Suspicious Magnetic Resonance Imaging Research Articles

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.

Normalised repeat serum prostate-specific antigen: associations with age and magnetic resonance imaging results.

To assess the value of a repeat prostate-specific antigen measurement (PSA2) before magnetic resonance imaging (MRI) in men with a raised PSA (PSA1) <10 µg/L. Medical records of men aged < 75 years referred in 2021 for PSA1 3.0-9.9 µg/L (< 70 years) or 5.0-9.9 µg/L (70-74 years) were reviewed. PSA2 was sampled before MRI within 60 days from PSA1. Odds ratios (ORs) were calculated with logistic regression. Chi-square and trend-test were used for categorical variables. A total of 341 men were included. Median time between PSA1 and PSA2 was 28 days (interquartile range 20-35 days). PSA normalised in 16% (95% confidence interval [CI]: 13-21). Younger men were more likely to have a normal PSA2 (OR: 0.95 per year older, 95% CI: 0.92-0.99). Among men aged < 70 years, those with PSA1 < 5 µg/L were more likely to have normalised PSA2 than those with PSA1 ≥ 5 µg/L (21% vs. 10%, p = 0.01). A greater proportion of men with normalised PSA2 had a Prostate Imaging Data and Reporting System MRI score of 1-3 than men with non-normalised PSA2 (93% vs. 77%, p = 0.01). A clinically significant proportion of men with a moderately raised PSA value have a normal PSA2. Younger men and men with lower PSA1 were more likely to have a normal PSA2. Few men with normalised PSA2 had suspicious MRI findings. Routine repeat PSA-testing may be motivated in men with a moderately raised PSA value to save MRI resources, particularly in younger men.

Do we need MRI in all biopsy naïve patients? A multicenter cohort analysis

PurposeThe combined approach (CB) of magnetic resonance imaging (MRI)-guided biopsy (TB) and systematic biopsy (SB) is strongly recommended based on numerous studies in biopsy naïve men with suspicion of clinically significant prostate cancer (csPCA). However, the unbalanced accessibility of MRI, challenges related to reimbursement and the scarcity of specialized medical practitioners continue to impede a widespread implementation.Therefore, our objective was to determine a subset of men that could undergo SB without an increased risk of underdiagnosis at reduced expenses.MethodsA multicenter analysis of 2714 men with confirmed PCA and suspicious MRI who underwent CB were enrolled. Cancer detection rates were compared between the different biopsy routes SB, TB and CB using McNemar paired test. Additionally, Gleason grade up- and down-grading was determined.ResultsCB detected more csPCA than TB and SB (p < 0.001), irrespective of MRI findings or biopsy route (transperineal vs. transrectal). Thereby, single biopsy approaches misgraded > 50% of csPCA. TB showed higher diagnostic efficiency, defined as csPCA detection per biopsy core than CB and SB (p < 0.001). For patients with abnormal DRE and PSA levels > 12.5 ng/ml, PSAD > 0.35 ng/ml/cm3, or > 75 years, SB and CB showed similar csPCA detection rates.ConclusionConducting CB provides the highest level of diagnostic certainty and minimizes the risk of underdiagnosis in almost all biopsy-naive men. However, in patients with suspicious DRE and high PSA levels, PSAD, or advanced age solely using SB leads to similar csPCA detection rates. Thus, a reduced biopsy protocol may be considered for these men in case resources are limited.

Multiparametric Magnetic Resonance Imaging in Prostate Cancer Screening at the Age of 45 Years: Results from the First Screening Round of the PROBASE Trial

