Recommendation 2: In patients who had a prior negative TRUS-SB and demonstrate a high risk of having csPCa in whom curative management is being considered:

• – mpMRI should be performed.
• – If the mpMRI is positive, targeted biopsy should be performed. Concomitant TRUS-SB can be considered depending on the patient’s risk profile and time since prior TRUS-SB biopsy.
• – If the mpMRI is negative, consider forgoing a TRUS-SB only after discussion of the risks and benefits with the patient as part of shared decision-making and ongoing followup.

Recommendation 3: mpMRI should be performed and interpreted in compliance with the current Prostate Imaging Reporting & Data System (PI-RADS) guidelines.     

How to optimize follow-up in patients with a suspicious multiparametric MRI and a subsequent negative targeted prostate biopsy. Results from a large,single-institution series

ObjectiveWe aimed at optimizing the follow-up for patients with a positive multiparametric magnetic resonance of the prostate (mpMRI) and a subsequent negative targeted biopsy (TBx) plus systematic biopsy (SBx).Materials and methodsA total of 308 men with a clinical suspicion of PCa and a positive mpMRI (PI-RADS ≥ 3) with concomitant negative systematic and targeted Bx performed at a single tertiary referral center. All patients were then followed with serial PSA measurements, digital rectal examination and eventual follow-up mpMRI and/or repeat Bx. The primary outcome was to evaluate the overall clinically significant PCa (csPCa)-free survival. The secondary outcome was to assess the role of a repeat mpMRI (Fu-mpMRI) and PSA density as predictors of csPCa diagnosis (defined as Gleason score ≥ 3 + 4) during follow-up. Kaplan Meier analysis and univariable Cox regression were used for survival and predictive analyses.ResultsMedian follow-up was 31 months (IQR: 23–43). During the study period 116 (37.7%) and 68 (22.1%) of men received a Fu-mpMRI and a Fu-Bx, respectively. Overall, 51 (16.6%) and 15 (4.9%) patients had a positive mpMRI and clinically significant (csPCa) diagnosis during follow-up, respectively. Among 68 men who received a Fu-Bx, the 2- and 3-years csPCa diagnosis-free survival in men with negative vs. positive Fu-mpMRI was 97% vs. 65% and 92% vs. 65%, respectively. At univariate Cox-regression analysis the presence of a positive Fu-mpMRI resulted to be significantly associated with the presence of csPCa at Fu-Bx (HR: 5.8, 95% CI: 1.3–26.6, P = 0.008). The 2- and 3-years csPCa diagnosis-free survival in men with PSAd <0.15 vs. ≥0.15 was 89% vs. 77%, and 86% vs. 66%, respectively (HR: 2.6, 95% CI: 0.75–8.87, P = 0.13). The combination of negative Fu-mpMRI and PSAd<0.15 furtherly reduced the probability of csPCa diagnosis at Fu-Bx at only 6% at 3years (HR: 9.9, 95% CI: 1.9–38.6, P < 0.001) in this subgroup of patients.ConclusionsAfter a negative TBx for a positive mpMRI, more than half of Fu-mpMRI were negative. A persistent positive mpMRI was associated with a significant risk of csPCa. The risk of csPCa diagnosis in men with negative mpMRI performed after negative TBx and low PSAd was negligible.     

The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies

Background

Guidelines advise multiparametric magnetic resonance imaging (mpMRI) before repeat biopsy in patients with negative systematic biopsy (SB) and a suspicion of prostate cancer (PCa), enabling MRI targeted biopsy (TB). No consensus exists regarding which of the three available techniques of TB should be preferred.

Prostate zonal anatomy correlates with the detection of prostate cancer on multiparametric magnetic resonance imaging/ultrasound fusion–targeted biopsy in patients with a solitary PI-RADS v2–scored lesion

