Diagnosis Of csPCa Research Articles

MP53-15 MRI-DIRECTED BIOPSY FOR PRIMARY DETECTION OF PROSTATE CANCER: MRI IN-BORE VS MRI-TRANSRECTAL ULTRASOUND FUSION-TARGETED TECHNIQUES

You have accessJournal of UrologyCME1 May 2022MP53-15 MRI-DIRECTED BIOPSY FOR PRIMARY DETECTION OF PROSTATE CANCER: MRI IN-BORE VS MRI-TRANSRECTAL ULTRASOUND FUSION-TARGETED TECHNIQUES Francesco Del Giudice, Maurizio Del Monte, Stefano Cipollari, Martina Pecoraro, Marco Bicchetti, Emanuele Messina, Ailin Dehghanpour, Alessandro Sciarra, Ettore De Berardinis, Benjamin I. Chung, Carlo Catalano, and Valeria Panebianco Francesco Del GiudiceFrancesco Del Giudice More articles by this author , Maurizio Del MonteMaurizio Del Monte More articles by this author , Stefano CipollariStefano Cipollari More articles by this author , Martina PecoraroMartina Pecoraro More articles by this author , Marco BicchettiMarco Bicchetti More articles by this author , Emanuele MessinaEmanuele Messina More articles by this author , Ailin DehghanpourAilin Dehghanpour More articles by this author , Alessandro SciarraAlessandro Sciarra More articles by this author , Ettore De BerardinisEttore De Berardinis More articles by this author , Benjamin I. ChungBenjamin I. Chung More articles by this author , Carlo CatalanoCarlo Catalano More articles by this author , and Valeria PanebiancoValeria Panebianco More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002628.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aimed to compare the detection rates of overall prostate cancer (PCa) and clinically significant PCa (csPCa) and the median percentage of cancer per biopsy core between MRI-guided In-bore and MRI-TRUS fusion-targeted biopsy (TBx). METHODS: In this retrospective study, 223 patients who underwent prostate multiparametric MRI (mpMRI) and subsequent MR-directed biopsy were included. A multivariable logistic regression model was developed to assess whether the biopsy technique (MRI-TRUS or MRI In-Bore) was an independent predictor for both the outcome of PCa and csPCa diagnosis. All the regression models were adjusted for age (<70 vs. >/=70 years), PSA (ng/dl), PSA density (<0.15 vs. >/=0.15), pre-Bx PI-RADS score (3 vs 4–5) as well as lesion volume (ml), location (transitional/anterior vs peripheral) and level (base, mid-gland, apex). According to the available literature and to the cohort quantitative descriptive distribution, after having assumed a relevant threshold of neoplastic median per-core percentage ≥50%, the same regression model was implemented to test the ability of one technique over the other to better characterize the overall sampled tumor tissue within the biopsy cores. RESULTS: Per-patient PCa and csPCa detection rates were 140/223 (62.8%) and 97/223 (43.5%), respectively. PCa-DR was 73/117 (62.4%) and 67/106 (63.2%) for MRI-TRUS and MRI In-Bore TBx (p = 0.9), while csPCa detection rate reached 50/117 (42.7%) and 47/106 (44.3%), respectively (p=0.81). The median per-patient percentage of malignant tissue within biopsy cores was 50% (IQR: 27–65%) for PCa and 60% (IQR: 35–68%) for csPCa, with a statistically significant difference between the techniques. At multivariable logistic regression analyzing only index lesions, the implementation of MRI-TRUS or In-Bore TBx was not independently associated with an increased ability of one technique over the other for both PCa and csPCa detection (ORPCa: 0.67, 95% CI: 0.43–1.51 and ORcsPCa: 0.72, 0.37–1.54). Differently, when analyzing the diagnostic outcome for the positive biopsy sampling threshold >50% within the overall biopsy core length, MRI In-Bore TBx was independently associated with more than threefold ability to reach the outcome in the case of PCa but not for csPCa (ORPCa: 3.26, 95% CI: 1.37–7.12, and ORcsPCa: 2.17, 95% CI: 0.82–5.34). CONCLUSIONS: No statistically significant difference in the detection rate of MRI In-bore and MRI-TRUS fusion TBx was found. MRI In-bore TBx showed higher per-core percentage of malignant cells. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e901 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesco Del Giudice More articles by this author Maurizio Del Monte More articles by this author Stefano Cipollari More articles by this author Martina Pecoraro More articles by this author Marco Bicchetti More articles by this author Emanuele Messina More articles by this author Ailin Dehghanpour More articles by this author Alessandro Sciarra More articles by this author Ettore De Berardinis More articles by this author Benjamin I. Chung More articles by this author Carlo Catalano More articles by this author Valeria Panebianco More articles by this author Expand All Advertisement PDF DownloadLoading ...

