Prostate Cancer Diagnostic Pathway Research Articles

Prostate MRI Was Negative-What's Next?

The primary benefit of prostate MRI in the modern diagnostic pathway for prostate cancer is that many men with elevated serum PSA can safely avoid an immediate biopsy if the MRI is nonsuspicious. It is less clear, though, how these patients should be followed thereafter. Are they to be followed the same as the general population, or do they warrant more attention because of the risk of a cancer missed on MRI? In this issue, Pylväläinen and colleagues report on incidence of clinically significant prostate cancer (csPCa) and clinically insignificant PCa (ciPCa) among patients who were referred for prostate MRI for clinical suspicion of csPCa in Helsinki but had a nonsuspicious MRI (nMRI). Compared with the general population in Finland, patients who had nMRI were approximately 3.4 times more likely to be diagnosed with csPCa and 8.2 times more likely to be diagnosed with ciPCa. Balancing the competing risks of a missed csPCa versus overdiagnosis in patients after nMRI requires integration of MRI and other risk factors, especially age and PSA density. This integration may be facilitated by multivariable models and quantitative pathology and imaging. See related article by Pylväläinen et al., p. 749.

Outcomes of a Diagnostic Pathway for Prostate Cancer Based on Biparametric MRI and MRI-Targeted Biopsy Only in a Large Teaching Hospital.

Diagnostic pathways for prostate cancer (PCa) balance detection rates and burden. MRI impacts biopsy indication and strategy. A prospectively collected cohort database (N = 496) of men referred for elevated PSA and/or abnormal DRE was analyzed. All underwent biparametric MRI (3 Tesla scanner) and ERSPC prostate risk-calculator. Indication for biopsy was PIRADS ≥ 3 or risk-calculator ≥ 20%. Both targeted (cognitive-fusion) and systematic cores were combined. A hypothetical full-MRI-based pathway was retrospectively studied, omitting systematic biopsies in: (1) PIRADS 1-2 but risk-calculator ≥ 20%, (2) PIRADS ≥ 3, receiving targeted biopsy-cores only. Significant PCa (GG ≥ 2) was detected in 120 (24%) men. Omission of systematic cores in cases with PIRADS 1-2 but risk-calculator ≥ 20%, would result in 34% less biopsy indication, not-detecting 7% significant tumors. Omission of systematic cores in PIRADS ≥ 3, only performing targeted biopsies, would result in a decrease of 75% cores per procedure, not detecting 9% significant tumors. Diagnosis of insignificant PCa dropped by 52%. PCa undetected by targeted cores only, were ipsilateral to MRI-index lesions in 67%. A biparametric MRI-guided PCa diagnostic pathway would have missed one out of six cases with significant PCa, but would have considerably reduced the number of biopsy procedures, cores, and insignificant PCa. Further refinement or follow-up may identify initially undetected cases. Center-specific data on the performance of the diagnostic pathway is required.

The Impact of Prostate Volume on the Prostate Imaging and Reporting Data System (PI-RADS) in a Real-World Setting.

Multiparametric magnetic resonance imaging (mpMRI) has emerged as a new cornerstone in the diagnostic pathway of prostate cancer. However, mpMRI is not devoid of factors influencing its detection rate of clinically significant prostate cancer (csPCa). Amongst others, prostate volume has been demonstrated to influence the detection rates of csPCa. Particularly, increasing volume has been linked to a reduced cancer detection rate. However, information about the linkage between PI-RADS, prostate volume and detection rate is relatively sparse. Therefore, the current study aims to assess the association between prostate volume, PI-RADS score and detection rate of csP-Ca, representing daily practice and contemporary mpMRI expertise. Thus, 1039 consecutive patients with 1151 PI-RADS targets, who underwent mpMRI-guided prostate biopsy at our tertiary referral center, were included. Prior mpMRI had been assessed by a plethora of 111 radiology offices, including academic centers and private practices. mpMRI was not secondarily reviewed in house before biopsy. mpMRI-targeted biopsy was performed by a small group of a total of ten urologists, who had performed at least 100 previous biopsies. Using ROC analysis, we defined cut-off values of prostate volume for each PI-RADS score, where the detection rate drops significantly. For PI-RADS 4 lesions, we found a volume > 61.5 ccm significantly reduced the cancer detection rate (OR 0.24; 95% CI 0.16-0.38; p < 0.001). For PI-RADS 5 lesions, we found a volume > 51.5 ccm to significantly reduce the cancer detection rate (OR 0.39; 95% CI 0.25-0.62; p < 0.001). For PI-RADS 3 lesions, none of the evaluated clinical parameters had a significant impact on the detection rate of csPCa. In conclusion, we show that enlarged prostate volume represents a major limitation in the daily practice of mpMRI-targeted biopsy. This study is the first to define exact cut-off values of prostate volume to significantly impair the validity of PI-RADS assessed in a real-world setting. Therefore, the results of mpMRI-targeted biopsy should be interpreted carefully, especially in patients with prostate volumes above our defined thresholds.