PurposeTo evaluate the positive predictive value (PPV) of the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) assessment method in patients with a single suspicious finding on prostate multiparametric magnetic resonance imaging (mpMRI).Patients and methodsA total of 176 patients underwent MRI/ultrasound fusion–targeted prostate biopsy after the detection of a single suspicious finding on mpMRI. The PPV for cancer detection was determined based on PI-RADS v2 assessment score and location.ResultsFusion biopsy detected prostate cancer in 60.2% of patients. Of these patients, 69.8% had Gleason score (GS) ≥7 prostate cancer. Targeted biopsy detected 90.5% of all GS≥7 prostate cancer. The PPV for GS≥7 detection of PI-RADS v2 category 5 (P5) and category 4 (P4) lesions was 70.2% and 37.7%, respectively. This increased to 88% and 38.5% for P5 and P4 lesions in the peripheral zone (PZ), respectively. Targeted biopsy did not miss GS≥7 disease compared with systematic biopsy in P5 lesions in the PZ and transition zone.ConclusionThe PPV of PI-RADS v2 for prostate cancer in patients with a single lesion on mpMRI is dependent on PI-RADS assessment category and location. The highest PPV was for a P5 lesion in the PZ.     

Determining the diagnostic value of PSMA-PET/CT imaging in patients with persistent high prostate specific antigen levels and negative prostate biopsies

PurposeTo assess the diagnostic performance of prostate specific membranous antigen (PSMA) positron emission tomography/computed tomography (PET/CT) imaging to localize primary prostate cancer (PCa) in men with persistent elevated prostate-specific antigen (PSA) levels and previous prostate biopsies that were negative for PCa.MethodsIn this study, 34 men with persistently elevated PSA-levels, previous negative for PCa biopsies and who subsequently underwent diagnostic PSMA-PET/CT imaging were retrospectively evaluated. Men were divided into 3 groups: 1. 12 men with a previous negative mpMRI scan (PI-RADS 1-2) 2. 17 men with a positive mpMRI scan (PI-RADS 3-5), but negative MRI-targeted biopsies and 3. Four men in whom mpMRI was contraindicated. If PSMA-avid lesions were seen, patients underwent 2-4 cognitive targeted biopsies in combination with systematic biopsies. The detection rate of PSMA-PET/CT for PCa, and the accuracy of (possible) targeted biopsies were calculated.ResultsIncluded men had a median PSA-level of 22.8 ng/mL (Interquartile Range 15.6–30.0) at the time of PSMA-PET/CT. Elevated PSMA-ligand uptake in the prostate suspicious for PCa was observed in 22/34 patients (64.7%). In 18/22 patients (54.5%), PSMA-targeted prostate biopsies were performed. In 3/18 patients (16.6%), the targeted biopsies showed International Society of Urological Pathology (ISUP) score 1–2 PCa. The other men had inflammation or benign findings after histopathological examination of the biopsy cores.ConclusionIn this study, the clinical value of PSMA-PET/CT for patients with an elevated PSA-level, and negative for PCa biopsies was low. Only very few men were diagnosed with PCa, and no clinically significant PCa was found.     

Can the combination of biparametric magnetic resonance imaging and PSA-related indicators predict the prostate biopsy outcome?

To assess the value of biparametric magnetic resonance imaging (bpMRI) for detecting and ruling out prostate cancer in patients with elevated prostate-specific antigen (PSA). The basic information and bpMRI images of enrolled patients who took transperineal template saturate biopsy were retrospectively collected for analysis. Based on our results, we found that free/total PSA, and PI-RADS score were independent risk factors of PCa (p < .05), the PSA density, PI-RADS score were the independent risk factors of csPCa (p < .05). PI-RADS score threshold of 3 could achieve the highest Yonder index for predicting PCa, and PI-RADS score threshold of 4 could achieve the highest Yonder index for predicting csPCa. Therefore, we draw a conclusion that PI-RADSv2 score-based bpMRI could diminish the unnecessary prostate biopsies in patients with elevated PSA when combined with other PSA-related indicators.     

Detection of clinically significant prostate cancer by transperineal multiparametric magnetic resonance imaging-ultrasound fusion targeted prostate biopsy in smaller prostates

