MRI-targeted Biopsy Research Articles

Comparative Evaluation of Detection Rates for Clinically Significant Prostate Cancer Using MRI‐Targeted Biopsy Alone Versus in Combination With Systematic Biopsies: Development of a Risk‐Stratification Scoring System

ABSTRACTObjectivesTo compare the detection rates for clinically significant prostate cancer (csPCa; grade group 2 or higher disease) using MRI‐targeted biopsy (MRI‐TB) versus systematic biopsy (SB) or their combination, and identify risk factors for detecting csPCa in MRI‐TB with systematic transrectal (TR)/transperineal (TP) biopsies (sTR/TP‐bx) and MRI‐TB with sTP‐bx.MethodsWe retrospectively analyzed 216 patients who underwent MRI‐TB with SB at our hospital between September 2020 and December 2023 and compared clinical characteristics for patients with and without prostate cancer.ResultscsPCa was detected in 132 (61.1%) patients by MRI‐TB with sTR/TP‐bx, in 121 (56.0%) patients using MRI‐TB with sTP‐bx, and in 101 (46.8%) patients using MRI‐TB. Older age, higher PSA density (PSAD), smaller prostate volume, region of interest in the peripheral zone, higher Prostate Imaging‐Reporting and Data System (PI‐RADS), and administration of dutasteride were more common in csPCa cases. A scoring system was constructed based on odds ratios for PSAD, PI‐RADS ≥ 4, and administration of dutasteride; accordingly, the detection rate of csPCa was 20.3% (14/69) in the low‐risk group (RG) and 95.5% (42/44) in high RG for MRI‐TB with sTR/TP‐bx, and 16.7% (12/72) in the low RG and 97.8% (45/46) in high RG for MRI‐TB with sTP‐Bx.ConclusionsThe addition of SB increased the detection rate of csPCa compared with MRI‐TB alone. PSAD, PI‐RADS ≥ 4, and administration of dutasteride significantly affect the detection of csPCa using MRI‐TB with SB and can be used for deciding whether to perform a biopsy or include sTR‐bx with MRI‐TB.

Predicting cancer detection rates from multiparametric prostate MRI

Introduction: Although the Prostate Imaging-Reporting and Data System (PI-RADS) categorization represents the standard method for assessing the risk of prostate cancer using prostate magnetic resonance imaging (MRI), there exists wide variation in cancer detection rates (CDRs) in real-world practice. We therefore evaluated the association of clinical and radiographic features with CDRs and developed a predictive model to improve clinical management. Methods: We identified men aged 18–89 years with elevated prostate-specific antigen (PSA) or on active surveillance for prostate cancer who underwent MRI-ultrasound (US) fusion biopsy or in-bore MRI-targeted biopsy. The associations of features with the per-lesion CDR (Gleason 6–10) and clinically significant (cs) CDR (Gleason 7–10) were examined using logistic regression, and results were operationalized into a predictive model. Results: Targeted biopsy was performed for 347 lesions in 281 patients. Overall, the CDR was 49.0% and the csCDR was 28.0%. On multivariable analysis, increasing PI-RADS category, no prior prostate biopsies, smaller prostate size, and increasing PSA density were independently associated with higher CDR, while 0–1 prior prostate biopsies, and a solitary PI-RADS 3–5 lesion were associated with higher csCDR. A predictive model provided a greater net benefit than a strategy of performing biopsy in all PI-RADS 3–5 lesions across a wide range of threshold probabilities. Conclusions: Several clinical and radiographic features are independently associated with the risk of prostate cancer in men undergoing MRI-targeted biopsy. A predictive model based on these features can improve clinical decisions regarding biopsy compared to the conventional strategy of performing biopsy for all PI-RADS 3–5 lesions.

Identifying the best candidate for focal therapy: a comprehensive review.