Use of artificial intelligence in the detection of primary prostate cancer in multiparametric MRI with its clinical outcomes: a protocol for a systematic review and meta-analysis

IntroductionMultiparametric MRI (mpMRI) has transformed the prostate cancer diagnostic pathway, allowing for improved risk stratification and more targeted subsequent management. However, concerns exist over the interobserver variability of images and...

Implementation and yield of upfront genomic profiling in a clinical prostate cancer diagnostic pathway.

Implementation and yield of upfront genomic profiling in a clinical prostate cancer diagnostic pathway.

Prostate MRI and image quality: The radiologist's perspective

Multiparametric MRI (mpMRI) of the prostate plays an important role in the healthcare pathway of prostate cancer. The implementation of the guidelines resulted in an almost vertical increase in the number of prostate MRI examinations. High image quality is important in the diagnostic pathway of prostate cancer. Standardization of prostate MRI quality using objective and pre-defined criteria is of utmost importance.

Reliability of Multiparametric Magnetic Resonance Imaging in Patients with a Previous Negative Biopsy: Comparison with Biopsy-Naïve Patients in the Detection of Clinically Significant Prostate Cancer.

Background: Multiparametric magnetic resonance is an established imaging utilized in the diagnostic pathway of prostate cancer. The aim of this study is to evaluate the accuracy and reliability of multiparametric magnetic resonance imaging (mpMRI) in the detection of clinically significant prostate cancer, defined as Gleason Score ≥ 4 + 3 or a maximum cancer core length 6 mm or longer, in patients with a previous negative biopsy. Methods: The study was conducted as a retrospective observational study at the University of Naples "Federico II", Italy. Overall, 389 patients who underwent systematic and target prostate biopsy between January 2019 and July 2020 were involved and were divided into two groups: Group A, which included biopsy-naïve patients; Group B, which included re-biopsy patients. All mpMRI images were obtained using three Tesla instruments and were interpreted according to PIRADS (Prostate Imaging Reporting and Data System) version 2.0. Results: 327 patients were biopsy-naïve, while 62 belonged to the re-biopsy group. Both groups were comparable in terms of age, total PSA (prostate-specific antigen), and number of cores obtained at the biopsy. 2.2%, 8.8%, 36.1%, and 83.4% of, respectively, PIRADS 2, 3, 4, and 5 biopsy-naïve patients reported a clinically significant prostate cancer compared to 0%, 14.3%, 39%, and 66.6% of re-biopsy patients (p < 0.0001-p = 0.040). No difference was reported in terms of post-biopsy complications. Conclusions: mpMRI confirms its role as a reliable diagnostic tool prior to performing prostate biopsy in patients who underwent a previous negative biopsy, reporting a comparable detection rate of clinically significant prostate cancer.