Multiparametric transrectal ultrasound for the diagnosis of peripheral zone prostate cancer and clinically significant prostate cancer: novel scoring systems

BackgroundTo evaluate the diagnostic performance of multiparametric transrectal ultrasound (TRUS) and to design diagnostic scoring systems based on four modes of TRUS to predict peripheral zone prostate cancer (PCa) and clinically significant prostate cancer (csPCa).MethodsA development cohort involved 124 nodules from 116 patients, and a validation cohort involved 72 nodules from 67 patients. Predictors for PCa and csPCa were extracted to construct PCa and csPCa models based on regression analysis of the development cohort. An external validation was performed to assess the performance of models using area under the curve (AUC). Then, PCa and csPCa diagnostic scoring systems were established to predict PCa and csPCa. The diagnostic accuracy was compared between PCa and csPCa scores and PI-RADS V2, using receiver operating characteristics (ROC) and decision curve analysis (DCA).ResultsRegression models were established as follows: PCa = − 8.284 + 4.674 × Margin + 1.707 × Adler grade + 3.072 × Enhancement patterns + 2.544 × SR; csPCa = − 7.201 + 2.680 × Margin + 2.583 × Enhancement patterns + 2.194 × SR. The PCa score ranged from 0 to 6 points, and the csPCa score ranged from 0 to 3 points. A PCa score of 5 or higher and a csPCa score of 3 had the greatest diagnostic performance. In the validation cohort, the AUC for the PCa score and PI-RADS V2 in diagnosing PCa were 0.879 (95% confidence interval [CI] 0.790–0.967) and 0.873 (95%CI 0.778–0.969). For the diagnosis of csPCa, the AUC for the csPCa score and PI-RADS V2 were 0.806 (95%CI 0.700–0.912) and 0.829 (95%CI 0.727–0.931).ConclusionsThe multiparametric TRUS diagnostic scoring systems permitted better identifications of peripheral zone PCa and csPCa, and their performances were comparable to that of PI-RADS V2.

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.

We 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). A 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. Median 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. After 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 value of magnetic resonance imaging-ultrasound fusion targeted biopsies for clinical decision-making among patients with previously negative transrectal ultrasound biopsy and persistent prostate-specific antigen elevation.

Targeted biopsy approaches have been shown to increase the detection of clinically significant prostate cancer (csPCa) within index prostate lesions. We report our initial experience with magnetic resonance imaging-ultrasound fusion biopsies (MRI-TB) in a population of men who had a previously negative transrectal ultrasound (TRUS) biopsy, persistent prostate-specific antigen (PSA) elevation, and ongoing suspicion of PCa. Patients were followed prospectively to assess for changes in clinical management following targeted biopsy. We prospectively followed the first 122 patients undergoing MRI-TB at our institution. All men had clinical suspicion of PCa, prior negative TRUS biopsies, and persistent PSA elevation. A total of 177 index lesions were identified on multiparametric MRI and reviewed using the Prostate Imaging Reporting and Data System (PI-RADS) v2 scoring system. Lesions classified as PI-RADS ≥3 received targeted biopsy. Biopsy-naive patients and those on active surveillance were excluded. The primary outcome was detection rate of csPCa, defined as International Society of Urological Pathology (ISUP) Grade Group (GG) ≥2. Multivariate analysis was used to determine predictors of csPCa on fusion biopsy. Prior to fusion biopsy, patients had a mean of 17.9±8.6 negative core biopsies per patient and a median PSA of 9.5 (standard deviation [SD] 6.2) ng/nl. MRI-TB resulted in diagnosis of csPCa in 42/122 (34.4%) patients. Clinically significant PCa was found in eight (13.1%), 14 (21.9%), and 25 (48.1%) of PI-RADS 3, 4, and 5 lesions, respectively. The location of csPCa was within the peripheral zone (55.3%), transitional zone (40.4%), and central zone (8.5%). Clinical outcomes of patients with newly diagnosed csPCa show 4.8%, 57.1%, and 38.1% receiving active surveillance, radiation treatment, and radical prostatectomy, respectively. Predictors for csPCa were presence of PI-RADS 5 lesions, age, length of time from MRI to biopsy, and smaller prostate volumes. MRI-TB yields high detection rates for csPCa in men with elusive PSA elevation and frequently guides a change in clinical management. Clinical decision-making based on MRI findings and PI-RADS lesion scores are best informed by an understanding of institutional reporting patterns.

MRI Based Radiomics Compared With the PI-RADS V2.1 in the Prediction of Clinically Significant Prostate Cancer: Biparametric vs Multiparametric MRI.

PurposeTo compare the performance of radiomics to that of the Prostate Imaging Reporting and Data System (PI-RADS) v2.1 scoring system in the detection of clinically significant prostate cancer (csPCa) based on biparametric magnetic resonance imaging (bpMRI) vs. multiparametric MRI (mpMRI).MethodsA total of 204 patients with pathological results were enrolled between January 2018 and December 2019, with 142 patients in the training cohort and 62 patients in the testing cohort. The radiomics model was compared with the PI-RADS v2.1 for the diagnosis of csPCa based on bpMRI and mpMRI by using receiver operating characteristic (ROC) curve analysis.ResultsThe radiomics model based on bpMRI and mpMRI signatures showed high predictive efficiency but with no significant differences (AUC = 0.975 vs 0.981, p=0.687 in the training cohort, and 0.953 vs 0.968, p=0.287 in the testing cohort, respectively). In addition, the radiomics model outperformed the PI-RADS v2.1 in the diagnosis of csPCa regardless of whether bpMRI (AUC = 0.975 vs. 0.871, p= 0.030 for the training cohort and AUC = 0.953 vs. 0.853, P = 0.024 for the testing cohort) or mpMRI (AUC = 0.981 vs. 0.880, p= 0.030 for the training cohort and AUC = 0.968 vs. 0.863, P = 0.016 for the testing cohort) was incorporated.ConclusionsOur study suggests the performance of bpMRI- and mpMRI-based radiomics models show no significant difference, which indicates that omitting DCE imaging in radiomics can simplify the process of analysis. Adding radiomics to PI-RADS v2.1 may improve the performance to predict csPCa.