Despite the evidence supporting the use of focal therapy (FT) in patients with localized prostate cancer (PCa), considerable variability exists in the patient selection criteria across current studies. This study aims to review the most recent evidence concerning the optimal approach to patient selection for FT in PCa. PubMed database was systematically queried for studies reporting patient selection criteria in FT for PCa before December 31, 2023. After excluding non-relevant articles and a quality assessment, data were extracted, and results were described qualitatively. There is no level I evidence regarding the best patient selection approach for FT in patients with PCa. Current international multidisciplinary consensus statements recommend multiparametric magnetic resonance imaging (mpMRI) followed by MRI-targeted and systematic biopsy for all candidates. FT may be considered in clinically localized, intermediate risk (Gleason 3 + 4 and 4 + 3), and preferably unifocal disease. Patients should have an acceptable life expectancy. Those with prostate volume >50 ml and erectile dysfunction should not be excluded from FT. Prostate-specific antigen (PSA) level of < 20 (ideally < 10) ng/mL is recommended. However, the utility of other molecular and genomic biomarkers in patient selection for FT remains unknown. FT may be considered in well-selected patients with localized PCa. This review provides a comprehensive insight regarding the optimal approach for patient selection in FT.

Predictive ability of magnetic resonance imaging (MRI) for detecting prostate cancer and its clinical significance in MRI-targeted biopsy for prostate imaging reporting and data system (PI-RADS) ≥3 lesions

Predictive ability of magnetic resonance imaging (MRI) for detecting prostate cancer and its clinical significance in MRI-targeted biopsy for prostate imaging reporting and data system (PI-RADS) ≥3 lesions

Prostate Cancer: A Review of Genetics, Current Biomarkers and Personalised Treatments.

Prostate cancer is the second leading cause of cancer deaths in men, second only to lung cancer. Despite this, diagnosis and prognosis methods remain limited, with effective treatments being few and far between. Traditionally, prostate cancer is initially tested for through a prostate serum antigen (PSA) test and a digital rectum examination (DRE), followed by confirmation through an invasive prostate biopsy. The DRE and biopsy are uncomfortable for the patient, so less invasive, accurate diagnostic tools are needed. Current diagnostic tools, along with genes that hold possible biomarker uses in diagnosis, prognosis and indications for personalised treatment plans, were reviewed in this article. Several genes from multiple families have been identified as possible biomarkers for disease, including those from the MYC and ETS families, as well as several tumour suppressor genes, Androgen Receptor signalling genes and DNA repair genes. There have also been advances in diagnostic tools, including MRI-targeted and liquid biopsies. Several personalised treatments have been developed over the years, including those that target metabolism-driven prostate cancer or those that target inflammation-driven cancer. Several advances have been made in prostate cancer diagnosis and treatment, but the disease still grows year by year, leading to more and more deaths annually. This calls for even more research into this disease, allowing for better diagnosis and treatment methods and a better chance of patient survival.

Transrectal versus transperineal prostate fusion biopsy: a pair-matched analysis to evaluate accuracy and complications

PurposeTo evaluate biopsy-related complications and detection rates of any PCa and clinically significant PCa (csPCa, intended as grade group ≥ 2) between MRI-targeted TP fusion biopsies (TPBx) and TR ones (TRBx).MethodsWe performed a multicentric study on 4841 patients who underwent fusion biopsy between 2016 and 2023. A case–control matching was performed to find comparable cohorts of 646 TPBx and 646 TRBx. Mean T test and Pearson chi-square tests were used to compare continuous and categorical variables.ResultsBaseline characteristics were comparable between the cohorts, except for target location with a higher rate of anterior lesions in TPBx group. Complications were rare and no difference was found between the groups, with similar rates of infections after TRBx and TPBx (N = 5 (0.8%) vs N = 2 (0.3%), p 0.45). All patients in TRBx and 90.1% in TPBx group received antibiotic prophylaxis. A higher csPCa detection rate was found in TPBx over the group (50.5% vs 36.2%, p < 0.001). On average, positive targeted cores were increased in TPBx group, for any PCa (1.6 vs 1.4, p 0.04) and csPCa (1.0 vs 0.8, p 0.02). Among the limitations of study, we acknowledge the retrospective design and the possible under-reporting of complications.ConclusionsMRI-targeted fusion TPBx achieves a significantly higher csPCa detection than TRBx, with a diagnostic advantage for apical and anterior lesions. No significant differences were found in terms of complications that were rare in both groups, considering a widespread adoption of antibiotic prophylaxis.