MP55-15 IS MICROULTRASOUND A RELIABLE TOOL FOR PROSTATE CANCER DIAGNOSIS? RESULTS FROM A SINGLE-INSTITUTION COHORT OF OVER 1,000 MEN

You have accessJournal of UrologyCME1 Apr 2023MP55-15 IS MICROULTRASOUND A RELIABLE TOOL FOR PROSTATE CANCER DIAGNOSIS? RESULTS FROM A SINGLE-INSTITUTION COHORT OF OVER 1,000 MEN Nicola Frego, Fabio De Carne, Paola Arena, Vittorio Fasulo, Davide Maffei, Chiarelli Giuseppe, Edoardo Beatrici, Marco Paciotti, Pier Paolo Avolio, Alberto Saita, Rodolfo Hurle, Massimo Lazzeri, Paolo Casale, Nicolò Maria Buffi, and Giovanni Lughezzani Nicola FregoNicola Frego More articles by this author , Fabio De CarneFabio De Carne More articles by this author , Paola ArenaPaola Arena More articles by this author , Vittorio FasuloVittorio Fasulo More articles by this author , Davide MaffeiDavide Maffei More articles by this author , Chiarelli GiuseppeChiarelli Giuseppe More articles by this author , Edoardo BeatriciEdoardo Beatrici More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Pier Paolo AvolioPier Paolo Avolio More articles by this author , Alberto SaitaAlberto Saita More articles by this author , Rodolfo HurleRodolfo Hurle More articles by this author , Massimo LazzeriMassimo Lazzeri More articles by this author , Paolo CasalePaolo Casale More articles by this author , Nicolò Maria BuffiNicolò Maria Buffi More articles by this author , and Giovanni LughezzaniGiovanni Lughezzani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003308.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Microultrasound (mUS) is a new imaging modality that has been proposed as a possible alternative to mpMRI for the diagnosis of Prostate Cancer (PCa). We evaluated the diagnostic performance in the detection of PCa and mUS specific predictors of PCa. METHODS: Between September 2017 and November 2021, data from 1,004 consecutive men who underwent mUS at our tertiary center were prospectively collected. Prior to prostate biopsy, all patients performed a mUS evaluation and those with lesions suspicious for PCa underwent transrectal cognitive targeted biopsies (TBx). PRI-MUS grading system was used to assess the risk of PCa, and any lesion with a PRI-MUS ≥ 3 was considered suspicious. All mUS assessment were performed by 2 urologists with years of experience in US. Primary endpoint was to assess the diagnostic performance of mUS in PCa and csPCa detection. The secondary endpoint was to assess the mUS-derived characteristics associated with PCa and csPCa diagnosis. RESULTS: Median age was 66 years (IQR:60-72); median PSA was 7 (IQR:5-10); 283 (28%) had a positive DRE; median prostate volume was 50 cc (IQR:35-70); 257 (25.6%) had familiarity for PCa; 392 (30%) had previous prostate biopsies; 766 (76.3%) patients had positive mUS; 193 (19.2%) had>1 mUS lesion; out of 766 positive mUS, 10.5% were PRI-MUS 3, 45.2% PRI-MUS 4, and 20.5% PRI-MUS 5. MicroUS detected suspicious lesions in 448/527 (85%) PCa patients and in 325/366 (88.8%) csPCa patients. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the detection of PCa were 85%, 32.3%, 58.6% and 65.7%, respectively; and 88.8%, 23.1%, 73.7% and 46% for csPCa. Out of 448 positive mUS, 172 (38.4%) PCa cases were diagnosed with mUS TBx, of which 147 were csPCa. At multivariable regression model with PCa diagnosis as outcome, having a positive mUS was significantly associated with PCa diagnosis (OR:2.01, 95%CIs:1.28-3.16). In the model with csPCa as main outcome, positive mUS was no longer a significant predictor (OR:1.84, 95%CIs:0.83-4.12). PRIMUS 5 lesion was the only mUS factor associated with PCa diagnosis (OR:2.69, 95%CIs:1.05-6.9). Furthermore, we found a significant increase in the trend of PCa detection at mUS by both operators comparing the first quarter (12,5 months) of the study period and the last 3 quarters (ptrend=0.02 for operator 1; ptrend=0.01 for operator 2). CONCLUSIONS: Our results confirmed the role of mUS in the diagnostic pathway of PCa. Further randomized studies are needed to confirm the potential role of mUS in the diagnostic pathway of PCa. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e769 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicola Frego More articles by this author Fabio De Carne More articles by this author Paola Arena More articles by this author Vittorio Fasulo More articles by this author Davide Maffei More articles by this author Chiarelli Giuseppe More articles by this author Edoardo Beatrici More articles by this author Marco Paciotti More articles by this author Pier Paolo Avolio More articles by this author Alberto Saita More articles by this author Rodolfo Hurle More articles by this author Massimo Lazzeri More articles by this author Paolo Casale More articles by this author Nicolò Maria Buffi More articles by this author Giovanni Lughezzani More articles by this author Expand All Advertisement PDF downloadLoading ...

