PI-RADS Score Research Articles

Tailoring 4Kscore thresholds to multiparametric MRI results.

31 Background: 4Kscore was developed and validated agnostic to prostate multiparametric MRI (mpMRI) findings, with current clinical paradigms utilizing a value of 7.5% to delineate the potential for high-grade disease. A growing body of evidence suggests improved diagnostic utility when used in conjunction with mpMRI results. Incorporation of mpMRI PIRADS scores may have potential to enhance diagnostic accuracy of 4Kscore, especially for non-definitive lesions. This study aims to examine the optimal 4Kscore threshold in PIRADS 3/4 lesions to maximize test utility and help guide clinical decision-making. Methods: A single-institution review of all patients with recorded 4Kscore, prostate MRI with dominant PIRADS 3/4 lesions, and final biopsy pathology from 2016-2020 was conducted from an IRB-approved database. Clinically significant prostate cancer (csPCa) was defined as Gleason score ≥3+4 on final biopsy. Receiver operating characteristic curves were generated, and the primary data point was chosen to maximize sensitivity and specificity. Results: 88 patients with dominant PIRADS 3 (n = 40) or PIRADS 4 (n = 48) lesions were identified. For patients with PIRADS 3 lesions, area under the curve (AUC) was 0.8083 (p < 0.0039) with optimal 4Kscore threshold to detect csPCa as 18.5% (sensitivity = 70.00%, specificity = 80.00%). Negative predictive value (NPV) at 4Kscore of 18.5% in PIRADS 3 lesions was 0.93. In patients with dominant PIRADS 4 lesions, AUC was 0.7735 (p < 0.002), and optimal threshold to detect csPCa was 21.5% (sensitivity = 70.59%, specificity = 76.67%). NPV at 4Kscore of 21.5% in PIRADS 4 lesions was 0.82. Conclusions: Stratification of mpMRI PIRADS 3/4 lesions suggests that utilization of more permissive 4Kscore thresholds can improve prediction of csPCa without sacrificing NPV, especially for PIRADS 3 lesions. These findings may enhance risk-adapted prostate cancer screening, reduce unnecessary prostate biopsies, and optimize clinical management.

Pathologic and radiographic outcomes following prostate cancer diagnosis aided by IsoPSA testing.

276 Background: IsoPSA is a structure-based assay previously demonstrated to outperform prostate specific antigen (PSA) and free-to-total PSA ratio in detecting clinically significant prostate cancer at the time of biopsy (Stovsky, Klein 2019). Herein we report pathologic outcomes in patients treated via radical prostatectomy (RP) whom had undergone IsoPSA testing prior to their diagnostic biopsy. We also explore IsoPSA status in the context of MRI dependent findings, including PIRADS scores and PSA density. Methods: We conducted a retrospective review of patients whom had undergone IsoPSA testing prior to biopsy and RP at our institution between 2019-2021. We also identified subsets of patients with pre-operative prostate MRI’s. Exploratory analyses were performed to determine associations between IsoPSA and adverse histologic (cribiform, intraductal status (CB/ID), grade group status) pathologic (extraprostatic extension, seminal vesicle involvement, surgical margins) and radiographic (PSA density, PIRADS, location) features. We examined these data points in a randomly selected control group of RP patients whom had not had IsoPSA testing. Student’s T-test, Mann Whitney U, Kruskal Wallis, were used where appropriate. Results: A total of 83 patients underwent RP following IsoPSA testing, with 72.2% (60/83) also undergoing pre-operative prostate MRI. The mean total PSA was 10.3 ng/dL, IsoPSA index was 10.2 and prostate size 46.8 cc. IsoPSA was significantly associated with PSA density (median IsoPSA of 9.9 vs 7.8 for PSA density > 0.15, <0.15 respectively, p < 0.001). The median IsoPSA index was higher when the dominant tumor was found in the transitional zone versus peripheral zone (12.7 vs 8.8 p = 0.011). IsoPSA trended towards but was not associated with PIRADS-v2 score (1-2 vs 3 vs 4-5) (p = 0.1). IsoPSA was not selectively associated with adverse pathological or histological features. Conclusions: IsoPSA has been shown to predict clinically significant disease on biopsy, and as such may improve the selection of men for such intervention. In our initial cohort, IsoPSA reliably identified patients with clinically significant disease without selecting for unique adverse pathologic/histologic features when compared to a control group. Radiographically, IsoPSA was significantly associated with elevated PSA density ( > 0.15), tumor location (TZ vs PZ), and trended towards significance with PIRADS v.2 score (p = 0.1. Further work is encouraged to explore its adjunctive benefit in correlation to MRI features.