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

PurposeBi-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. MethodsOne 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. ResultsIn 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). ConclusionSynthetic MRI with relaxometry maps shows promise for contrast media-free evaluation of csPCa.

Prostate Health Index Density Outperforms Prostate Health Index in Clinically Significant Prostate Cancer Detection

BackgroundProstate-specific antigen (PSA) is considered neither sensitive nor specific for prostate cancer (PCa). We aimed to compare total PSA (tPSA), percentage of free PSA (%fPSA), the PSA density (PSAD), Prostate Health Index (PHI), and the PHI density (PHID) to see which one could best predict clinically significant prostate cancer (csPCa): a potentially lethal disease.MethodsA total of 412 men with PSA of 2–20 ng/mL were prospectively included. Serum biomarkers for PCa was collected before transrectal ultrasound guided prostate biopsy. PHI was calculated by the formula: (p2PSA/fPSA) x √tPSA. PHID was calculated as PHI divided by prostate volume measured by transrectal ultrasound.ResultsOf the 412 men, 134 (32.5%) and 94(22.8%) were diagnosed with PCa and csPCa, respectively. We used the area under the receiver operating characteristic curve (AUC) and decision curve analyses (DCA) to compare the performance of PSA related parameters, PHI and PHID in diagnosing csPCa. AUC for tPSA, %fPSA, %p2PSA, PSAD, PHI and PHID were 0.56、0.63、0.76、0.74、0.77 and 0.82 respectively for csPCa detection. In the univariate analysis, the prostate volume, tPSA, %fPSA, %p2PSA, PHI, PSAD, and PHID were all significantly associated with csPCa, and PHID was the most important predictor (OR 1.41, 95% CI 1.15–1.72). Besides, The AUC of PHID was significantly larger than PHI in csPCa diagnosis (p=0.004). At 90% sensitivity, PHID had the highest specificity (54.1%) for csPCa and could reduce the most unnecessary biopsies (43.7%) and miss the fewest csPCa (8.5%) when PHID ≥ 0.67. In addition to AUC, DCA re-confirmed the clinical benefit of PHID over all PSA-related parameters and PHI in csPCa diagnosis. The PHID cut-off value was positively correlated with the csPCa ratio in the PHID risk table, which is useful for evaluating csPCa risk in a clinical setting.ConclusionThe PHID is an excellent predictor of csPCa. The PHID risk table may be used in standard clinical practice to pre-select men at the highest risk of harboring csPCa.

MP26-08 MAGNETIC RESONANCE IMAGING-TARGETED BIOPSY FOR PRIMARY DETECTION OF PROSTATE CANCER: MRI IN-BORE VERSUS MRI-TRUS FUSION TECHNIQUE PERFORMED BY THE SAME OPERATORS' TEAM

