Prostate Cancer Diagnostic Pathway Research Articles

A sustainable and expedited ‘One‐Stop’ prostate cancer diagnostic pathway to reduce environmental impact and enhance accessibility

AbstractObjectiveTo assess the carbon footprint, accessibility, and diagnostic performance of an expedited ‘One‐Stop’ prostate cancer (PCa) diagnostic pathway.Materials and methodsA total of 1083 consecutive patients undergoing magnetic resonance imaging (MRI) followed by transrectal ultrasound fusion‐guided prostate biopsy (PBx) were identified from a prospective database. The patients were divided according to the diagnostic pathway: One‐Stop, with MRI and same‐day PBx (3 hours apart), or Standard, with MRI followed by a second visit for PBx. Socioeconomic status was evaluated by the Distressed Communities Index (DCI) and the carbon footprint by the United States (U.S.) Environmental Protection Agency Greenhouse Gases Equivalencies Calculator.ResultsOverall, 260 patients underwent the One‐Stop and 823 the Standard pathway. The One‐Stop patients lived farther from the hospital (163 vs. 23 km; p < 0.001), had lower socioeconomic status with DCI scores of 49 versus 30 (p < 0.001), and were more likely to be Latinos (21% vs. 13%, p < 0.001) compared to the Standard patients, respectively. The One‐Stop saved 69 575 km in round trips, over 16 tons of travel‐related CO2 emissions, and $8214 U.S. dollars. For patients with Prostate Imaging Reporting & Data System (PIRADS) 3–5, the clinically significant PCa detection (53% vs. 50%, p = 0.55) was similar for the One‐Stop and Standard pathways, respectively.ConclusionsThe One‐Stop PCa diagnostic pathway reduces carbon footprint, distance travelled, and patient‐level cost while maintaining clinical outcomes comparable to the Standard pathway. It facilitates access to tertiary‐level care for minorities and underserved populations.

Early economic evaluation of magnetic resonance imaging for prostate cancer detection in primary care.

To explore the potential impacts of incorporating prebiopsy magnetic resonance imaging into primary care as a triage test within the prostate cancer diagnostic pathway. Decision analytic modelling with decision trees was utilised for this early economic evaluation. A conceptual model was developed reflecting the common primary care routes to diagnosis for prostate cancer: opportunistic, asymptomatic prostate-specific antigen (PSA) screening or symptomatic presentation. The use of multiparametric MRI (mpMRI) or biparametric MRI (bpMRI) as a primary care triage test following an elevated PSA result was evaluated. A health system perspective was adopted with a time horizon of 12 months. Health effects were expressed in terms of utilities drawn from the literature. The primary outcome was prostate cancer diagnosis. Evidence used to inform the model was drawn from published primary studies, systematic reviews, and secondary analyses of primary and secondary care datasets. Base case analysis showed that the PSA pathway was dominated by both mpMRI- and bpMRI-based pathways for patients undergoing opportunistic screening and symptomatic assessment. bpMRI pathways had greater improvement in cost and utility than mpMRI pathways in both clinical scenarios. Significantly more MRI scans would be performed using the modelled approach (66 626 scans vs. 37 456 scans per 100 000 patients per annum), with fewer subsequent urgent suspected cancer referrals for both mpMRI (38% reduction for screening and symptomatic patients) and bpMRI (72% reduction for screening; 71% for symptomatic) pathways, and a small increase in number of missed cancer diagnoses. Deterministic sensitivity analyses, varying each parameter to its upper and lower 95% confidence intervals, showed no significant change in the dominance of the MRI-based prostate cancer diagnostic pathways. Using prostate MRI as a second-level triage test for suspected prostate cancer in primary care could reduce health service costs without a detrimental effect on patient utility.

A clinician survey on the current practices within the prostate cancer diagnostic pathway in the United Kingdom

A clinician survey on the current practices within the prostate cancer diagnostic pathway in the United Kingdom

Optimising the use of the prostate- specific antigen blood test in asymptomatic men for early prostate cancer detection in primary care: report from a UK clinical consensus.

Screening is not recommended for prostate cancer in the UK. Asymptomatic men aged ≥50 years can request a prostate-specific antigen (PSA) test following counselling on potential harms and benefits. There are areas of clinical uncertainty among GPs, resulting in the content and quality of counselling varying. To produce a consensus that can influence guidelines for UK primary care on the optimal use of the PSA test in asymptomatic men for early prostate cancer detection. Prostate Cancer UK facilitated a RAND/UCLA consensus. Statements covering five topics were developed with a subgroup of experts. A panel of 15 experts in prostate cancer scored (round one) statements on a scale of one (strongly disagree) to nine (strongly agree). Panellists met to discuss statements before rescoring (round two). A lived experience panel of seven men scored a subset of statements with outcomes fed into the main panel. Of the initial 94 statements reviewed by the expert panel, a final 48/85 (56%) achieved consensus. In the absence of screening, there was consensus on proactive approaches to initiate discussions about the PSA test with men who were at higher-than-average risk. Improvements in the prostate cancer diagnostic pathway may have reduced some of the harms associated with PSA testing; however, several areas of uncertainty remain in relation to screening, including optimal PSA thresholds for referral and intervals for retesting. There is consensus on proactive approaches to testing in higher-than-average risk groups. This should prompt a review of current guidelines.