Clinical and pathologic characteristics to select patients for focal therapy or partial gland ablation of nonmetastatic prostate cancer.

Focal therapy or partial gland ablation for nonmetastatic prostate cancer is gaining popularity not just as an alternative to active surveillance, but as an acceptable alternative to whole gland therapy in appropriate cases. This review summarizes recent evidence to help select patients for optimal outcomes. Recommendations by expert panels have become less conservative with each meeting. As experience with older modalities for focal therapy grows, newer modalities continue to be introduced. We are now in a position to offer personalized treatment pathway considering nuances of each focal therapy modality. The ideal case for focal therapy should be an MRI visible significant lesion (PIRADS score ≥ 3), with a positive biopsy for significant cancer (Gleason grade group 2-3) in the corresponding targeted biopsy area, and insignificant or absent disease in the nontarget random biopsy areas. Multifocal disease can also be selectively treated. Salvage focal ablation is an attractive treatment option for radio-recurrent or index focal therapy failure cases.

Prostate MRI quality: clinical impact of the PI-QUAL score in prostate cancer diagnostic work-up.

To assess the reproducibility and impact of prostate imaging quality (PI-QUAL) scores in a clinical cohort undergoing prostate multiparametric MRI. PI-QUAL scores were independently recorded by three radiologists (two senior, one junior). Readers also recorded whether MRI was sufficient to rule-in/out cancer and if repeat imaging was required. Inter-reader agreement was assessed using Cohen's κ. PI-QUAL scores were further correlated to PI-RADS score, number of biopsy procedures, and need for repeat imaging. Image quality was sufficient (≥PI-QUAL-3) in 237/247 (96%) and optimal (≥PI-QUAL-4) in 206/247 (83%) of males undergoing 3T-MRI. Overall PI-QUAL scores showed moderate inter-reader agreement for senior (K = 0.51) and junior-senior readers (K = 0.47), with DCE showing highest agreement (K = 0.47). With PI-QUAL-5 studies, the negative MRI calls increased from 50 to 87% and indeterminate PI-RADS-3 rates decreased from 31.8. to 10.4% compared to lower quality PI-QUAL-3 studies. More patients with PI-QUAL scores 1-3 underwent biopsy for negative (47%) and indeterminate probability (100%) MRIs compared to PI-QUAL score 4-5 (30 and 75%, respectively). Ability to rule-in cancer increased with PI-QUAL score, from 50% at PI-QUAL 1-2 to 90% for PI-QUAL 4-5, with a similarly, but greater effect for ruling-out cancer and at a lower threshold, from 0% for scans of PI-QUAL 1-2 to 67.1% for PI-QUAL 4 and 100% for PI-QUAL-5. Higher PI-QUAL scores for image quality are associated with decreased uncertainty in MRI decision-making and improved efficiency of diagnostic pathway delivery. This study demonstrates moderate inter-reader agreement for PI-QUAL scoring and validates the score in a clinical setting, showing correlation of image quality to certainty of decision making and clinical outcomes of repeat imaging and biopsy of low-to-intermediate risk cases.

A critical analysis of deficiencies in the quality of information contained in prostate multiparametric MRI requests and reports.

Multiparametric magnetic resonance imaging (mpMRI) has been increasingly recognised as an important tool in the diagnosis of prostate cancer. PI-RADSv2 guidelines recommend that important clinical information including prostate-specific antigen (PSA) levels, examination findings, and biopsy information should be included in mpMRI requests. PIRADS score and PSA density (PSAD) are both independent predictors for the presence of a clinically significant prostate cancer. This study aims to evaluate the quality of mpMRI requests and reports at our institution in accordance with these parameters. All prostate mpMRIs performed by radiology services in Galway University Hospital between 1st September 2019 and 1st March 2020 were reviewed. Exclusion criteria were applied. Requests and reports were analysed for the presence of the following parameters: PSA-results, examination findings, biopsy information, PI-RADS score, prostate volume, and PSAD. A total of 586 mpMRIs were performed, and of these, 546 were included. PSA value was provided in 497 (91%) of requests, exam findings in 355 (65%), and biopsy information in 452 (82%). PIRADS score was included in 224 (41%) of reports, prostate volume in 178 (32.6%), and PSAD in 106 (19%). Great variation in the quality of information contained in both requests and reports for prostate mpMRIs exists within our service. We aim to improve this by collaborating with our radiology colleagues to develop a proforma for requesting and reporting of mpMRIs for our radiology systems to ensure important clinical and radiological information is provided in future.