Active surveillance for low-risk prostate cancer with high tumor burden at biopsy: lessons learned from a contemporary radical prostatectomy cohort.

To investigate whether initial tumor burden at biopsy could predict adverse features after radical prostatectomy (RP) in International Society of Urological Pathology (ISUP) 1 prostate cancer (PCa) patients. This retrospective study was conducted in six referral centers. The cohort included patients with ISUP 1 PCa at systematic and MRI-targeted biopsy. We defined a high tumor burden at biopsy if ≥ 20% of cores were positive. The endpoint of the study was adverse features at RP, defined as ≥ pT3a stage and/or N1 and/or ISUP ≥ 3. Sensitivity analyses were performed to assess associations between different thresholds on biopsy (percentage of positive cores [PPC] ≥ 25%, ≥ 33%, ≥ 50%, bilateral positivity and positive cores > 3) and adverse features. As the number of targeted biopsies sampled may influence the number of positive cores, we used a virtual biopsy model in which all targeted biopsy results were interpreted as a single targeted biopsy. A total of 312 contemporary patients were included. At final pathology, 99 patients (32%) had adverse features. In multivariate logistic regression analysis, there was no statistical association between PPC > 20% and adverse features (OR = 1.22; 95%CI:0.69-2.22, p = 0.5). In sensitivity analysis, tumor burden at biopsy was not associated with the risk of adverse features, regardless of the definition used (all p > 0.05). When we considered a unique virtual targeted biopsy, tumor burden remained not associated with adverse features (all p > 0.05). ISUP 1 PCa tumor burden at biopsy did not predict adverse features in this study, suggesting that it should not be used alone as an exclusion criterion when assessing eligibility for active surveillance.

Role of Systematic Biopsy in the Era of Targeted Biopsy: A Review.

Prostate cancer (PCa) is a major public health issue, as the second most common cancer and the fifth leading cause of cancer-related deaths among men. Many PCa cases are indolent and pose minimal risk, making active surveillance a suitable management approach. However, clinically significant prostate carcinoma (csPCa) can lead to serious health issues, including progression, metastasis, and death. Differentiating between insignificant prostate cancer (inPCa) and csPCa is crucial for determining appropriate treatment. Diagnosis of PCa primarily involves trans-perineal and transrectal systematic biopsies. Systematic transrectal prostate biopsy, which typically collects 10-12 tissue samples, is a standard method, but it can miss csPCa and is associated with some complications. Recent advancements, such as magnetic resonance imaging (MRI)-targeted biopsies, have been suggested to improve risk stratification and reduce overtreatment of inPCa and undertreatment of csPCa, thereby enhancing patient quality of life and treatment outcomes. Guided biopsies are increasingly recommended for their ability to better detect high-risk cancers while reducing identification of low-risk cases. MRI-targeted biopsies, especially when used as an initial biopsy in biopsy-naïve patients and those under active surveillance, have become more common. Utilization of MRI-TB alone can decrease septic complications; however, the combining of targeted biopsies with perilesional sampling is recommended for optimal detection of csPCa. Future advancements in imaging and biopsy techniques, including AI-augmented lesion detection and robotic-assisted sampling, promise to further improve the accuracy and effectiveness of PCa detection.

Refining clinically relevant cut-offs of prostate specific antigen density for risk stratification in patients with PI-RADS 3 lesions.