Artificial intelligence and radiologists in prostate cancer detection on MRI (PI-CAI): an international, paired, non-inferiority, confirmatory study

Artificial intelligence (AI) systems can potentially aid the diagnostic pathway of prostate cancer by alleviating the increasing workload, preventing overdiagnosis, and reducing the dependence on experienced radiologists. We aimed to investigate the performance of AI systems at detecting clinically significant prostate cancer on MRI in comparison with radiologists using the Prostate Imaging-Reporting and Data System version 2.1 (PI-RADS 2.1) and the standard of care in multidisciplinary routine practice at scale. In this international, paired, non-inferiority, confirmatory study, we trained and externally validated an AI system (developed within an international consortium) for detecting Gleason grade group 2 or greater cancers using a retrospective cohort of 10 207 MRI examinations from 9129 patients. Of these examinations, 9207 cases from three centres (11 sites) based in the Netherlands were used for training and tuning, and 1000 cases from four centres (12 sites) based in the Netherlands and Norway were used for testing. In parallel, we facilitated a multireader, multicase observer study with 62 radiologists (45 centres in 20 countries; median 7 [IQR 5-10] years of experience in reading prostate MRI) using PI-RADS (2.1) on 400 paired MRI examinations from the testing cohort. Primary endpoints were the sensitivity, specificity, and the area under the receiver operating characteristic curve (AUROC) of the AI system in comparison with that of all readers using PI-RADS (2.1) and in comparison with that of the historical radiology readings made during multidisciplinary routine practice (ie, the standard of care with the aid of patient history and peer consultation). Histopathology and at least 3 years (median 5 [IQR 4-6] years) of follow-up were used to establish the reference standard. The statistical analysis plan was prespecified with a primary hypothesis of non-inferiority (considering a margin of 0·05) and a secondary hypothesis of superiority towards the AI system, if non-inferiority was confirmed. This study was registered at ClinicalTrials.gov, NCT05489341. Of the 10 207 examinations included from Jan 1, 2012, through Dec 31, 2021, 2440 cases had histologically confirmed Gleason grade group 2 or greater prostate cancer. In the subset of 400 testing cases in which the AI system was compared with the radiologists participating in the reader study, the AI system showed a statistically superior and non-inferior AUROC of 0·91 (95% CI 0·87-0·94; p<0·0001), in comparison to the pool of 62 radiologists with an AUROC of 0·86 (0·83-0·89), with a lower boundary of the two-sided 95% Wald CI for the difference in AUROC of 0·02. At the mean PI-RADS 3 or greater operating point of all readers, the AI system detected 6·8% more cases with Gleason grade group 2 or greater cancers at the same specificity (57·7%, 95% CI 51·6-63·3), or 50·4% fewer false-positive results and 20·0% fewer cases with Gleason grade group 1 cancers at the same sensitivity (89·4%, 95% CI 85·3-92·9). In all 1000 testing cases where the AI system was compared with the radiology readings made during multidisciplinary practice, non-inferiority was not confirmed, as the AI system showed lower specificity (68·9% [95% CI 65·3-72·4] vs 69·0% [65·5-72·5]) at the same sensitivity (96·1%, 94·0-98·2) as the PI-RADS 3 or greater operating point. The lower boundary of the two-sided 95% Wald CI for the difference in specificity (-0·04) was greater than the non-inferiority margin (-0·05) and a p value below the significance threshold was reached (p<0·001). An AI system was superior to radiologists using PI-RADS (2.1), on average, at detecting clinically significant prostate cancer and comparable to the standard of care. Such a system shows the potential to be a supportive tool within a primary diagnostic setting, with several associated benefits for patients and radiologists. Prospective validation is needed to test clinical applicability of this system. Health~Holland and EU Horizon 2020.

Assessing the efficacy of clinical triage in the prostate cancer best practice pathway

Objective: The Prostate Cancer UK timed prostate cancer diagnostic pathway is a new UK pathway to deliver a diagnosis within 28 days for patients with suspected prostate cancer. We aim to review our experience of implementing this pathway, in particular the success of clinical triage. Subjects/patients (or materials) and methods: We reviewed consecutive referrals to the prostate cancer best timed pathway from September 2019 to September 2020. Patients were triaged either straight to test multiparametric magnetic resonance imaging (mpMRI) or straight to outpatient clinic. Inappropriate triage was defined as either: patients referred straight to test mpMRI who were diagnosed with prostate cancer and managed with watchful waiting or androgen deprivation therapy (ADT) or patients who were referred straight to clinic who subsequently had an mpMRI and underwent radical treatment. Results: A total of 154/155 (99.6%) of patients were appropriately triaged in the straight to mpMRI group. A total of 124/132 (94.0%) of patients were appropriately triaged in the straight to clinic group (patients who required review to ascertain if mpMRI was appropriate and then received radical treatment). Conclusion: The implementation of a consultant supervised triage process has been successful in avoiding unnecessary mpMRIs or unnecessary clinic appointments before a patient received a diagnosis or reassuring test. We advise that outcomes are audited regularly to ensure the effective use of resources. Level of evidence: 2C

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.