Diagnostic performance of fusion (US/MRI guided) prostate biopsy: propensity score matched comparison of elastic versus rigid fusion system.

Many software for US/MRI guided fusion prostate biopsy (FPB), have been developed in the last years. However, there are few data comparing diagnostic accuracy of different fusion systems. We assessed diagnostic performance of elastic (EF) versus rigid fusion (RF) PB in a propensity score matched (PSM) analysis. A total of 314 FPB were prospectively collected from two different centers. All patients were biopsy naïve and all mpMRI reported a single suspicious area. Overall, 211PB were performed using a RF system and 103 using an EF software. The two groups were compared for the main clinical features. A 1:1 PSM analysis was employed to reduce covariate imbalance to < 10%. Detection rate (DR) for any prostate cancer (PCa) and clinically significant (cs) PCa were compared and stratified for PI-RADS Score. A per target univariable and multivariable regression analyses were applied to identity predictors of anyPCa and csPCa. After applying the PSM, two cohorts of 83 cases were selected. DR of any PCa cancer and csPCa were comparable between the two cohorts (all p > 0.077) as well as DR of csPCa for every PIRADS score. At univariable regression analysis lesion size, PI-RADS Score, PSA Density and EF system were predictors of any PCa (all p < 0.001); however, at multivariable analysis only PI-RADS Score was independent predictor of any PCa (p = 0.027). At multivariable analysis only PI-RADS score was independent predictor of csPCa. Fusion PB guarantees high diagnostic accuracy for csPCa, regardless of the fusion technology. Prospective randomized study is needed to confirm these data.

Risk-based MRI-directed diagnostic pathway outperforms non-risk-based pathways in suspected prostate cancer biopsy-naïve men: a large cohort validation study.

To investigate and compare the performance of different proposed diagnostic pathways in a cohort of biopsy-naïve men at risk for prostate cancer (PCa), in terms of biopsy avoidance, accurate diagnosis of clinically significant prostate cancer (csPCa), and reduction in overdiagnosis of clinically insignificant cancer (cisPCa), with particular focus on a recently suggested "risk-based" MRI-directed diagnostic pathway. Single-center, retrospective cohort study, including 499 biopsy-naïve men at risk for PCa. All men underwent PI-RADS-compliant prostate MRI, transrectal ultrasound fusion-guided targeted (TBx), and systematic biopsy (SBx). Five diagnostic pathways were retrospectively evaluated and compared for. Outcome measures were biopsy avoidance, combined with missed csPCa and detected cisPCa. csPCa and cisPCa were defined as ISUP grade group ≥ 2 and grade = 1, respectively. Chi-square test was used for statistical analysis. Decision curve analyses were used to compare the benefits of the pathways across a range of biopsy thresholds. The prevalence (detection-focused [reference] pathway) of csPCa and cisPCa was 52.9% (264/499) and 23.0% (115/499). MRI-focused pathway (no biopsy in PI-RADS 1-2 men) did not significantly reduce ISUP ≥ 2 cancer detection (52.1% (260/499); p = 0.13), but significantly reduced ISUP 1 cancers diagnosed (20.6% (103/499); p < 0.01), and biopsy avoidance was 11.8% (59/499). The risk-based MRI-directed pathway (no biopsy in low-risk PI-RADS 1-3 men) resulted in a small reduction of ISUP ≥ 2 diagnosed (51.7% (258/499); p = 0.04), however non-significant when compared to MRI-focused pathway (p = 0.625). Moreover, the risk-based pathway further reduced detection of ISUP 1 (18.6% (93/499); p < 0.01), and biopsy avoidance was 19.2% (96/499). Decision curve analysis showed maximized net benefit of the risk-based pathway, for the range of threshold probabilities between 6.25 and 65%. The risk-based MRI-directed pathway for prostate cancer diagnosis was optimal in balancing accurate diagnosis, reducing overdiagnosis, and maximizing biopsy avoidance. This substantial evidence should inform guideline recommendations towards using "risk-based" MRI-directed biopsy decisions in biopsy-naïve men at risk of significant prostate cancer. • Our study recognizes the added value of prostate MRI and MR-targeted biopsies in order to propose clinical diagnostic pathways for prostate cancer, towards maximizing the potential avoidance of unnecessary biopsies, while maintaining optimal detection rate of clinically significant prostate cancer. • The risk-based MRI-directed pathway incorporates risk factors such as PSA density, digital rectal examination, and family history to further refine the initial stratification of patients based on PI-RADS scores. • In this study, the risk-based pathway had the most optimal performance in terms of combination of outcomes, with the highest rate of biopsy avoidance (19.2%), while keeping a high detection rate of clinically significant prostate cancer (51.7%), when compared to the reference standard (52.9%).