PurposeTransperineal (TP) multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy (TBx) has been shown to detect more clinically significant (cs) prostate cancer (PCa) than standard template biopsies (SBx). Current data supports the inclusion of both TBx and SBx in obtaining an optimal csPCa detection rate. We compared csPCa detection rates in patients with different prostate volumes to examine the benefit of performing TBx in smaller prostates through the TP approach.MethodsWe identified all men who with suspicious lesions on mpMRI and underwent TP TBx (3-core) and concomitant SBx (20-core) in our single hospital from September 2019 to February 2021. Clinical, MRI and biopsy pathological characteristics were evaluated and compared between TBx and SBx. Grade group 2 or greater prostate adenocarcinoma was defined as csPCa.ResultsThree hundred and one (n = 301) men were included. The median prostate volume by MRI was 45 ml. The patients were divided by prostate volume into three groups: ≤30ml group (19.9%), >30 to ≤45 ml group (31.3%) and >45ml group (48.8%). Patients in the ≤30ml group showed significantly higher frequency of combined (both TBx and/or SBx) csPCa detection rate (65.0%) than patients in the >45ml group (39.5%) but similar frequency to the >30 to ≤45 ml group (54.2%,). By TBx only (55.0% vs 27.9%) or by SBx only (56.7% vs. 34.0%), patients in the ≤30ml group consistently showed significantly higher rates of csPCa detection than patients in the >45 ml group. In the ≤30ml group, the detection rate of csPCa was comparable by TBx, SBx or when combined. Four of 6 csPCa cases missed by TBx but detected by SBx were present at the base location.ConclusionOur data suggest that performing TBx with limited additional cores may potentially achieve the same csPCa detection rate as the combined SBx and TBx in smaller prostates.     

靶向穿刺与靶向联合系统穿刺对前列腺PI-RADS评分4~5分患者的诊断效能比较

目的比较靶向穿刺与靶向联合系统穿刺对多参数磁共振(mpMRI)前列腺影像报告与数据系统(PI-RADS)评分4~5分患者的诊断效能。方法回顾性分析2018年1月至2020年2月南京大学医学院附属鼓楼医院378例前列腺PI-RADS评分为4~5分且接受前列腺靶向穿刺联合系统穿刺患者的临床资料。中位年龄69(64,75)岁,中位前列腺特异性抗原9.5(6.7,16.3)ng/ml,中位前列腺体积34.1(23.5,48.4)ml。PI-RADS评分4分240例,5分138例。所有患者均行经会阴前列腺穿刺,在mpMRI/经直肠超声融合图像引导下,先行2针靶向穿刺,再行12针系统穿刺。评估穿刺病理及穿刺阳性的Gleason评分,通过χ²检验或Fisher精确检验比较不同穿刺方式前列腺癌和有临床意义前列腺癌(CsPCa)的检出情况。结果378例中290例阳性,88例阴性。靶向穿刺平均2.4针/例,系统穿刺平均12.0针/例,靶向穿刺与系统穿刺对前列腺癌的检出率差异无统计学意义[73.3%(277/378)与68.3%(258/378),P=0.129],对CsPCa的检出率差异无统计学意义[55.8%(211/378)与49.7%(188/378),P=0.094],准确率差异无统计学意义[79.1%(299/378)与77.8%(294/378),P=0.658],穿刺针数阳性率差异有统计学意义[64.2%(580/904)与23.1%(1049/4536),P<0.001]。靶向穿刺与靶向穿刺联合系统穿刺的病理符合率为92.3%(349/378),对前列腺癌的检出率差异无统计学意义[73.3%(277/378)与76.7%(290/378),P=0.275],对CsPCa的检出率差异无统计学意义[55.8%(211/378)与62.2%(235/378),P=0.076]。靶向穿刺对前列腺癌的漏诊率为4.5%(13/290),对CsPCa的漏诊率为10.2%(24/235)。在PI-RADS评分4分的患者中,靶向穿刺与靶向穿刺联合系统穿刺对前列腺癌的检出率差异无统计学意义[65.4%(157/240)与69.2%(166/240),P=0.381],对CsPCa的检出率差异无统计学意义[46.7%(112/240)与52.9%(127/240),P=0.171];靶向穿刺的准确率为82.1%(197/240),对前列腺癌的漏诊率为5.4%(9/166),对CsPCa的漏诊率为11.8%(15/127)。在PI-RADS评分5分的患者中,靶向穿刺与靶向穿刺联合系统穿刺对前列腺癌的检出率差异无统计学意义[87.0%(120/138)与89.9%(124/138),P=0.452],对CsPCa的检出率差异无统计学意义[71.7%(99/138)与78.3%(108/138),P=0.211];靶向穿刺的准确率为73.9%(102/138),对前列腺癌的漏诊率为3.2%(4/124),对CsPCa的漏诊率为8.3%(9/108)。结论对于PI-RADS评分为4~5分的高危前列腺癌患者,靶向穿刺以更少的穿刺针数可获得与靶向穿刺联合系统穿刺相近的检出效果,但仍存在诊断不准确及漏诊的可能。     