You have accessJournal of UrologyProstate Cancer: Detection & Screening II (MP26)1 Sep 2021MP26-08 MAGNETIC RESONANCE IMAGING-TARGETED BIOPSY FOR PRIMARY DETECTION OF PROSTATE CANCER: MRI IN-BORE VERSUS MRI-TRUS FUSION TECHNIQUE PERFORMED BY THE SAME OPERATORS' TEAM Martina Pecoraro, Francesco Del Giudice, Riccardo Campa, Maurizio Del Monte, Emanuele Messina, Marco Bicchetti, Alessandro Sciarra, Carlo Catalano, and Valeria Panebianco Martina PecoraroMartina Pecoraro More articles by this author , Francesco Del GiudiceFrancesco Del Giudice More articles by this author , Riccardo CampaRiccardo Campa More articles by this author , Maurizio Del MonteMaurizio Del Monte More articles by this author , Emanuele MessinaEmanuele Messina More articles by this author , Marco BicchettiMarco Bicchetti More articles by this author , Alessandro SciarraAlessandro Sciarra More articles by this author , Carlo CatalanoCarlo Catalano More articles by this author , and Valeria PanebiancoValeria Panebianco More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002023.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: (I) To compare the difference in the detection of overall PCa and csPCa between MRI-guided In-bore and MRI-TRUS targeted biopsy (TBx), performed by the same operators’ team. (II) To compare the two MR-directed biopsy (MRDB) techniques in terms of median percentage of cancer per biopsy core. METHODS: Retrospective single-center study. 263 patients enrolled. Prostate mpMRI was performed for the entire cohort. MRDB was performed when a PI-RADS score ≥3 was reported. For PCa and csPCa detection rate (DR), 2x2 contingency tables were tested via the Pearson’s chi-squared to explore the variance of the outcome distribution. The % of positive malignant cores was tested with a two-tailed Mann-Withney test.A multivariable logistic regression model was developed to assess the relative influence of MRI-TRUS vs. In-Bore TBx for both the outcome of PCa and csPCa diagnosis. Moreover, according to available literature and to the cohort quantitative descriptive distribution, after having assumed, as per secondary outcome, a relevant threshold of neoplastic median per-core percentage ≥50%, we implemented the same regression model to test the ability of one technique over the other to better characterize the overall sampled tumor tissue within the biopsy cores. RESULTS: Overall, per-patient PCa and csPCa detection rate was 140/223 (62.8%) and 97/223 (43.5%), respectively. PCa-DR was 73/117 (62.4%) and 67/106 (63.2%) for MRI-TRUS and MRI In-Bore TBx (p=0.9), while csPCa detection rate reached 50/117 (42.7%) and 47/106 (44.3%), respectively (p=0.81). The median overall per-patient percentage of malignant tissue within the total biopsy cores was 50% (IQR: 27–65%) for PCa and 60% (IQR: 35–68%) for csPCa, with a significant discrepancy between the two techniques. MRI In-Bore TBx was independently associated with more than 3-fold ability to reach the outcome in the case of PCa but not for csPCa (ORPCa: 3.34, 95%CI: 1.46–7.6, and ORcsPCa: 2.21, 95%CI: 0.86–5.7 respectively). CONCLUSIONS: No statistically significant difference was detected in terms of cancer DR comparing MRI In-Bore and TRUS TBx. MRI-TB showed highest per-core malignant cells percentage and lower mean volume of the targets compared to MRI-TRUS TBx. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e465-e465 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Martina Pecoraro More articles by this author Francesco Del Giudice More articles by this author Riccardo Campa More articles by this author Maurizio Del Monte More articles by this author Emanuele Messina More articles by this author Marco Bicchetti More articles by this author Alessandro Sciarra More articles by this author Carlo Catalano More articles by this author Valeria Panebianco More articles by this author Expand All Advertisement Loading ...

Significance of the prostate central gland and total gland volume ratio in the diagnosis of prostate cancer patients in the prostate specific antigen grey zone

ObjectiveTo explore the significance of the prostate central gland to total gland volume ratio (PVc/PV) in the diagnosis of prostate cancer (PCa) in patients with prostate specific antigen (PSA) levels in the grey zone (4–10 ng/ml).MethodsThis retrospective study enrolled patients that had undergone prostate biopsy. The volume of the prostate and the central prostate gland were measured. The differences in PSA, the ratio of free to total PSA (f/tPSA), PSA density (PSAD) and PVc/PV between the PCa and non-PCa groups were compared. Receiver operating characteristic curve analysis for PCa and clinically significant PCa (csPCa) diagnosis were calculated according to PSA (reference), f/tPSA, PSAD and PVc/PV.ResultsThis study enrolled 136 patients. There was no significant difference in PSA and f/tPSA between the PCa and non-PCa groups, while there were significant differences in PSAD and PVc/PV. The area under the curve values of PVc/PV for PCa or csPCa diagnosis were 0.876 and 0.933, respectively; and for PSAD, they were 0.705 and 0.790, respectively. These were significantly different compared with the PSA curve, whereas f/tPSA showed no significant difference from the PSA curve.ConclusionPVc/PV could be a predictor of PCa when PSA is between 4–10 ng/ml.

Diagnostic performance of MRI/TRUS fusion-guided biopsies vs. systematic prostate biopsies in biopsy-naïve, previous negative biopsy patients and men undergoing active surveillance.

We aimed to assess the detection rate of overall PCa and csPCa, and the clinical impact of MRI/TRUS fusion targeted biopsy (FUSION-TB) compared to TRUS guided systematic biopsy (SB) in patients with different biopsy settings. Three hundred and five patients were submitted to FUSION-TB, divided into three groups: biopsy naïve patients, previous negative biopsies and patients under active surveillance (AS). All patients had a single suspicious index lesion at mpMRI. Within these groups, we enrolled men underwent both to FUSION-TB and SB in the same session. Overall detection rate of PCa and csPCa for the two biopsy methods were compared separately between the three groups of patients. No differences were observed between the three groups concerning clinical and radiological characteristics. We found no differences in terms of overall PCa detection (66% vs. 63.8%, P=0.617) and csPCa detection (56.4% vs. 51.1%; P=0.225) concerning biopsy naïve patients. In patients previously submitted to a negative biopsy, FUSION-TB showed higher detection rate of csPCa compared to SB alone (41,3% vs. 27% respectively, P=0.038). In patients under AS, no differences were observed between FUSION-TB and SB in terms of overall PCa (50% vs. 73.1%) and csPCa (30.8% vs. 26.9%, respectively; P=0.705) detection. Our results suggest that in men with previously negative biopsy, FUSION-TB showed significantly higher diagnostic performance for clinically significant PCa as compared to SB. Combination of FUSION-TB and SB should be recommended in AS population to offer higher chance of csPCa diagnosis.