Population-based randomized trial of screening for clinically significant prostate cancer ProScreen: a pilot study.

ObjectivesTo evaluate the feasibility of a population‐based screening trial using prostate‐specific antigen (PSA), a kallikrein panel and multiparametric magnetic resonance imaging (MRI) aimed at minimizing overdiagnosis, while retaining mortality benefit.Patients and MethodsFeasibility of the screening algorithm was evaluated in terms of participation, screening test results and cancer detection. A random sample of 400 men aged 65 years was identified from the population registry and invited for screening with three stepwise tests (PSA, kallikrein panel and MRI). Men with PSA levels ≥3 ng/mL were further tested with the kallikrein panel, and those with positive findings (risk >7.5%) were referred for prostate MRI. Men with positive MRI (Prostate Imaging Reporting and Data System [PI‐RADS] score 3–5) had targeted biopsies only. Men with negative MRI, but PSA density ≥0.15 underwent systematic biopsies.ResultsOf the 399 men invited, 158 (40%) participated and 27 had PSA levels ≥3 ng/mL (7% of the invited and 17% of the participants). Of these, 22 had a positive kallikrein panel (6% of the invited and 81% of the PSA‐positive men). Finally, 10 men (3% of the invited and 45% of 4Kscore [kallikrein panel]‐positive) had a suspicious MRI finding (PI‐RADS score ≥3) and five were diagnosed with a clinically significant prostate cancer (Gleason Grade Group [GG] ≥2) at fusion biopsy (3% of the participants), with two GG 1 cases (1%). Additional testing (kallikrein panel and MRI) after PSA reduced biopsies by 56%.ConclusionThe findings constitute proof of principle for our screening protocol, as we achieved a substantial detection rate for clinically significant cancer with few clinically insignificant cases. Participation, however, was suboptimal.

Improvement prostate cancer detection rate of suspicious lesions through MRI/TRUS fusion guided biopsy by a multiteam of radiologists

BackgroundThe objective of our study was to analyze the data of our biopsies, determine a detection rate (DR), compare it with the data in the literature and draw possible deductions, so as to offer the patient the possibility of not having other biopsies in the future.MethodsWe have enrolled 189 biopsy-naive patients in the period between September 2018 and December 2020. Each patient underwent multiparametric (mp)-MRI which was reviewed by our team of radiologists. In our center, each examination is examined by 4 radiologists separately with an overall final result. Through the t student test, any statistically significant differences between the DRs and the concordance rate between the positive cores and the suspected area on MRI were analyzed for each urologist who performed the procedure.ResultsThe absolute (DR) was 69.3% (131/189 patients). The relative DR for each PIRADS score was 41% for PIRADS 3, 70.2% for PIRADS 4, 89.3% for PIRADS 5. We found a high percentage of agreement between the positive biopsy samples and the suspicious area identified on MRI: 90.8% (119/131 patients). There were no statistically significant differences between the DRs of the urologists who performed the procedure (p = 0.89), nor for the percentage of agreement between the positivity of the core and the suspected area on MRI (p = 0.92).ConclusionsMRI in the future could become the gold standard for performing MRI fusion-guided biopsies to have a better diagnostic result and avoid rebiopsies. A team MRI reading allows greater accuracy in identifying the suspected lesion, which is demonstrated by a high rate of agreement with the positivity of the cores (90.8%). There is a cost problem due to the need to carry out the mpMRI but it could have less impact in the future. In addition, the MRI provides useful information on the extent of the disease (e.g., cT3a/b) which allows you to better plan the surgical strategy or other therapies.