Comparison of initial and second opinion reads of multiparametric magnetic resonance imaging of the prostate for transperineal template-guided biopsies with MRI-Ultrasound fusion

PurposeTo investigate the value of second-opinion evaluation of multiparametric prostate magnetic resonance imaging (MRI) by subspecialised uroradiologists for the detection of significant cancer in transperineal fusion prostate biopsy.MethodsThe evaluated data included age, PSA (ng/ml), PSA density, Gleason score, digital rectal examination (DRE), prostate volume of 149 patients. Twenty-seven patients (18%) had no previous prostate biopsy, 114 patients (77%) had a previous negative biopsy, and 8 patients (5%) were on active surveillance. Using PI-RADS v2 scores for mpMRI a second report was performed by a specialist uroradiologist. In all cases a subsequent transperineal biopsy was performed with at least 2 cores per target and additional background systemic cores. Initial and second-opinion radiology reports were evaluated for detection of any cancer and Gleason score (GS) 7-10 cancer, including positive predictive value and negative (NPV) and compared by Fisher's exact test.ResultsAt transperineal biopsy, 51 % (76/149) of patients had a GS 6-10 prostate cancer (PCa), 27 % (40/149) of patients had a GS 3 + 3 PCa and 12 % (18/149) a GS 3 + 4 and 12 % (18/149) had a GS ≥4 + 3 PCa. Agreement between initial and second-opinion reads was observed in 57.7% (86/149; kappa value = 0.32). The detection of clinically significant cancers with second-opinion reads was significantly higher (0.61; 17/28) compared to initial reads (0.35; 17/49); P = 0.034.ConclusionsSecond reading of prostate mpMRIs by subspecialised uroradiologists significantly improved the positive predictive value for detection of clinically significant prostate cancer and showed a trend towards improved NPV for MRI-negative cases where biopsy could be safely avoided. Urologists should be aware that the experience of the reporter will affect the report when making decisions if and how to obtain biopsies. Reporter experience may help to reduce overcalling and avoid over-targeting of lesions.     

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.     

Prediction of clinically significant prostate cancer after negative prostate biopsy: The current value of microscopic findings

ObjectiveTo assess the current ability of atypical small acinar proliferation (ASAP), multifocal high-grade prostatic intraepithelial neoplasia (mHGPIN), HGPIN with atypia (PINATYP) and other non-malignant lesions to predict clinically significant prostate cancer (csPCa) in repeat prostate biopsies.MethodsThis retrospective study analyzed 377 repeat prostate biopsies, carried out between 2.014 and 2.017, and excluding those with previous PCa or 5-alpha reductase inhibitors treatment. ASAP, mHGPIN, PINATYP, prostatic atrophy, prostatic hyperplastic atrophy, proliferative inflammatory atrophy (PIA), chronic prostatitis, acute prostatitis, or granulomatous prostatitis, were prospectively reported after 12-core transrectal ultrasound (TRUS) systematic negative previous biopsies. 3T-multiparametric magnetic resonance imaging (mpMRI) was performed previous repeat biopsies. At least 2-core TRUS targeted biopsies of Prostate Imaging-Reporting and Data Systemv2 lesions ≥3, and/or 12-core TRUS systematic biopsy were performed in repeat prostate biopsies. The main outcome measurements were csPCa detection, which was defined when the International Society of Uro-Pathology group grade >1 and avoided biopsies. After logistic regression analysis the most efficient model was selected, nomogram was designed with internal validation, and clinical utility was analyzed.ResultsNormal benign tissue alone was present in less than 2% of previous negative biopsies. mHGPIN (39.7%), ASAP (4.3%) and PINATYP (3.7%) failed to predict csPCa risk in repeat biopsies. The finding of PIA (38.2%) associated with a decreased the risk of csPCa with an Odd ratio of 0.54 (95% confidence interval: 0.31–0.95), P= 0.031. The area under the curve, to predict csPCa, of mpMRI was 0.736, increasing up to 0.860 (95% confidence internal:0.82–0.90) when PSA density, age, digital rectal examination, and differential PSA between biopsies and PIA finding were integrated in a predictive model. At 6% threshold, more than 20% of repeat prostate biopsies were saved without missing csPCa.ConclusionCurrently, mHGPIN in negative prostate biopsy seems not able to predict the risk of future csPCa. The low incidence of ASAP and PINATYP, in our series, did not allow us to draw conclusions. PIA finding associated with a reduced risk of csPCa, and it could be integrated in a useful based-mpMRI predictive nomogram.     