Prostate Imaging Reporting and Data System (PI-RADS) 3 lesions, identified through multiparametric magnetic resonance imaging (mpMRI), present a clinical challenge due to their equivocal nature in predicting clinically significant prostate cancer (csPCa). Aim of the study is to improve risk stratification of patients with PI-RADS 3 lesions and candidates for prostate biopsy. A cohort of 4841 consecutive patients who underwent MRI and subsequent MRI-targeted and systematic biopsies between January 2016 and April 2023 were retrospectively identified from independent prospectively maintained database. Only patients who have PI-RADS 3 lesions were included in the final analysis. A multivariable logistic regression analysis was performed to identify covariables associated with csPCa defined as International Society of Urological Pathology (ISUP) grade group ≥2. Performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC), calibration, and net benefit. Significant predictors were then selected for further exploration using a Chi-squared Automatic Interaction Detection (CHAID) analysis. Overall, 790 patients had PI-RADS 3 lesions and 151 (19%) had csPCa. Significant associations were observed for age (OR: 1.1 [1.0-1.1]; p = 0.01) and PSA density (OR: 1643 [2717-41,997]; p < 0.01). The CHAID analysis identified PSAd as the sole significant factor influencing the decision tree. Cut-offs for PSAd were 0.13 ng/ml/cc (csPCa detection rate of 1% vs. 18%) for the two-nodes model and 0.09 ng/ml/cc and 0.16 ng/ml/cc for the three-nodes model (csPCa detection rate of 0.5% vs. 2% vs. 17%). For individuals with PI-RADS 3 lesions on prostate mpMRI and a PSAd below 0.13, especially below 0.09, prostate biopsy can be omitted, in order to avoid unnecessary biopsy and overdiagnosis of non-csPCa.

The Global Reading Room: A Patient With a Benign MRI-Targeted Biopsy of a PI-RADS Category 4 Lesion.

The Global Reading Room: A Patient With a Benign MRI-Targeted Biopsy of a PI-RADS Category 4 Lesion.

MRI-Targeted Prostate Fusion Biopsy: What Are We Missing outside the Target? Implications for Treatment Planning.

Introduction: This study aimed to evaluate the added diagnostic value of systematic biopsies (SBx) after magnetic resonance imaging (MRI)-targeted biopsies (TBx) and the presence of prostate cancer (PCa) outside MRI targets, in a prospective, contemporary, multicentric series of fusion biopsy patients. Methods: We collected data on 962 consecutive patients who underwent fusion biopsy between 2022 and 2024. Prostate cancer was considered clinically significant (csPCa) in the case of grade ≥ 2. Median test and Fisher exact chi-square tests were used. To identify predictors of out-field positivity, univariate and multivariable logistic regression analyses were performed. Results: Prostate cancer and csPCa were detected by TBx only in 56% and 50%, respectively, and by SBx only in 55% and 45%, respectively (p < 0.001). Prostate cancer and csPCa were diagnosed by TBx in 100 (10%) and 82 (8%) SBx-negative cases and by SBx in 86 (9%) and 54 (6%) TBx-negative cases (p < 0.001). Tumors outside MRI targets were found in 213 (33%) cases in the same lobe and 208 (32%) in the contralateral lobe, most of them being csPCa. Predictors of out-field contralateral PCa were positive DRE (HR 1.50, p 0.03), PSA density ≥ 0.15 (HR 2.20, p < 0.001), and PI-RADS score 5 (HR 2.04, p 0.01). Conclusions: Both TBx and SBx identify a non-negligible proportion of csPCa when the other modality is negative. SBx after TBx should always be considered given the risk of missing other csPCa foci within the prostate, especially in patients with positive DRE, PSA density ≥ 0.15, and PIRADS 5 lesions.

Targeted Ablation Using Ultrasound-Guided Irreversible Electroporation of Index Tumors (TARGET Study): Prospective Development Study Evaluating Safety, Patient-Reported Outcomes, and Oncologic Efficacy.

We studied patient-reported functional outcomes, safety, and oncologic efficacy of focal irreversible electroporation as a primary treatment for intermediate-risk prostate cancer. Between February 2015 and April 2017, 20 consecutive patients elected irreversible electroporation and underwent 22 treatments. All underwent MRI-targeted and systematic transrectal biopsies. Eligibility criteria were grade group 2/3 prostate cancer in a maximum of 2 adjacent sextant prostate sectors in 1 hemigland without extraprostatic extension on MRI. Ablation was performed with a 5-mm cancer margin. Any grade group 1 cancer outside mapped index lesion was untreated. Outcome measures were based on the Prostate Quality of Life Survey, Male Sexual Health Questionnaire, and MRI-targeted and systematic biopsies at 3 and 12 months. Nineteen patients completed irreversible electroporation. One had electrocardiographic changes, and irreversible electroporation was aborted. No deterioration was detected in urinary or sexual domains (-0.2, 95% CI -1.4, 0.9, P = .7, and -1.9, 95% CI -10.1, 6.4, P = .6, respectively) or health-related quality of life (-0.2, 95% CI -1.4, 1.0, P = .7) at 6 months post ablation. Ejaculation volume decreased at 12 months (-1.5 points, 95% CI -2.4, -0.5, P = .003). At 12 months of follow-up, 14/19 patients (74%, 95% CI 49%, 91%) had no clinically significant cancer anywhere in the prostate. Radical treatment-free survival was 79% at 2 years (95% CI 53%, 92%) and 73% at 4 years (95% CI 47%, 88%). Our data show promising oncologic and functional outcomes following focal irreversible electroporation treatment for carefully selected patients with intermediate-risk prostate cancer. Further research should compare irreversible electroporation with active surveillance.