A Nomogram for Predicting Pelvic Lymph Node Metastasis in Prostate Cancer

<i>Background</i>: Prostate cancer (PCa) is prone to lymph node metastasis. In this report, the authors described a model predictive of the probability of lymph node metastasis in prostate cancer patients. <i>Methods</i>: Two-hundred seventy-eight middle-high-risk PCa patients who received laparoscopic radical prostatectomy (LRP) combined with extended pelvic lymph node dissection (e-PLND) in our hospital were selected as the subjects and the authors performed a retrospective analysis. According to the postoperative pathological results, the patients were divided into a pelvic lymph node metastasis group (n=100) and a non-pelvic lymph node metastasis group (n=178). Univariable and multivariable logistic regression analyses were performed to identify independent risk factors for pelvic lymph node metastasis from PCa. Finally, a clinical prediction model nomogram was further established and verified, and a calibration plot was drawn to verify the accuracy of the model. <i>Results</i>: The TPSA level, FPSA level, PI-RADS score, biopsy ISUP classification and Gleason score of the two groups were statistically different (P<0.05), and there was no statistical difference between the age groups (P>0.05). Receiver operating characteristic curve (ROC) showed that the best diagnostic cut-off value of TPSA was 77.45 ng/ml (AUC=0.785, 95%CI: 0.729-0.842), and the best diagnostic cut-off value of FPSA was 0.085 ng/ml (AUC=0.282, 95%CI: 0.215-0.348). Univariable and multivariable logistic regression analyses showed that, TPSA level (OR=1.00, 95%Cl: 1.000-1.006, P<0.05), FPSA level (OR=0.00, 95%Cl: 0.000-0.089, P<0.01), PI-RADS score (OR=9.26, 95%CI: 5.278-16.248, P<0.01) and biopsy ISUP grade (OR=1.69, 95%CI: 1.163-2.450, P<0.01) were independent predictors of pelvic lymph node metastasis. <i>Conclusions</i>: The nomogram established in this study has a good predictive ability for pelvic lymph node metastasis in patients with PCa, and can provide a reference for the selection of clinical treatment options.

The Effectiveness of Prostate Imaging and Reporting and Data System Version 2 in the Diagnosis of Prostate Cancer with Screening Parameters Correlation.

Prostate cancer is the most commonly diagnosed cancer and the second most common reason for cancer-related mortality in men. The purpose of cancer screening is to detect the disease at an early stage to help effective treatment. This study aimed to investigate the effectiveness of MRI and PI-RADS in the diagnosis of prostate cancer and examine the relation between screening parameters with prostate cancer. The PACS system was analyzed and MRI images between September 2016 and April 2018 were listed. The state of patients regarding having pathology results were obtained. PSA values were listed. The prostate volume and the prostate density was calculated. PI-RADS assessment was used for each prostate lesion. Data of 138 patients were included in the study. The mean age was 63±8.9. The mean prostate gland volume was 63.8±39.3ml, the mean PSA value was 12.51±25.22 and the mean PSA density was calculated as 0.319±0.945. A statistically significant difference was found between age and prostate volume and cancer. The age of the cancer cases was higher than those who did not have cancer (p<0.05). A negative correlation was found between prostate volume and cancer status. The prostate volume of non-cancer cases was higher compared to cancer cases (p=0.0001). 55 patients had no malignancy. It was observed that 56.4% of cancer patients had significant cancer. The frequency of using PI-RADS scores was 4% for P1, 36% for P2, 14% for P3, 28% for P4, and 18% for P5. Clinically significant cancer was present in 57.9% of patients with PI-RADS score4 and 69.6% of patients with PI-RADS score5. It was found that diagnostic values were significantly high for prostate cancer screening in patients with PI-RADS scores4 and 5 (Sensitivity 76.4%, Specificity 73.5%, Negative predictive value 82.4%, Positive predictive value 65.6%). PI-RADS and MRI can be useful for the diagnosis of the clinically significant prostate cancer in patients at risk for prostate cancer. It is a non-invasive, repeatable method for prostate cancer screening and diagnosis. In prostate screening PSA reliability may be questioned. Additional methods are needed for the diagnosis. For this reason MRI and PI-RADSv2 is an effective predictor of prostate cancer in patients with high PSA levels.

Number of cores needed to diagnose prostate cancer during MRI targeted biopsy decreases after the learning curve.

We hypothesized that the number of cores needed to detect prostate cancer would decrease with increasing MRI-targeted biopsy (TBx) experience. All patients undergoing TBx at our institution from May 2017 to August 2019 were enrolled in a prospectively maintained database. Five biopsy cores were obtained from each lesion ≥3 on PI-RADS v2.0 followed by a systematic 12-core biopsy. To assess learning curve, the study population was divided into quartiles by sequential biopsies. Clinically significant prostate cancer (csPC) was defined as Gleason Grade Group 2 or higher. 377 patients underwent prostate biopsy (533 lesions); 233 lesions (44%) were positive for prostate cancer and 173 lesions (32%) were csPC. There was a significant decline in the number of cores required for diagnosing any cancer (P < 0.001) and csPC (P < 0.05) after the first quartile. There was no difference when stratifying by PI-RADS score or lesion volume. Within the first quartile, limiting the biopsy to 3 cores would miss 16.2% of csPC, decreasing to 6.6% after approximately 100 patients. MRI TBx is associated with a learning curve of approximately 100 cases. Four or 5 cores should be considered during the initial experience, but thereafter, 3 cores per lesion is sufficient to detect csPC.