超声引导下12+x针前列腺穿刺活检单中心407例临床分析

目的:分析单中心超声引导下12+x针前列腺穿刺活检结果,比较不同穿刺途径的临床效果。方法:回顾分析2016年6月~2019年12月我院完成的407例前列腺穿刺活检的临床资料,经直肠前列腺穿刺290例(经直肠组),经会阴前列腺穿刺117例(经会阴组),均采用超声引导下12+x针法,前列腺影像学正常者行系统穿刺,影像学异常者行系统+靶向穿刺。比较两组前列腺癌(PCa)的检出率及并发症差异,分析两组按PSA、影像学分层PCa检出率的差异,比较靶向穿刺与系统穿刺癌检出率的差异,分析临床有意义前列腺癌(csPCa)的检出情况。结果:(1)PCa总检出率为44.0%(179/407),经直肠组与经会阴组PCa检出率比较差异无统计学意义[44.8%(130/290)vs.41.9%(49/117),P>0.05]。其中,PSA≤4 ng/mL、4 ng/mL20 ng/mL各水平分层中,两组PCa检出率比较差异无统计学意义(P>0.05)。两组中前列腺影像学异常者的PCa检出率均高于影像学正常者(P<0.05)。影像学异常者中,经直肠组与经会阴组PCa检出率比较差异无统计学意义(P>0.05)。(2)前列腺影像学异常者总的PCa检出率为57.5%(111/193),靶向穿刺PCa检出率为42.0%(81/193),系统穿刺为47.7%(92/193),两者比较差异无统计学意义(P>0.05),但靶向穿刺单针阳性率比系统穿刺更高(P<0.01)。同一途径下的靶向穿刺与系统穿刺PCa检出率比较差异无统计学意义(P>0.05)。两组中分别比较靶向穿刺、系统穿刺的PCa检出率,差异均无统计学意义(P>0.05)。(3)在所有患者中,经直肠途径csPCa检出率为36.9%(107/290),经会阴途径csPCa检出率为40.2%(47/117),两者比较差异无统计学意义(P>0.05)。靶向穿刺与系统穿刺在csPCa的检出率上比较差异无统计学意义。csPCa在诊断出的PCa患者中的占比,经会阴途径占比高于经直肠途径[95.9%(47/49)vs.82.3%(107/130),P<0.05]。(4)经直肠组总并发症发生率显著高于经会阴组[39.3%(114/290)vs.20.5%(24/117),P<0.01]。经直肠组发热、血便发生率比经会阴组更高,分别为[10.3%(30/290)vs.3.4%(4/117),P<0.05]、[14.1%(41/290)vs.1.7%(2/117),P<0.01],两组在血尿、下尿路症状、尿潴留、迷走反射发生率上比较差异均无统计学意义(P>0.05)。结论:超声引导下12+x针前列腺穿刺活检PCa检出率较好,影像学异常者靶向穿刺与系统穿刺PCa、csPCa检出率差异均无统计学意义,靶向穿刺单针阳性率较高。经直肠途径与经会阴途径在PCa、csPCa检出率比较差异无统计学意义,经会阴途径并发症更少。在诊断出的PCa中,经会阴途径可检出更多的csPCa。     

MRI combined with PSA density in detecting clinically significant prostate cancer in patients with PSA serum levels of 4∼10 ng/mL: Biparametric versus multiparametric MRI