End-to-end prostate cancer detection in bpMRI via 3D CNNs: Effects of attention mechanisms, clinical priori and decoupled false positive reduction

We present a multi-stage 3D computer-aided detection and diagnosis (CAD) model22Source code and algorithm have been made publicly available at: https://github.com/DIAGNijmegen/prostateMR_3D-CAD-csPCa https://grand-challenge.org/algorithms/prostate-mri-cad-cspca for automated localization of clinically significant prostate cancer (csPCa) in bi-parametric MR imaging (bpMRI). Deep attention mechanisms drive its detection network, targeting salient structures and highly discriminative feature dimensions across multiple resolutions. Its goal is to accurately identify csPCa lesions from indolent cancer and the wide range of benign pathology that can afflict the prostate gland. Simultaneously, a decoupled residual classifier is used to achieve consistent false positive reduction, without sacrificing high sensitivity or computational efficiency. In order to guide model generalization with domain-specific clinical knowledge, a probabilistic anatomical prior is used to encode the spatial prevalence and zonal distinction of csPCa. Using a large dataset of 1950 prostate bpMRI paired with radiologically-estimated annotations, we hypothesize that such CNN-based models can be trained to detect biopsy-confirmed malignancies in an independent cohort.For 486 institutional testing scans, the 3D CAD system achieves 83.69±5.22% and 93.19±2.96% detection sensitivity at 0.50 and 1.46 false positive(s) per patient, respectively, with 0.882±0.030 AUROC in patient-based diagnosis –significantly outperforming four state-of-the-art baseline architectures (U-SEResNet, UNet++, nnU-Net, Attention U-Net) from recent literature. For 296 external biopsy-confirmed testing scans, the ensembled CAD system shares moderate agreement with a consensus of expert radiologists (76.69%; kappa = 0.51±0.04) and independent pathologists (81.08%; kappa = 0.56±0.06); demonstrating strong generalization to histologically-confirmed csPCa diagnosis.

Evaluation of Weighted Diffusion Subtraction for Detection of Clinically Significant Prostate Cancer.

Diffusion-weighted imaging (DWI) is an important method for clinically significant prostate cancer (csPCa) diagnosis; however, the Prostate Imaging-Reporting and Data System (PI-RADS) requires the subjective assessment of "markedly hypointense or not" on apparent diffusion coefficient (ADC) map. We hypothesize that weighted diffusion subtraction (WDS) images, created by weighted subtraction of high and low b-value DWIs, might better show areas of ADC values below a set threshold, thus decreasing the subjectivity of the assessment. To evaluate the diagnostic ability of WDS for csPCa by comparing scores based on WDS images (DWI/WDS) with those based on PI-RADS DWI (DWI/ADC). Retrospective. Eighty-six PCa patients. 3.0 T; DWI. Four readers assessed the probability of csPCa in lesions (overall, in the peripheral zone [PZ] and transitional zone [TZ]) using 5-point DWI/ADC and DWI/WDS scores. Prostatectomy specimens were the reference standard. ADC values and contrast between csPCa and normal prostate tissue on ADC maps and WDS images were calculated with reference to the pathological map. Diagnostic ability was evaluated by Jackknife alternative free-response receiver-operating characteristic curve. Figure of merit (FOM), sensitivity, and positive predictive value (PPV) between the DWI/ADC and DWI/WDS scores were compared using paired t-test. Inter-reader agreement was analyzed using κ statistics, and the significance probability was calculated using the Z statistic. Wilcoxon signed-rank test was used to compare contrast between csPCa and normal prostate tissue on ADC maps and WDS images. A P value <0.05 was considered statistically significant. FOM and sensitivity of the DWI/WDS scores were significantly better than those of the DWI/ADC scores overall, in the PZ and TZ (FOM: overall, 0.715 vs. 0.783; PZ, 0.756 vs. 0.815; TZ, 0.653 vs. 0.738. Sensitivity: overall, 0.512 vs. 0.607; PZ, 0.485 vs. 0.573; TZ, 0.636 vs. 0.761). For PPV, a statistically significant difference was observed overall (0.727 vs. 0.777). The κ value of DWI/WDS score was significantly higher than that of DWI/ADC score overall and in the PZ (overall, 0.614 vs. 0.792; PZ, 0.609 vs. 0.797). Contrast was significantly higher overall in the PZ and TZ in WDS images (median, 1.26, 1.19, and 1.61) than in ADC maps (0.46, 0.47, and 0.41). WDS images performed better than ADC maps in the diagnosis of csPCa and in inter-reader agreement of the diagnosis. 4 Technical Efficacy Stage: 2.

Pharmacokinetic modeling of dynamic contrast-enhanced (DCE)-MRI in PI-RADS category 3 peripheral zone lesions: preliminary study evaluating DCE-MRI as an imaging biomarker for detection of clinically significant prostate cancers.