An Analysis of MRI-Fusion Prostate Biopsy Results in PI-RADS 3 MRI Findings in a Cohort of Men in a Community Hospital Setting

Introduction: With the advent of multiparametric MRI (mpMRI), clinicians added an important tool for helping to decide whether a man should undergo a prostate biopsy. The MRI PI-RADS system stratifies the risk of finding cancer on prostate biopsy. PI-RADS 3 lesions often prove to be a diagnostic challenge, and many men are advised not to proceed with a biopsy based on this finding. The goal of our paper was to evaluate the likelihood of finding cancer of clinical significance in this group. Methods: A retrospective 4-year data and quality analysis was performed of 312 evaluable men undergoing prostate MRI. Of the subset with scores of PI-RADS 3 who underwent biopsy (N = 32), 100 percent were biopsied using an MRI-guided fusion technique, greatly raising the likelihood that the MRI lesion was, in fact, the area sampled. Results: A total of 34% of the men with PI-RADS 3 lesions were found to have Grade Group ≥ 1, with 15.6 % demonstrating Grade Group ≥ 2. In the men with cancer, we analyzed and report the relationship to age, ethnicity, PSA density, and the presence or absence of cribriform findings. Conclusions: We found that many men with PI-RADS 3 findings on multiparametric MRI do, in fact, have clinically significant prostate cancer. We suggest that many factors (such as rate of rise of PSA over time, family history, and rectal examination findings) be considered in addition to the MRI PI-RADS score to advise whether or not to proceed with a biopsy of the prostate. Our findings, from a single, large, community hospital with a diverse ethnic makeup, parallel the findings of large trials done at academic centers of excellence. This demonstrates that comparable diagnostic mpMRI/biopsy quality may be found in the community setting.

Predicting the Performance of Concurrent Systematic Random Biopsies during Image Fusion Targeted Sampling of Multi-Parametric MRI Detected Prostate Cancer. A Prospective Study (PRESET Study).

Simple SummaryThe study provides a predictive model by using clinical factors in selecting men who may benefit from the addition of systematic biopsies with an image fusion targeted approach. The approach is likely to improve the detection of csPCa and avoid unnecessary detection of indolent prostate cancers.The study was aimed to develop a predictive model to identify patients who may benefit from performing systematic random biopsies (SB) in addition to targeted biopsies (TB) in men suspected of having prostate cancer. A total of 198 patients with positive pre-biopsy MRI findings and who had undergone both TB and SB were prospectively recruited into this study. The primary outcome was detection rates of clinically significant prostate cancer (csPCa) in SB and TB approaches. The secondary outcome was net clinical benefits of SB in addition to TB. A logistic regression model and nomogram construction were used to perform a multivariate analysis. The detection rate of csPCa using SB was 51.0% (101/198) compared to a rate of 56.1% (111/198) for TB, using a patient-based biopsy approach. The detection rate of csPCa was higher using a combined biopsy (64.6%; 128/198) in comparison to TB (56.1%; 111/198) alone. This was statistically significant (p < 0.001). Age, PSA density and PIRADS score significantly predicted the detection of csPCa by SB in addition to TB. A nomogram based on the model showed good discriminative ability (C-index; 78%). The decision analysis curve confirmed a higher net clinical benefit at an acceptable threshold.

Second-opinion reads in prostate MRI: added value of subspecialty interpretation and review at multidisciplinary rounds.

PurposeThis study evaluates the impact of second-opinion review of multiparametric prostate MRI for cancer detection by a multidisciplinary review board at a tertiary care center when compared with the initial community radiologist interpretation.MethodsCases were collected retrospectively from multidisciplinary prostate MRI rounds from 2017 to 2020 at a single tertiary care center. Patients with suspected prostate cancer or on active surveillance were referred for consideration of TRUS/MRI-fusion biopsy based on community-read prostate MRIs. All MRIs were re-read by subspecialized abdominal radiologists and a PI-RADS score assigned. Targeted fusion and 8–12 core systematic biopsy was performed in patients with PIRADS ≥ 3 lesions. Cohen kappa values were used to quantify interobserver agreement. Positive predictive value (PPV) was used to determine accuracy of PI-RADS score for detection of clinically significant prostate cancer (csPCa) (ISUP Grade Group ≥ 2).ResultsThree hundred and thirty-two lesions in 303 patients were reviewed and 252 lesions in 198 patients biopsied. The PI-RADS score was concordant in 60.5% of lesions, downgraded in 17.8%, and upgraded in 7.8%. Agreement between community and tertiary center interpretation was fair (κ = 0.354), with greater agreement for PI-RADS ≥ 4 (κ = 0.523) than PI-RADS ≥ 3 (κ = 0.456), and peripheral zone (κ = 0.419) than transition zone lesions (κ = 0.251). Prevalence of csPCa in biopsied lesions was 40.9%.ConclusionThere is variability in community and tertiary care center interpretation of prostate MRI in cancer detection, with higher concordance rates for higher grade and peripheral zone lesions. These differences demonstrate the added value of multidisciplinary round review and highlight the need for ongoing education and feedback.Graphical abstract

Structured reporting in radiologic education - Potential of different PI-RADS versions in prostate MRI controlled by in-bore MR-guided biopsies.