MP09-09 CORRELATION BETWEEN PROSTATE MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING AND HIGH-RESOLUTION MICRO-ULTRASOUND

You have accessJournal of UrologyCME1 Apr 2023MP09-09 CORRELATION BETWEEN PROSTATE MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING AND HIGH-RESOLUTION MICRO-ULTRASOUND Nicholas Pickersgill, M. Hassan Alkazemi, Joel Vetter, Adam Ostergar, Nimrod Barashi, Grant Henning, and Arjun Sivaraman Nicholas PickersgillNicholas Pickersgill More articles by this author , M. Hassan AlkazemiM. Hassan Alkazemi More articles by this author , Joel VetterJoel Vetter More articles by this author , Adam OstergarAdam Ostergar More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , Grant HenningGrant Henning More articles by this author , and Arjun SivaramanArjun Sivaraman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003224.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate multiparametric magnetic resonance imaging (pMRI) has emerged as a valuable tool in the diagnostic pathway for prostate cancer. The recent introduction of high-resolution micro-ultrasound (microUS) guided prostate biopsy aims to further improve the detection of clinically significant prostate cancer (CSCaP). The correlation between these two imaging modalities is poorly understood. We investigated correlation in lesion identification between microUS and pMRI. METHODS: We reviewed our prospectively maintained database of 200 consecutive patients who underwent transperineal microUS-guided biopsy with the ExactVu™platform (Exact Imaging, Markham, Canada) between February 2021 and April 2022. The Prostate Risk Identification using MicroUS (PRI-MUS) protocol was utilized to risk stratify prostate lesions, with PRI-MUS 3-5 defined as positive. pMRI lesions were classified according to PI-RADS version 2. Clinicopathologic outcomes were analyzed. Spearman correlation testing was computed to assess the relationship between PRI-MUS and PI-RADS. Patients with sufficient data for analysis were included. RESULTS: A total of 159 patients met inclusion criteria. Of these, 117 were biopsy-naïve, 19 had a prior negative biopsy and 20 were on active surveillance. Mean±standard deviation (SD) age was 66.6±7.7 years and PSA was 10.1±4.4 ng/mL. A total of 112 patients underwent multiparametric magnetic resonance imaging (mpMRI) prior to biopsy, of which 56 were found to have PIRADS 3-5 lesions. There was a weak positive correlation between PRI-MUS and PI-RADS (r=0.23, p=0.013) (Figure 1). CONCLUSIONS: This preliminary comparison between PRI-MUS and PI-RADS scoring demonstrates a weak positive correlation between the two modalities. This may be attributable to a significant number of patients with negative pMRI who were found to have PRI-MUS 3-5 lesions. Given the rising utilization of micro-US-guided prostate biopsy and widespread use of pMRI, further prospective studies are needed to compare their ability to detect clinically significant prostate cancer. Source of Funding: Midwest Stone Institute © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e107 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicholas Pickersgill More articles by this author M. Hassan Alkazemi More articles by this author Joel Vetter More articles by this author Adam Ostergar More articles by this author Nimrod Barashi More articles by this author Grant Henning More articles by this author Arjun Sivaraman More articles by this author Expand All Advertisement PDF downloadLoading ...

Can systematic biopsy be omitted from the prostate cancer diagnostic pathway?

Can systematic biopsy be omitted from the prostate cancer diagnostic pathway?