To determine if pharmacokinetic modeling of DCE-MRI can diagnose CS-PCa in PI-RADS category 3 PZ lesions with subjective negative DCE-MRI. In the present IRB approved, bi-institutional, retrospective, case-control study, we identified 73 men with 73 PZ PI-RADS version 2.1 category 3 lesions with MRI-directed-TRUS-guided targeted biopsy yielding: 12 PZ CS-PCa (ISUP Grade Group 2; N = 9, ISUP 3; N = 3), 27 ISUP 1 PCa and 34 benign lesions. An expert blinded radiologist segmented lesions on ADC and DCE images; segmentations were overlayed onto pharmacokinetic DCE-MRI maps. Mean values were compared between groups using univariate analysis. Diagnostic accuracy was assessed by ROC. There were no differences in age, PSA, PSAD or clinical stage between groups (p = 0.265-0.645). Mean and 10th percentile ADC did not differ comparing CS-PCa to ISUP 1 PCa and benign lesions (p = 0.376 and 0.598) but was lower comparing ISUP ≥ 1 PCa to benign lesions (p < 0.001). Mean Ktrans (p = 0.003), Ve (p = 0.003) but not Kep (p = 0.387) were higher in CS-PCa compared to ISUP 1 PCa and benign lesions. There were no differences in DCE-MRI metrics comparing ISUP ≥ 1 PCa and benign lesions (p > 0.05). AUC for diagnosis of CS-PCa using Ktrans and Ve were: 0.69 (95% CI 0.52-0.87) and 0.69 (0.49-0.88). Pharmacokinetic modeling of DCE-MRI parameters in PI-RADS category 3 lesions with subjectively negative DCE-MRI show significant differences comparing CS-PCa to ISUP 1 PCa and benign lesions, in this study outperforming ADC. Studies are required to further evaluate these parameters to determine which patients should undergo targeted biopsy for PI-RADS 3 lesions.

Techniques and Outcomes of MRI-TRUS Fusion Prostate Biopsy.

The goal of this study is to review recent findings and evaluate the utility of MRI transrectal ultrasound fusion biopsy (FBx) techniques and discuss future directions. FBx detects significantly higher rates of clinically significant prostate cancer (csPCa) than ultrasound-guided systematic prostate biopsy (SBx), particularly in repeat biopsy settings. FBx has also been shown to detect significantly lower rates of clinically insignificant prostate cancer. In addition, a dedicated prostate MRI can assist in more accurately predicting the Gleason score and provide further information regarding the index cancer location, prostate volume, and clinical stage. The ability to accurately evaluate specific lesions is vital to both focal therapy and active surveillance, for treatment selection, planning, and adequate follow-up. FBx has been demonstrated in multiple high-quality studies to have improved performance in diagnosis of csPCa compared to SBx. The combination of FBx with novel technologies including radiomics, prostate-specific membrane antigen positron emission tomography (PSMA PET), and high-resolution micro-ultrasound may have the potential to further enhance this performance.

The Utility of Combined Target and Systematic Prostate Biopsies in the Diagnosis of Clinically Significant Prostate Cancer Using Prostate Imaging Reporting and Data System Version 2 Based on Biparametric Magnetic Resonance Imaging.

This study aimed to determine the predictive value of the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) based on biparametric magnetic resonance imaging (bpMRI) with combined target biopsy (TBx) and systematic biopsy (SBx) in patients with suspicion of having clinically significant prostate cancer (csPCa). In this retrospective study, we reviewed the clinical and pathological records of 184 consecutive patients who underwent bpMRI before prostate biopsy. We focused on patients with PI-RADS v2 scores ≥ 3. MRI was performed using a 3-Tesla clinical scanner with a 32-channel phased-array receiver coil. PI-RADS v2 was used to describe bpMRI findings based on T2-weighted imaging and diffusion-weighted imaging scores. The primary endpoint was the diagnostic accuracy rate of PI-RADS v2 based on bpMRI for patients with prostate cancer (PCa) who underwent combined TBx and SBx. A total of 104 patients were enrolled in this study. Combined TBx and SBx was significantly superior to either method alone for PCa detection in patients with suspicious lesions according to PI-RADS v2. TBx and SBx detected concordant csPCa in only 24.1% of the patients. In addition, the rate of increase in the Gleason score was similar between SBx (41.5%) and TBx (34.1%). The diagnostic accuracy of bpMRI is comparable to that of standard multiparametric MRI for the detection of csPCa. Moreover, combined TBx and SBx may be optimal for the accurate determination of csPCa diagnosis, the International Society of Urological Pathology grade, and risk classification.

Performance of Prostate Imaging Reporting and Data System Version 2.1 for Diagnosis of Prostate Cancer: A Systematic Review and Meta-Analysis.