Objectives:To evaluate the efficiency of structured reporting in radiologic education – based on the example of different PI-RADS score versions for multiparametric MRI (mpMRI) of the prostate.Methods:MpMRI of 688 prostate lesions in 180 patients were retrospectively reviewed by an experienced radiologist and by a student using PI-RADS V1 and V2. Data sets were reviewed for changes according to PI-RADS V2.1. The results were correlated with results obtained by MR-guided biopsy. Diagnostic potency was evaluated by ROC analysis. Sensitivity, specificity and correct-graded samples were evaluated for different cutpoints. The agreement between radiologist and student was determined for the aggregation of the PI-RADS score in three categories. The student’s time needed for evaluation was measured.Results:The area under curve of the ROC analysis was 0.782/0.788 (V1/V2) for the student and 0.841/0.833 (V1/V2) for the radiologist. The agreement between student and radiologist showed a Cohen‘s weighted κ coefficient of 0.495 for V1 and 0.518 for V2. Median student’s time needed for score assessment was 4:34 min for PI-RADSv1 and 2:00 min for PI-RADSv2 (p < 0.001). Re-evaluation for V2.1 changed the category in 1.4% of all ratings.Conclusion:The capacity of prostate cancer detection using PI-RADS V1 and V2 is dependent on the reader‘s experience. The results from the two observers indicate that structured reporting using PI-RADS and, controlled by histopathology, can be a valuable and quantifiable tool in students‘ or residents’ education. Herein, V2 was superior to V1 in terms of inter-observer agreement and time efficacy.Advances in knowledge:Structured reporting can be a valuable and quantifiable tool in radiologic education. Structured reporting using PI-RADS can be used by a student with good performance. PI-RADS V2 is superior to V1 in terms of inter-observer agreement and time efficacy.

Urinary MyProstateScore (MPS) to Rule out Clinically-Significant Cancer in Men with Equivocal (PI-RADS 3) Multiparametric MRI: Addressing an Unmet Clinical Need

ObjectiveTo evaluate the complementary value of urinary MyProstateScore (MPS) testing and multiparametric MRI (mpMRI) and assess outcomes in patients with equivocal mpMRI. Materials and MethodsIncluded patients underwent mpMRI followed by urine collection and prostate biopsy at the University of Michigan between 2015 –2019. MPS values were calculated from urine specimens using the validated model based on serum PSA, urinary PCA3, and urinary TMPRSS2:ERG. In the PI-RADS 3 population, the discriminative accuracy of PSA, PSAD, and MPS for GG≥2 cancer was quantified by the AUC curve. Decision curve analysis was used to assess net benefit of MPS relative to PSAD. ResultsThere were 540 patients that underwent mpMRI and biopsy with MPS available. The prevalence of GG≥2 cancer was 13% for PI-RADS 3, 56% for PI-RADS 4, and 87% for PI-RADS 5. MPS was significantly higher in men with GG≥2 cancer [median 44.9, IQR (29.4 –57.5)] than those with negative or GG1 biopsy [median 29.2, IQR (14.8 –44.2); P <.001] in the overall population and when stratified by PI-RADS score. In the PI-RADS 3 population (n = 121), the AUC for predicting GG≥2 cancer was 0.55 for PSA, 0.62 for PSAD, and 0.73 for MPS. MPS provided the highest net clinical benefit across all pertinent threshold probabilities. ConclusionIn patients that underwent mpMRI and biopsy, MPS was significantly associated with GG≥2 cancer across all PI-RADS scores. In the PI-RADS 3 population, MPS significantly outperformed PSAD in ruling out GG≥2 cancer. These findings suggest a complementary role of MPS testing in patients that have undergone mpMRI.