Abstract P067: Evaluating the risk of clinically significant prostate cancer in lesions detected on multiparametric MRI of the prostate

Abstract Introduction: Multiparametric Magnetic Resonance Imaging (mpMRI) is a valuable tool in the prostate cancer diagnostic pathway. mpMRI has a negative predictive value (NPV) of approximately 90% for detecting clinically significant prostate cancer (csPCa), defined as the presence of any Gleason Grade (GG) 4 or 5. Lesions detected on mpMRI are scored using the PIRADS scoring system from 1 to 5. PIRADS-3, 4 and 5 lesions are recommended for biopsy. The use of mpMRI to guide prostate biopsy has been shown to be superior to systematic biopsy alone for detecting early csPCa as small lesions can be identified and accurately targeted. We analysed the outcome of targeted biopsy of prostate lesions detected on mpMRI, and systematic biopsy when no lesions were detected, to determine the risk of csPCa based on mpMRI findings. Methods: Men attending our prostate diagnostic pathway were offered mpMRI before biopsy. The criteria for pre-biopsy mpMRI were any man suitable for radical surgery or radiotherapy, plus one or more of PSA &amp;gt; 3, palpable lesion on digital rectal examination, or family history of PCa in a first degree relative (father or brother). mpMRI was performed with a 1.5-Tesla magnet and included T2, DWI and DCE sequences. Men with PIRADS 3, 4, and 5 lesions were offered targeted biopsy with 2-4 biopsy cores per lesion, and men with no lesion on MRI were offered systematic prostate biopsy with 8-16 biopsy cores. Results: 546 targeted lesions were biopsied in 349 men. 159 lesions were PIRADS-3, 226 were PIRADS-4, and 161 were PIRADS-5. 141 men with negative mpMRI had systematic prostate biopsy. Of the PIRADS-3 lesions, 84% were benign, 5% had GG 3, 11% had GG 4 and none had GG 5. Of the PIRADS-4 lesions, 44% were benign, 12% had GG 3, 42% had GG 4, and 2% had GG 5. Of the PIRADS-5 lesions, 23% were benign, 2% had GG 3, 62% had GG 4, and 13% had GG 5. Of the men with no lesion on mpMRI, 9% had GG 3, 4% had GG 4, and none had GG 5. Conclusion: Most men with negative mpMRI or PIRADS-3 lesions have benign tissue on biopsy or early PCa and are unlikely to have csPCa. A decision for biopsy vs PSA monitoring in these men should weigh the risks and benefits of biopsy and should be a shared decision taking into consideration individual risk factors for PCa, age and co-morbidities. Citation Format: Chidi N. Molokwu, Christos Gkikas, Nicola Lee, Joanna Lesniak-Buzon, Faisal Ali, Harry Bardgett. Evaluating the risk of clinically significant prostate cancer in lesions detected on multiparametric MRI of the prostate. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P067.

Multiparametric Magnetic Resonance Imaging of the Prostate and Prostate-specific Membrane Positron Emission Tomography Prior to Prostate Biopsy (MP4 Study)