Enhancing Prostate Cancer Diagnosis: Artificial Intelligence–Driven Virtual Biopsy for Optimal Magnetic Resonance Imaging-Targeted Biopsy Approach and Gleason Grading Strategy

An optimal approach to magnetic resonance imaging fusion targeted prostate biopsy (PBx) remains unclear (number of cores, intercore distance, Gleason grading [GG] principle). The aim of this study was to develop a precise pixel-wise segmentation diagnostic artificial intelligence (AI) algorithm for tumor detection and GG as well as an algorithm for virtual prostate biopsy that are used together to systematically investigate and find an optimal approach to targeted PBx. Pixel-wise AI algorithms for tumor detection and GG were developed using a high-quality, manually annotated data set (slides n = 442) after fast-track annotation transfer into segmentation style. To this end, a virtual biopsy algorithm was developed that can perform random biopsies from tumor regions in whole-mount whole-slide images with predefined parameters. A cohort of 115 radical prostatectomy (RP) patient cases with clinically significant, magnetic resonance imaging-visible tumors (n = 121) was used for systematic studies of the optimal biopsy approach. Three expert genitourinary (GU) pathologists (Y.T., A.P., A.Q.) participated in the validation. The tumor detection algorithm (aware version sensitivity/specificity 0.99/0.90, balanced version 0.97/0.97) and GG algorithm (quadratic kappa range vs pathologists 0.77-0.78) perform on par with expert GU pathologists. In total, 65,340 virtual biopsies were performed to study different biopsy approaches with the following results: (1) 4 biopsy cores is the optimal number for a targeted PBx, (2) cumulative GG strategy is superior to using maximal Gleason score for single cores, (3) controlling for minimal intercore distance does not improve the predictive accuracy for the RP Gleason score, (4) using tertiary Gleason pattern principle (for AI tool) in cumulative GG strategy might allow better predictions of final RP Gleason score. The AI algorithm (based on cumulative GG strategy) predicted the RP Gleason score of the tumor better than 2 of the 3 expert GU pathologists. In this study, using an original approach of virtual prostate biopsy on the real cohort of patient cases, we find the optimal approach to the biopsy procedure and the subsequent GG of a targeted PBx. We publicly release 2 large data sets with associated expert pathologists’ GG and our virtual biopsy algorithm.

Comparison of Multiparametric MRI-targeted and Systematic Biopsies for Detection of Cribriform and Intraductal Carcinoma Prostate Cancer.