Establishment and evaluation of a model for predicting ISUP pathological grade≥2 before radical prostatectomy

Objective: Based on the 2014 version of the International Association of Urological Pathology (ISUP) pathological classification standards, a prediction model that can predict the pathological classification of ISUP ≥2 in patients with prostate cancer (PCa) before radical prostatectomy (RP) was established and evaluated. Methods: The clinical data of 171 patients who had undergone RP from January 2017 to September 2020 in the Second Affiliated Hospital of Soochow University and obtained postoperative pathological results of all specimens were retrospectively collected. The patients were 46-83 (70±7) years old. For patients with RP ISUP pathologic stage as the gold standard, according to the pathological grading is level 2 or higher is divided into two groups(42 patients with ISUP grade=1 and 129 patients with ISUP grade ≥2). the predictors of ISUP pathology grade ≥2 after RP were screened by logistics regression analysis, predictive models were established and ROC curves were used to evaluate the efficacy of each model in diagnosing RP with pathological grade ≥2, and comparisons were conducted by DeLong test. Results: Compared with patients with ISUP grade=1, patients with ISUP grade≥2 had higher prostate specific antigen (PSA) and prostate specific antigen density (PSAD) (14.21(8.57, 24.98)ng/ml vs 7.98(5.41, 12.54)ng/ml, 0.33(0.20, 0.74)μg.L-1.ml-1 vs 0.16(0.12, 0.24)μg.L-1.ml-1), lower prostate volume (PV) (48.62(34.17,73.99)ml vs 38.94(28.15,54.84)ml)(all P<0.05). Multi-parameter magnetic resonance imaging (mp-MRI) prostate imaging and reporting system (PI-RADS) score, the positive ratio of puncture needles and the pathological grade of puncture ISUP were also significantly different between the two groups (all P<0.05). The combined mp-MRI PI-RADS score (OR=3.337, 95%CI: 1.990-5.593, P<0.001) and puncture ISUP pathological grading (OR=4.041, 95%CI: 1.960-8.334, P<0.001) had the highest diagnostic efficacy for pathological grading ≥2 after RP (AUC=0.916, P<0.05). Conclusion: The combined mp-MRI PI-RADS score and puncture ISUP pathological grading had the highest diagnostic efficacy for pathological grading ≥2 after RP.

A correlation of PI-RADS score and pathological grading outcome post radical prostatectomy: A retrospective review

Objective: To investigate the correlation between the PI-RADS score and the pathologic Gleason score in the final pathological grading and to detect risk factors associated with the outcomes. Materials and Methods: Data from January 2017 to September 2019 were reviewed. Inclusion criteria included patients who had undergone standard protocol prostate magnetic resonance imaging (MRI) in King Chulalongkorn Memorial Hospital and underwent radical prostatectomy during the period. Data collected were age, PI-RADS score, Gleason score (GS), prostate-specific antigen (PSA), prostate size, PSA density, lesion size, and extraprostatic extension (EPE) evident in MRI. Results: One hundred and eight patients were included. PI-RADS was significantly associated with GS (Chi-Square p = 0.039). The percentage of significant tumors found in PI-RADS 3, 4, 5 were 66%, 86% 90% respectively. Analysis of independent risk factors only found PI-RADS 5 to have a statistically significant association with GS ≥ 7 (OR6.67 (1.24-35.71) p = 0.03). The cut-off value of lesion size ≥ 15 vs &lt; 15 and PI-RADS 4 had a higher odds ratio than other parameters (OR 3.89 (0.82-18.41) p = 0.09, OR 3.29 (0.79-13.86) p = 0.11 respectively). Conclusion: The PI-RADS scoring system was found to be highly associated with Gleason’s grading score. No association was found between any significant risk factor and significant prostate cancer. Lesion size could be used to combine with the PI-RADS scoring system in the detection of significant tumors. A high percentage of significant tumors were found with a PI-RADS 3 score and it may be worth taking a biopsy in the case of a PI-RADS 3 lesion.

Automatic PI-RADS assignment by means of formal methods.

The Prostate Imaging Reporting and Data System (PI-RADS) version 2 emerged as standard in prostate magnetic resonance imaging examination. The Pi-RADS scores are assigned by radiologists and indicate the likelihood of a clinically significant cancer. The aim of this paper is to propose a methodology to automatically mark a magnetic resonance imaging with its related PI-RADS. We collected a dataset from two different institutions composed by DWI ADC MRI for 91 patients marked by expert radiologists with different PI-RADS score. A formal model is generated starting from a prostate magnetic resonance imaging, and a set of properties related to the different PI-RADS scores are formulated with the help of expert radiologists and pathologists. Our methodology relies on the adoption of formal methods and radiomic features, and in the experimental analysis, we obtain a specificity and sensitivity equal to 1. The proposed methodology is able to assign the PI-RADS score by analyzing prostate magnetic resonance imaging with a very high accuracy.