The Prostate Imaging Reporting and Data System (PI-RADS) was introduced in 2012 and updated to version 2.1 (v2.1) in early 2019 to improve diagnostic performance and interreader reliability. To evaluate the diagnostic performance of PI-RADS v2.1 in comparison with v2. A systematic review and meta-analysis of the literature was performed using MEDLINE, EMBASE, and Cochrane databases to identify studies evaluating the diagnostic performance of PI-RADS v2.1 for diagnosing clinically significant prostate cancer (csPCa). Systematic review and meta-analysis. One thousand two hundred forty-eight patients with 1406 lesions from 10 eligible articles. Conventional MR sequences at 1.5 T and 3 T. Two reviewers independently identified and reviewed the original articles reporting diagnostic performance of PI-RADS v2.1. Meta-analytic summary sensitivity and specificity were calculated using a bivariate random effects model. Meta-analytic sensitivity and specificity between PI-RADS v2 and v2.1 were compared. The pooled sensitivity and specificity of PI-RADS v2.1 were 87% (95% confidence intervals, 82-91%) and 74% (63-82%), respectively. In five studies available for a head-to-head comparison between PI-RADS v2.1 and v2, there were no significant differences in either sensitivity (90% [86-94%] vs. 88% [83-93%], respectively) or specificity (76% [59-93%] vs. 61% [39-83%], respectively; P=0.37). The sensitivity and specificity were 81% (73-87%) and 82% (68-91%), respectively, for a PI-RADS score cutoff of ≥4, and 94% (88-97%) and 56% (35-97%) for ≥3. Regarding the zonal location, the sensitivity and specificity for the transitional zone only were 90% (84-96%) and 76% (62-90%) respectively, whereas for the whole gland they were 85% (79-91%) and 71% (57-85%). PI-RADS v2.1 demonstrated good overall performance for the diagnosis of csPCa. PI-RADS v2.1 tended to show higher specificity than v2, but the difference lacked statistical significance. 3 TECHNICAL EFFICACY STAGE: 3.

Prevalence of Prostate Cancer in PI-RADS Version 2.1 Transition Zone Atypical Nodules Upgraded by Abnormal DWI: Correlation With MRI-Directed TRUS-Guided Targeted Biopsy.

BACKGROUND. In PI-RADS version 2.1 (v2.1), atypical transition zone (TZ) nodules (homogeneous circumscribed nodules without full encapsulation) assigned category 2 can be upgraded to category 3 when showing markedly restricted diffusion. The prevalence of prostate cancer (PCa) in DWI-upgraded atypical nodules is unknown. OBJECTIVE. The purpose of this study was to evaluate the prevalence of PCa in DWI-upgraded TZ atypical nodules and compare PCa diagnosis rate with that for conventional score 3 TZ nodules. METHODS. We retrospectively identified 104 consecutive cases of men who underwent MRI-directed transrectal ultrasound-guided targeted biopsy of 109 TZ category 3 or lower nodules performed between January 2015 and July 2018. Three radiologists who were blinded to the scores independently rescored lesions using PI-RADS v2.1. Agreement was assessed by Cohen kappa score. Consensus diagnosis was established by a second-round joint review. The number of TZ atypical nodules with or without DWI-upgraded and conventional score 3 TZ nodules were recorded and compared with targeted biopsy results including any PCa or clinically significant PCa (csPCa, defined as International Society of Urological Pathology [ISUP] grade group ≥ 2) using chi-square analysis. RESULTS. There were 95 PI-RADS v2.1 category 3 (55 conventional T2-weighted MRI score 3 and 40 DWI-upgraded atypical nodules) and 14 category 2 or 1 nodules at consensus review with patient mean age of 64.8 ± 8.4 (SD) years, PSA of 10.6 ± 7.2 ng/mL, and nodule size of 15.1 ± 5.5 mm. Interobserver agreement ranged from slight to substantial for radiologists 1 and 2 (κ = 0.329), radiologists 1 and 3 (κ = 0.548), and radiologists 2 and 3 (κ = 0.652). From the 40 upgraded atypical nodules, 27.5% (11/40) had PCa and 7.5% (3/40) had csPCa (8 ISUP grade 1, 2 ISUP grade 2, 1 ISUP grade 3), compared with 43.6% (24/55) PCa and 20.0% (11/55) csPCa (13 ISUP grade 1, 6 ISUP grade 2, 3 ISUP grade 3, 2 ISUP grade 4) diagnosed in conventional T2-weighted score 3 nodules (p = .09 for csPCA and p = .11 for PCa). PCa was not diagnosed in any atypical nodule that was not upgraded on DWI. CONCLUSION. The prevalence of PCa in DWI-upgraded TZ atypical nodules was low (≈ 28% for any PCa and ≈ 8% for csPCa) and compared favorably to csPCa diagnosis rates in conventional TZ score 3 nodules. CLINICAL IMPACT. This study validates the DWI upgrade rule introduced in PI-RADS v2.1 for atypical nodules, which showed significant prostate cancer detection rates at targeted biopsy similar to those of conventional T2-weighted MRI TZ score 3 nodules.

Diagnostic Yield of Incremental Biopsy Cores and Second Lesion Sampling for In-Gantry MRI-Guided Prostate Biopsy.