Background Intraductal carcinoma (IDC) and invasive cribriform (Cr) subtypes of prostate cancer (PCa) are an indication of aggressiveness, but the evidence regarding whether MRI can be used to detect Cr/IDC-pattern PCa is contradictory. Purpose To compare the detection of Cr/IDC-pattern PCa at multiparametric MRI (mpMRI)-targeted biopsy versus systematic biopsy in biopsy-naive men at risk for PCa. Materials and Methods This study was a secondary analysis of a prospective randomized controlled trial that recruited participants with a clinical suspicion of PCa between April 2017 and November 2019 at five centers. Participants were randomized 1:1 to either the MRI arm or the systematic biopsy arm. Targeted biopsy was performed in participants with a Prostate Imaging Reporting and Data System score of at least 3. MRI features were recorded, and biopsy slides and prostatectomy specimens were reviewed for the presence or absence of Cr/IDC histologic patterns. Comparison of Cr/IDC patterns was performed using generalized linear mixed modeling. Results A total of 453 participants were enrolled, with 226 in the systematic biopsy arm (median age, 65 years [IQR, 59-70 years]; 196 biopsies available for assessment) and 227 in the mpMRI-targeted biopsy arm (median age, 67 years [IQR, 60-72 years]; 132 biopsies available for assessment). Identification of Cr/IDC PCa was lower in the systematic biopsy arm compared with the mpMRI arm (31 of 196 biopsies [16%] vs 33 of 132 biopsies [25%]; P = .01). No evidence of a difference in mean cancer core length (CCL) (11.3 mm ± 4.4 vs 9.7 mm ± 4.5; P = .09), apparent diffusion coefficient (685 µm2/sec ± 178 vs 746 µm2/sec ± 245; P = .52), or dynamic contrast-enhanced positivity (27 [82%] vs 37 [90%]; P = .33) for clinically significant PCa (csPCa) was observed between participants with or without Cr/IDC disease in the MRI arm. Cr/IDC-positive histologic patterns overall had a higher mean CCL compared with Cr/IDC-negative csPCa (11.1 mm ± 4.4 vs 9.2 mm ± 4.1; P = .009). Conclusion MRI-targeted biopsy showed increased detection of Cr/IDC histologic patterns compared with systematic biopsy. Clinical trial registration no. NCT02936258 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Scialpi and Martorana in this issue.

Multiparametric Prostate MRI Accuracy of Prostate Imaging Reporting and Data System (v2.1) Scores 4 and 5: The Influence of Image Quality According to the Prostate Imaging Quality Score.

Purpose: The accuracy of multiparametric magnetic resonance imaging (mpMRI) heavily relies on image quality, as evidenced by the evolution of the prostate imaging quality (PI-QUAL) scoring system for the evaluation of clinically significant prostate cancer (csPC). This study aims to evaluate the impact of PI-QUAL scores in detecting csPC within PI-RADS 4 and 5 lesions. Methods: We retrospectively selected from our database all mpMRI performed from January 2019 to March 2022. Inclusion criteria were as follows: (1) mpMRI acquired in our institution according to the technical requirements from the PI-RADS (v2.1) guidelines; (2) single lesion scored as PI-RADS (v2.1) 4 or 5; (3) MRI-TBx performed in our institution; (4) complete histology report; and (5) complete clinical record. Results: A total of 257 male patients, mean age 70.42 ± 7.6 years, with a single PI-RADS 4 or 5 lesion undergoing MRI-targeted biopsy, were retrospectively studied. Of these, 61.5% were PI-RADS 4, and 38.5% were PI-RADS 5, with 84% confirming neoplastic cells. In high-quality image lesions (PI-QUAL ≥ 4), all PI-RADS 5 lesions were accurately identified as positive at the final histological examination (100% of CDR). For PI-RADS 4 lesions, 37 (23%) were negative, resulting in a cancer detection rate of 77% (95% CI: 67.51-84.83). Conclusions: The accuracy of mpMRI, independently of the PI-RADS score, progressively decreased according to the decreasing PI-QUAL score. These findings emphasize the crucial role of the PI-QUAL scoring system in evaluating PI-RADS 4 and 5 lesions, influencing mpMRI accuracy.

Prostate cancer detection rate with MRI-targeted biopsy alone using outpatient transperineal prostate biopsy.