BackgroundProstate-specific membrane antigen (PSMA) positron emission tomography/computerised tomography (PET/CT) is increasingly being utilised in the diagnostic pathway for prostate cancer (PCa). Recent publications have suggested that this might help identify those who can avoid biopsy. ObjectiveThe primary objective of this study was to determine whether PET magnetic resonance imaging (MRI) fusion could negate the need to biopsy prior to prostatectomy in a selected population of men. Design, setting, and participantMultiparametric MRI (mpMRI) for PCa is our standard of care prior to prostate biopsy. Biopsy-naïve men with one or more Prostate Imaging Reporting and Data System (PI-RADS) 4 or 5 lesions ≥10 mm on mpMRI were invited to undergo PSMA PET/CT prior to biopsy. Following ethics approval, 60 men were recruited between September 2020 and March 2021. The key exclusion criteria included a previous history of PCa and previous prostate surgery or biopsy. Outcome measurements and statistical analysisA positive PET MRI fusion scan was defined as “consistent with” as per the Memorial Sloan Kettering Cancer Center lexicon of certainty, and concordance with biopsy results was analysed. Clinically significant PCa (csPCa) was defined as grade group (GG) ≥2 on pathology. A chi-square analysis was performed with statistical significance defined at p < 0.05. Results and limitationsA total of 71 mpMRI lesions were positive on 61 (86%) PET MRI fusion scans. Fifty-nine of 61 lesions biopsied confirmed csPCa in 54 (92%). Of five of 59 lesions for which either biopsy was negative or low-grade cancer was found, three had rebiopsy of which two were confirmed to have csPCa corroborating with PET MRI fusion and one was reconfirmed to have GG1 only. For the remaining two, both had another lesion elsewhere in the gland confirming csPCa, and hence rebiopsy was not performed. Ultimately, 56 of 59 (95%) lesions with a positive PET MRI fusion scan were confirmed to have csPCa. All GG ≥3 cancers had a positive PET MRI fusion scan. ConclusionsThis prospective study of PET MRI fusion assessment of men with PI-RADS 4 or 5 lesion ≥10 mm on mpMRI confirms that the majority of men (95%) with a positive PET MRI fusion scan will have csPCa. This supports recently published retrospective data suggesting that selected men might avoid prostate biopsy prior to radical prostatectomy. Patient summaryIn this research, we have confirmed that prostate-specific membrane antigen positron emission tomography/computerised tomography in combination with magnetic resonance imaging could have an important role in enabling a diagnosis of prostate cancer. Using the combination of these scans, we could confidently predict the presence of aggressive prostate cancer in some men for which treatment is warranted. This means that there are some men who could possibility proceed directly to having prostate cancer surgery without the need for a confirmatory prostate biopsy.

The rapid assessment for prostate imaging and diagnosis (RAPID) prostate cancer diagnostic pathway.

To report outcomes within the Rapid Assessment for Prostate Imaging and Diagnosis (RAPID) diagnostic pathway, introduced to reduce patient and healthcare burdens and standardize delivery of pre-biopsy multiparametric magnetic resonance imaging (MRI) and transperineal biopsy. A total of 2130 patients from three centres who completed the RAPID pathway (3 April 2017 to 31 March 2020) were consecutively entered as a prospective registry. These patients were also compared to a pre-RAPID cohort of 2435 patients. Patients on the RAPID pathway with an MRI score 4 or 5 and those with PSA density ≥0.12 and an MRI score 3 were advised to undergo a biopsy. Primary outcomes were rates of biopsy and cancer detection. Secondary outcomes included comparison of transperineal biopsy techniques, patient acceptability and changes in time to diagnosis before and after the introduction of RAPID. The median patient age and PSA level were 66 years and 6.6 ng/mL, respectively. Biopsy could be omitted in 43% of patients (920/2130). A further 7.9% of patients (168/2130) declined a recommendation for biopsy. The percentage of biopsies avoided among sites varied (45% vs 36% vs 51%; P < 0.001). In all, 30% (221/742) had a local anaesthetic (grid and stepper) transperineal biopsy. Clinically significant cancer detection (any Gleason score ≥3 + 4) was 26% (560/2130) and detection of Gleason score 3 + 3 alone constituted 5.8% (124/2130); detection of Gleason score 3 + 3 did not significantly vary among sites (P = 0.7). Among participants who received a transperineal targeted biopsy, there was no difference in cancer detection rates among local anaesthetic, sedation and general anaesthetic groups. In the 2435 patients from the pre-RAPID cohor, time to diagnosis was 32.1 days (95% confidence interval [CI] 29.3-34.9) compared to 15.9 days (95% CI 12.9-34.9) in the RAPID group. A total of 141 consecutive patient satisfaction surveys indicated a high satisfaction rate with the pathway; 50% indicated a preference for having all tests on a single day. The RAPID prostate cancer diagnostic pathway allows 43% of men to avoid a biopsy while preserving good detection of clinically significant cancers and low detection of insignificant cancers, although there were some centre-level variations.

Survey on prostate MRI reading and interpretation among urology residents in Italy, Brazil and the UK: a cry for help.