BACKGROUND. In-gantry MRI-guided biopsy (MRGB) of the prostate has been shown to be more accurate than other targeted prostate biopsy methods. However, the optimal number of cores to obtain during in-gantry MRGB remains undetermined. OBJECTIVE. The purpose of this study was to assess the diagnostic yield of obtaining an incremental number of cores from the primary lesion and of second lesion sampling during in-gantry MRGB of the prostate. METHODS. This retrospective study included 128 men with 163 prostate lesions who underwent in-gantry MRGB between 2016 and 2019. The men had a total of 163 lesions sampled with two or more cores, 121 lesions sampled with three or more cores, and 52 lesions sampled with four or more cores. A total of 40 men underwent sampling of a second lesion. Upgrade on a given core was defined as a greater International Society of Urological Pathology (ISUP) grade group (GG) relative to the previously obtained cores. Clinically significant prostate cancer (csPCa) was defined as ISUP GG 2 or greater. RESULTS. The frequency of any upgrade was 12.9% (21/163) on core 2 versus 10.7% (13/121) on core 3 (p = .29 relative to core 2) and 1.9% (1/52) on core 4 (p = .03 relative to core 3). The frequency of upgrade to csPCa was 7.4% (12/163) on core 2 versus 4.1% (5/121) on core 3 (p = .13 relative to core 2) and 0% (0/52) on core 4 (p = .07 relative to core 3). The frequency of upgrade on core 2 was higher for anterior lesions (p < .001) and lesions with a higher PI-RADS score (p = .007); the frequency of upgrade on core 3 was higher for apical lesions (p = .01) and lesions with a higher PI-RADS score (p = .01). Sampling of a second lesion resulted in an upgrade in a single patient (2.5%; 1/40); both lesions were PI-RADS category 4 and showed csPCa. CONCLUSION. When performing in-gantry MRGB of the prostate, obtaining three cores from the primary lesion is warranted to optimize csPCa diagnosis. Obtaining a fourth core from the primary lesion or sampling a second lesion has very low yield in upgrading cancer diagnoses. CLINICAL IMPACT. To reduce patient discomfort and procedure times, operators may refrain from obtaining more than three cores or second lesion sampling.

Equivocal PI-RADS Three Lesions on Prostate Magnetic Resonance Imaging: Risk Stratification Strategies to Avoid MRI-Targeted Biopsies.

We aimed to investigate the relation between largest lesion diameter, prostate-specific antigen density (PSA-D), age, and the detection of clinically significant prostate cancer (csPCa) using first-time targeted biopsy (TBx) in men with Prostate Imaging—Reporting and Data System (PI-RADS) 3 index lesions. A total of 292 men (2013–2019) from two referral centers were included. A multivariable logistic regression analysis was performed. The discrimination and clinical utility of the built model was assessed by the area under the receiver operation curve (AUC) and decision curve analysis, respectively. A higher PSA-D and higher age were significantly related to a higher risk of detecting csPCa, while the largest index lesion diameter was not. The discrimination of the model was 0.80 (95% CI 0.73–0.87). When compared to a biopsy-all strategy, decision curve analysis showed a higher net benefit at threshold probabilities of ≥2%. Accepting a missing ≤5% of csPCa diagnoses, a risk-based approach would result in 34% of TBx sessions and 23% of low-risk PCa diagnoses being avoided. In men with PI-RADS 3 index lesions scheduled for first-time TBx, the balance between the number of TBx sessions, the detection of low-risk PCa, and the detection of csPCa does not warrant a biopsy-all strategy. To minimize the risk of missing the diagnosis of csPCa but acknowledging the need of avoiding unnecessary TBx sessions and overdiagnosis, a risk-based approach is advisable.

Impact of the Number of Cores on the Prostate Cancer Detection Rate in Men Undergoing in-Bore Magnetic Resonance Imaging-Guided Targeted Biopsies.

To determine the incremental detection rate of clinically significant prostate cancer (csPCa) provided by sequential cores during in-bore magnetic resonance imaging (MRI)-guided prostate biopsies. Single-center, retrospective interpretation of prospectively acquired data in men without previous diagnosis of csPCa who underwent in-bore MRI-guided prostate biopsy between May 2017 and December 2019. Endpoints included detection of csPCa (grade group [GG] ≥ 2) and rate of GG upgrade provided by additional cores. Descriptive statistics presented as mean and standard deviation for the continuous variables, and frequency and percentage for the categorical variables. Four hundred and forty-three men with 747 lesions met eligibility criteria. Clinically significant prostate cancer was detected in 43.1% (322/747) of the biopsied lesions and GG 2 PCa or greater was identified by the first core in 78.3% (252/322) of them. On a per-core basis, cores 2, 3, 4, and 5 found new csPCa in 6% (42/744), 4% (26/719), 1% (2/137), and 0% (0/11) of the cases. Core biopsy 2, 3, 4, and 5 resulted in GG upgrade in 12% (91/744), 7% (49/719), 7% (9/137), and 0% (0/11) of the lesions, respectively. Each additional core was associated with a mean increase of 5 minutes in the duration of the biopsy. In men undergoing in-bore MRI-guided prostate biopsies, 3 targeted cores per lesion provide an optimal trade-off between detection of clinically significant tumors and biopsy duration.