We aimed to compare the detection rate of prostate cancer (PCa) and clinically significant (cs) PCa by magnetic resonance imaging-guided targeted biopsy (MTBx) alone and MTBx plus systematic biopsy (SBx) using an outpatient transperineal (TP) approach under local anesthesia. A retrospective study of patients who underwent outpatient TP prostate biopsy under local anesthesia at our tertiary institution between 2019 and 2022 was performed. To compare the proportions of PCa and csPCa in both pathways, McNemar's tests were used. Multivariable logistic regression model was fitted to determine the predictors of csPCa. Of 255 men included, 177 (69%) underwent MTBx alone. MTBx had similar detection rate for PCa (56%) and csPCa (47%) compared to the combination of MTBx and SBx (PCa 61%; csPCa 49%; p=0.1 and p=0.3, respectively). MTBx had lower median number of biopsy cores compared to the combination of MTBx and SBx (6 vs. 11, p<0.001). At multivariable logistic regression analysis, age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.04-1.13, p<0.001), prior negative biopsy (OR 0.19, 95% CI 0.09-0.44, p<0.001), prostate-specific antigen density cutoff ≥0.15 (OR 3.17, 95% CI 1.67-6.01, p<0.001), and prostate imaging reporting and data system ≥4 (OR 12.2, 95% CI 4.21-35.6, p<0.001) were independent predictors of csPCa. MTBx showed similar diagnostic performance to the combination of MTBx and SBx in patients undergoing outpatient TP prostate biopsy. Future studies are needed to evaluate the role of MTBx in avoiding unnecessary biopsies.

External validation and comparison of magnetic resonance imaging-based risk prediction models for prostate biopsy stratification.

Magnetic resonance imaging (MRI) is a promising tool for risk assessment, potentially reducing the burden of unnecessary prostate biopsies. Risk prediction models that incorporate MRI data have gained attention, but their external validation and comparison are essential for guiding clinical practice. The aim is to externally validate and compare risk prediction models for the diagnosis of clinically significant prostate cancer (csPCa). A cohort of 4606 patients across fifteen European tertiary referral centers were identified from a prospective maintained database between January 2016 and April 2023. Transrectal or transperineal image-fusion MRI-targeted and systematic biopsies for PI-RADS score of ≥ 3 or ≥ 2 depending on patient characteristics and physician preferences. Probabilities for csPCa, defined as International Society of Urological Pathology (ISUP) grade ≥ 2, were calculated for each patients using eight models. Performance was characterized by area under the receiver operating characteristic curve (AUC), calibration, and net benefit. Subgroup analyses were performed across various clinically relevant subgroups. Overall, csPCa was detected in 2154 (47%) patients. The models exhibited satisfactory performance, demonstrating good discrimination (AUC ranging from 0.75 to 0.78, p < 0.001), adequate calibration, and high net benefit. The model described by Alberts showed the highest clinical utility for threshold probabilities between 10 and 20%. Subgroup analyses highlighted variations in models' performance, particularly when stratified according to PSA level, biopsy technique and PI-RADS version. We report a comprehensive external validation of risk prediction models for csPCa diagnosis in patients who underwent MRI-targeted and systematic biopsies. The model by Alberts demonstrated superior clinical utility and should be favored when determining the need for a prostate biopsy.

Transition from Transrectal to Transperineal MRI-Fusion Prostate Biopsy Does Not Comprise Detection Rates of Clinically Significant Prostate Cancer at a Tertiary Care Center.

A remarkable paradigm shift has emerged regarding the preferred prostate biopsy approach, favoring the transperineal (TP) over the transrectal (TR) approach due to the reduced risk of severe urinary tract infections. However, its impact on the detection of clinically significant prostate cancer (csPCa) remains unclear. We relied on a prospectively maintained tertiary care database to identify patients who underwent either TP or TR prostate biopsy between 01/2014 and 12/2023. Of those, only patients with suspicious magnetic resonance imaging (MRI) PIRADS lesions (Likert-scale: 3,4,5) received MRI-targeted and systematic biopsies. Detection rates of csPCa (International Society of Urological Pathology [ISUP] ≥ 2) were compared between biopsy approach (TP vs. TR) according to index lesion. Subsequently, uni- and multivariable logistic regression models were applied to investigate the predictive status of the biopsy approach within each subcohort. Of 2063 patients, 1118 (54%) underwent combined MRI-guided and systematic prostate biopsy and were included in the final cohort. Of those, 127 (11%) and 991 (89%) underwent TP vs. TR. CsPCa rates, regardless of differences in patients' demographics and distribution of index PIRDAS lesions, did not differ statistically significantly and were 51 vs. 52%, respectively (p = 0.8). CsPCa detection rates for PIRDAS-3, PIRADS-4 and PIRADS-5 did not differ and were 24 vs. 23%, 48 vs. 51% and 72 vs. 76% for PIRADS-3, PIRADS-4 and PIRADS-5 subgroups for TP vs. TR, respectively (all p ≥ 0.9) Conclusions: The current results support the available data indicating that TP biopsy approach is comparable to transrectal biopsy approach regarding csPCa detection rates.