PurposeTo compare the performance of biparametric magnetic resonance imaging (bpMRI) to that of multiparametric MRI (mpMRI) in combination with prostate-specific antigen density (PSAD) in detecting clinically significant prostate cancer (csPCa) in patients with PSA serum levels of 4∼10 ng/mL.Materials and methodsA total of 123 men (mean age, 66.3 ± 8.9 [SD]; range: 42–83 years) with PSA serum levels of 4∼10 ng/mL with suspected csPCa were included. All patients underwent mpMRI at 3 Tesla and transrectal ultrasound-guided prostate biopsy in their clinical workup and were followed-up for >1 year when no csPCa was found at initial biopsy. The mpMRI images were reinterpreted according to the Prostate Imaging Reporting and Data System (PI-RADS, v2.1) twice in two different sessions using either mpMRI sequences or bpMRI sequences. The patients were divided into 2 groups according to whether csPCa was detected. The PI-RADS (mpMRI or bpMRI) categories and PSAD were used in combination to detect csPCa. Receiver operating characteristic (ROC) curve and decision curve analyses were performed to compare the efficacy of the different models (mpMRI, bpMRI, PSAD, mpMRI + PSAD and bpMRI + PSAD).ResultsThirty-seven patients (30.1%, 37/123) had csPCa. ROC analysis showed that bpMRI (AUC = 0.884 [95% confidence interval (CI): 0.814–0.935]) outperformed mpMRI (AUC = 0.867 [95% CI: 0.794–0.921]) (P = 0.035) and that bpMRI and mpMRI performed better than PSAD (0.682 [95% CI: 0.592–0.763]) in detecting csPCa; bpMRI + PSAD (AUC = 0.907 [95% CI: 0.841–0.952]) performed similarly to mpMRI + PSAD (AUC = 0.896 [95% CI: 0.828–0.944]) (P = 0.151) and bpMRI (P = 0.224). The sensitivity and specificity were 81.1% (95% CI: 64.8–92.0%) and 88.4% (95% CI: 79.7–94.3%), respectively for bpMRI, and 83.8% (95% CI: 68.0–93.8%) and 80.2% (95% CI: 70.2–88.0%), respectively for mpMRI (P > 0.999 for sensitivity and P = 0.016 for specificity). Among the 5 decision models, the decision curve analysis showed that all models (except for PSAD) achieved a high net benefit.ConclusionIn patients with PSA serum levels of 4∼10 ng/mL, bpMRI and bpMRI combined with PSAD achieve better performance than mpMRI in detecting csPCa; bpMRI has a higher specificity than mpMRI, which could decrease unnecessary biopsy, and may serve as a potential alternative to mpMRI to optimize clinical workup.     

A magnetic resonance imaging-based nomogram for predicting clinically significant prostate cancer at radical prostatectomy

PurposeTo develop a nomogram incorporating clinical and multiparametric magnetic resonance imaging (mpMRI) parameters for the detection of clinically significant prostate cancer (csCaP) at radical prostatectomy (RP).Materials and MethodsWe retrospectively analyzed all consecutive patients who underwent robotic RP between 2016 and 2020. All patients underwent a 1.5-T mp-MRI according to the PI-RADS-v2 scoring system. RP specimens were examined with the whole-mount technique. csCaP definition: any tumor with a volume larger than 0.5 cm³ or with a Gleason score ≥7. Univariable logistic regression models explored the association between clinical and imaging data and the risk of csCaP. Significant variables (P < 0.05) were selected into multivariable regression models to identify independent predictors. A nomogram was designed to select the significant relevant predictors. The nomogram was internally validated in terms of discrimination and calibration. Receiver operating characteristics of the area under the curve was used to assess the discrimination ability of the nomogram. To assess the predictive performance of mpMRI, the accuracy of the mpMRI-based nomogram was compared with that excluding either PI-RADS score or mpMRI IL size.ResultsThe analysis involved 393 patients. The median age was 65(9) years. The median prostate specific antigen was 5.81(3.76) ng/ml. 363 had csCaP. PI-RADS v2 score of 4-5, prostate specific antigen density of 0.15 or more, and mpMRI index lesion (IL) size were significantly associated with csCaP in the multivariable regression analyses. Based on these variables, a diagnostic model was developed. The full model yielded an area under the curve of 0.77 (95%CI:0.75–0.80) which was significantly better than those excluding mpMRI findings (P = 0.02) Decision curve analysis showed a slight but significant net benefit associated with the use of the mp-MRI based nomograms compared with those excluding either PI-RADS score (Delta net benefit 0.0278) or mpMRI maximum IL size (Delta net benefit 0.0111).ConclusionsThe nomogram constructed in this study can assist urologists in assessing an individual's risk of csCaP at RP.