Prostate MRI is an essential tool in the diagnostic pathway of prostate cancer and its accurate reading helps decision to biopsy. The aim of this study was to assess the Urology residents' level of confidence in reading and interpreting prostate MRI, their interest in new learning opportunities and whether prostate MRI training should be part of the urology core curriculum during residency. A 23-item survey has been created and distributed via Web to an international cohort of Urology residents over a 3-month period. Surveys obtained from Countries representing >10% total distribution of responses were analyzed. A total of 304 complete surveys were obtained from Urology residents, with a geographical prevalence from Europe (59.54%, 181/304) and South America (29.28%, 89/304). Only 17-20% of residents reported having received formal prostate MRI training during residency. Overall, <20% residents expressed to feel confident in reading and interpreting prostate MRI. As a result, >90% Urology trainees stated they would be willing to receive a formal training and would be interested in new learning opportunities in MRI reading and interpretation during residency, independently of their year of training. Despite UK Urology trainees showed to have a higher availability of MRI resources and MRI-based biopsies compared to the other countries, they still expressed concerns in regard to not feeling confident with MRI reading and interpretation and requested a formal training. This survey highlights the need for major learning opportunities and a formal training in prostate MRI reading and interpretation during urology residency.

SC6 - Has the introduction of mpMRI in the diagnostic pathway of prostate cancer led to improved oncological outcomes after radical prostatectomy? Result from a large single-institutional series

SC6 - Has the introduction of mpMRI in the diagnostic pathway of prostate cancer led to improved oncological outcomes after radical prostatectomy? Result from a large single-institutional series

Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway.

Multiparametric MRI of the prostate is now recommended as the initial diagnostic test for men presenting with suspected prostate cancer, with a negative MRI enabling safe avoidance of biopsy and a positive result enabling MRI-directed sampling of lesions. The diagnostic pathway consists of several steps, from initial patient presentation and preparation to performing and interpreting MRI, communicating the imaging findings, outlining the prostate and intra-prostatic target lesions, performing the biopsy and assessing the cores. Each component of this pathway requires experienced clinicians, optimized equipment, good inter-disciplinary communication between specialists, and standardized workflows in order to achieve the expected outcomes. Assessment of quality and mitigation measures are essential for the success of the MRI-directed prostate cancer diagnostic pathway. Quality assurance processes including Prostate Imaging-Reporting and Data System, template biopsy, and pathology guidelines help to minimize variation and ensure optimization of the diagnostic pathway. Quality control systems including the Prostate Imaging Quality scoring system, patient-level outcomes (such as Prostate Imaging-Reporting and Data System MRI score assignment and cancer detection rates), multidisciplinary meeting review and audits might also be used to provide consistency of outcomes and ensure that all the benefits of the MRI-directed pathway are achieved.

Prebiopsy 68Ga-PSMA PET imaging: can we improve the current diagnostic pathway for prostate cancer?

Prebiopsy 68Ga-PSMA PET imaging: can we improve the current diagnostic pathway for prostate cancer?

Cost-Effectiveness Analysis of Stockholm 3 Testing Compared to PSA as the Primary Blood Test in the Prostate Cancer Diagnostic Pathway: A Decision Tree Approach.

ObjectiveThis study evaluated the cost effectiveness of using Stockholm 3 (STHLM3) testing compared to the prostate-specific antigen (PSA) test in the diagnostic pathway for prostate cancer.MethodsWe created a decision tree model for PSA (current standard) and STHLM3 (new alternative). Cost effectiveness was evaluated in a hypothetical cohort of male individuals aged 50–69 years. The study applied a Danish hospital perspective with a time frame restricted to the prostate cancer diagnostic pathway, beginning with the initial PSA/STHLM3 test, and ending with biopsy and histopathological diagnosis. Estimated values from the decision-analytical model were used to calculate the incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses were conducted to test the robustness of the base-case analysis.ResultsThe model-based analysis revealed that STHLM3 testing was more effective than the PSA, but also more costly, with an incremental cost-effectiveness ratio of €511.7 (95% credible interval, 359.9–674.3) for each additional correctly classified individual. In the deterministic sensitivity analysis, variations in the cost of STHLM3 had the greatest influence on the incremental cost-effectiveness ratio. In the probabilistic sensitivity analysis, all iterations were positioned in the north-east quadrant of the incremental cost-effectiveness scatterplot. At a willingness to pay of €700 for an additional correctly classified individual, STHLM3 had a 100% probability of being cost effective.ConclusionsCompared to the PSA test as the initial testing modality in the prostate cancer diagnostic workup, STHLM3 testing showed improved incremental effectiveness, however, at additional costs. The results were sensitive to the cost of the STHLM3 test; therefore, a lower cost of the STHLM3 test would improve its cost effectiveness compared with PSA tests.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40258-022-00741-0.