Bi-Parameter MRI Could Quantitatively Assess the Zonal Heterogeneity of Prostate Cancer

IntroductionProstate cancer (PCa) located in the peripheral zone (PZ) and transitional zone (TZ) showed a different clinical and pathological characteristic. This passage aims to preliminarily evaluate the relationship between the zonal heterogeneity of PCa quantitatively assessed by bpMRI and pathological risk stratification of the primary lesion. MethodsThis prospective study was conducted from January 2019 to February 2023. A total of 113 PCa patients whose bpMRI data indicated that the lesions located in only 1 single zone of the prostate were selected. A transrectal ultrasound and MRI-targeted biopsy were performed to verify the bpMRI results, and then radical prostatectomy (RP) was performed in 3 weeks after the biopsy. The high-risk (HR) group was defined as ISUP grades ≥ 3. Binary regression was performed to evaluate if the zonal heterogeneity could be an independent predictor of the HR group. The receiver operator characteristic (ROC) curve was performed to analyze the added value of zonal location in predicting the HR group. ResultsPSA, T staging, and ISUP grades, incidence of positive surgical margins were significantly lower in the TZ PCa, and the ADCmin, and ADCmean values in the TZ PCa were significantly higher (all P < .01). The zonal heterogeneity could independently predict the HR group patients (OR: 5.170 [1.663-16.067], P = .005) and improve the predicting efficiency of HR patients (AUC 0.824, 95% CI, 0.741-0.889). ConclusionsBpMRI could quantitively assess the zonal heterogeneity of PCa precisely and increase the predicting efficacy of HR patients, which can provide better help for clinical individualized treatment.

Prostate health index density aids the diagnosis of prostate cancer detected using magnetic resonance imaging targeted prostate biopsy in Taiwanese multicenter study.

Multiparametric magnetic resonance imaging (mpMRI) followed by MRI-targeted prostate biopsy is the current standard for diagnosing prostate cancer (PCa). However, studies evaluating the value of biomarkers, including prostate health index (PHI) and its derivatives using this method are limited. We aimed to investigate the efficacy of PHI density (PHID) in guiding MRI-targeted prostate biopsies to identify clinically significant PCas (csPCa). The multicenter prospectively registered prostate biopsy database from three medical centers in Taiwan included patients with PHI and MRI-targeted and/or systematic prostate biopsies. We assessed the required values of prostate-specific antigen (PSA), prostate volume, PHI, PHID, and Prostate Imaging Reporting & Data System (PI-RADS) score using multivariable analyses, receiver operating characteristic curve analysis, and decision curve analyses (DCA). csPCa was defined as the International Society of Urological Pathology Gleason group ≥2 PCa, with an emphasis on reducing unwarranted biopsies. The study cohort comprised 420 individuals. Diagnoses of PCa and csPCa were confirmed in 62.4% and 47.9% of the participants, respectively. The csPCa diagnosis rates were increased with increasing PI-RADS scores (20.5%, 44.2%, and 73.1% for scores 3, 4, and 5, respectively). Independent predictors for csPCa detection included PHI, prostate volume, and PI-RADS scores of 4 and 5 in multivariable analyses. The area under the curve (AUC) for csPCa of PHID (0.815) or PHI (0.788) was superior to that of PSA density (0.746) and PSA (0.635) in the entire cohort, and the superiority of PHID (0.758) was observed in PI-RADS 3 lesions. DCA revealed that PHID achieved the best net clinical benefit in PI-RADS 3-5 and 4/5 cases. Among PI-RADS 3 lesions, cutoff values of PHID 0.70 and 0.43 could eliminate 51.8% and 30.4% of omitted biopsies, respectively. PHI-derived biomarkers, including PHID, performed better than other PSA-derived biomarkers in diagnosing PCa in MRI-detected lesions.