Assessment of the Utility of Multiparametric Magnetic Resonance Imaging for Initial Detection of Prostate Cancer

BACKGROUND: An accurate diagnosis is essential for the effective treatment of prostate cancer (PCa) and for the patients’ well-being. AIM: Thе main purpose of this study was to assess the utility of multiparametric magnetic resonance imaging (mp-MRI) for initial detection of PCa among the Bulgarian population of men with prostate diseases. MATERIALS AND METHODS: Fifty-three patients, aged 44 to 82 years, were evaluated for clinically significant PCa. Assessment methods included prostate-specific antigen (PSA) serum levels, transrectal ultrasonography (TRUS), GE Discovery 3T MRI, and 12-core TRUS biopsy. RESULTS: mp-MRI showed 83.20% concordance with TRUS biopsy: sensitivity of 91.43% (76.90–98.20), specificity of 75.00% (34.90–96.80), positive predictive values 94.10% (82.80–98.20) and negative predictive values 66.70% (38.70–86.40). Of the patients classified in prostate imaging–reporting and data system (PI-RADS) levels 4 and 5, 94.12% had positive TRUS biopsy, as well as 44.40% of PI-RADS had level 3. Irrespective of the patients’ age and PSA, PI-RADS was found to be a significant predictor of a positive TRUS biopsy (p = 0.009). PSA serum levels showed a low concordance with TRUS biopsy (area under the curve = 0.539; 95% confidence interval [CI]: 0.363–0.712) and a low, although significant, correlation with PI-RADS (rs = 0.416; 95% CI: 0.164–0.617). CONCLUSION: According to our findings, mp-MRI and TRUS biopsy have a high level of concordance for the initial detection of PCa. The incorporation of mp-MRI into the diagnostic pathway for PCa can significantly reduce the number of incorrect diagnoses based on PSA serum levels and/or suspicious physical and digital examinations.

Diagnostic value of the abnormal digital rectal examination in the modern MRI-based prostate cancer diagnostic pathway.

Currently the National Institute for Health and Care Excellence (NICE) recommends an abnormal digital rectal examination (DRE) as a standalone referral criterion for suspected prostate cancer. Unlike referrals for a raised prostate-specific antigen (PSA) which are triaged directly to magnetic resonance imaging (MRI), an abnormal DRE requires re-examination in a secondary clinic first. Here, we investigated the ongoing value of the abnormal DRE as a referral criterion. This study is a retrospective review of patients referred to secondary care for suspected prostate cancer based on an abnormal DRE over a 15-month period at a single UK hospital (n = 158). Age, PSA, primary and repeat DRE findings and eventual diagnosis were collated. A concurrent raised PSA was present in 65/158 (41%). Concordance between primary and secondary care DRE was only 72/158 (46%). The overall and significant cancer detection rate was 26/158 (16%) and 22/158 (14%), respectively. Among men with a concurrent raised PSA, 19/65 (29%) had significant cancer found, whereas with an abnormal primary care DRE and normal PSA (n = 93), only 3/93 (3%) had a significant cancer. Mandating a PSA before referral for an abnormal DRE would have redirected 65/158 (41%) of men to MRI first, negating the need for a repeat DRE (p < 0.0001). This finding was recapitulated in a second prospective validation cohort (n = 30) with 9/30 (30%) redirected to MRI first. This is one of the first studies to investigate the value of the DRE in contemporary practice. We propose that PSA is used to triage men with an abnormal DRE to MRI without needing a repeat DRE. If the PSA is normal, the diagnostic yield is low but may still warrant a repeat DRE to assess the need for further investigations. Additional multicentre studies are required to further validate our findings. 4.