BackgroundMagnetic resonance imaging (MRI) has been suggested as a tool for guiding biopsy recommendations in prostate cancer (PC) screening. ObjectiveTo determine the performance of multiparametric MRI (mpMRI) in young men at age 45 yr who participated in a PC screening trial (PROBASE) on the basis of baseline prostate-specific antigen (PSA). Design, setting, and participantsParticipants with confirmed PSA ≥3 ng/ml were offered mpMRI followed by MRI/transrectal ultrasound fusion biopsy (FBx) with targeted and systematic cores. mpMRI scans from the first screening round for men randomised to an immediate PSA test in PROBASE were evaluated by local readers and then by two reference radiologists (experience >10 000 prostate MRI examinations) blinded to the histopathology. The PROBASE trial is registered as ISRCTN37591328 Outcome measurements and statistical analysisThe local and reference Prostate Imaging-Data and Reporting System (PI-RADS) scores were compared, and the sensitivity, negative predictive value (NPV), and accuracy were calculated for both readings for different cutoffs (PI-RADS 3 vs 4). Results and limitationsOf 186 participants, 114 underwent mpMRI and FBx. PC was detected in 47 (41%), of whom 33 (29%) had clinically significant PC (csPC; International Society of Urological Pathology grade group ≥2). Interobserver reliability between local and reference PI-RADS scores was moderate (k = 0.41). At a cutoff of PI-RADS 4, reference reading showed better performance for csPC detection (sensitivity 79%, NPV 91%, accuracy of 85%) than local reading (sensitivity 55%, NPV 80%, accuracy 68%). Reference reading did not miss any PC cases for a cutoff of PI-RADS <3. If PI-RADS ≥4 were to be used as a biopsy cutoff, mpMRI would reduce negative biopsies by 68% and avoid detection of nonsignificant PC in 71% of cases. ConclusionsProstate MRI in a young screening population is difficult to read. The MRI accuracy of for csPC detection is highly dependent on reader experience, and double reading might be advisable. More data are needed before MRI is included in PC screening for men at age 45 yr. Patient summaryMeasurement of prostate specific antigen (PSA) is an effective screening test for early detection of prostate cancer (PC) and can reduce PC-specific deaths, but it can also lead to unnecessary biopsies and treatment. Magnetic resonance imaging (MRI) after a positive PSA test has been proposed as a way to reduce the number of biopsies, with biopsy only recommended for men with suspicious MRI findings. Our results indicate that MRI accuracy is moderate for men aged 45 years but can be increased by a second reading of the images by expert radiologists. For broad application of MRI in routine screening, double reading may be advisable.

Uterine mesenchymal tumors: development and preliminary results of a magnetic resonance imaging (MRI) diagnostic algorithm.

The aim of our study is to propose a diagnostic algorithm to guide MRI findings interpretation and malignancy risk stratification of uterine mesenchymal masses with a multiparametric step-by-step approach. A non-interventional retrospective multicenter study was performed: Preoperative MRI of 54 uterine masses was retrospectively evaluated. Firstly, the performance of MRI with monoparametric and multiparametric approach was assessed. Reference standard for final diagnosis was surgical pathologic result (n = 53 patients) or at least 1-year MR imaging follow-up (n = 1 patient). Subsequently, a diagnostic algorithm was developed for MR interpretation, resulting in a Likert score from 1 to 5 predicting risk of malignancy of the uterine lesion. The accuracy and reproducibility of the MRI scoring system were then tested: 26 preoperative pelvic MRI were double-blind evaluated by a senior (SR) and junior radiologist (JR). Diagnostic performances and the agreement between the two readers with and without the application of the proposed algorithm were compared, using histological results as standard reference. Multiparametric approach showed the best diagnostic performance in terms of accuracy (94.44%,) and specificity (97.56%). DWI was confirmed as the most sensible parameter with a relative high specificity: low ADC values (mean 0.66) significantly correlated to uterine sarcomas diagnosis (p < 0.01). Proposed algorithm allowed to improve both JR and SR performance (algorithm-aided accuracy 88.46% and 96%, respectively) and determined a significant increase in inter-observer agreement, helping even the less-experienced radiologist in this difficult differential diagnosis. Uterine leiomyomas and sarcomas often show an overlap of clinical and imaging features. The application of a diagnostic algorithm can help radiologists to standardize their approach to a complex myometrial mass and to easily identify suspicious MRI features favoring malignancy.

Is Active Surveillance an Option for the Management of Men with Low-grade Prostate Cancer and a Positive Family History? Results from a Large, Single-institution Series

BackgroundFamily history (FH) of prostate cancer (PCa) is associated with an increased risk of PCa and adverse disease features. However, whether patients with localized PCa and FH could be considered for active surveillance (AS) remains controversial. ObjectiveTo assess the association between FH and reclassification of AS candidates, and to define predictors of adverse outcomes in men with positive FH. Design, setting, and participantsOverall, 656 patients with grade group (GG) 1 PCa included in an AS protocol at a single institution were identified. Outcome measurements and statistical analysisKaplan-Meier analyses assessed the time to reclassification (GG ≥2 and GG ≥3 at follow-up biopsies) overall and according to FH status. Multivariable Cox regression tested the impact of FH on reclassification and identified the predictors among men with FH. Men treated with delayed radical prostatectomy (n = 197) or external-beam radiation therapy (n = 64) were identified, and the impact of FH on oncologic outcomes was assessed. Results and limitationsOverall, 119 men (18%) had FH. The median follow-up was 54 mo (interquartile range 29–84 mo), and 264 patients experienced reclassification. The 5-yr reclassification-free survival rate was 39% versus 57% for FH versus no FH (p = 0.006), and FH was associated with reclassification to GG ≥2 (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.19–2.15, p = 0.002). In men with FH, the strongest predictors of reclassification were prostate-specific antigen (PSA) density (PSAD), high-volume GG 1 (≥33% of cores involved or ≥50% of any core involved), and suspicious magnetic resonance imaging (MRI) of the prostate (HRs 2.87, 3.04, and 3.87, respectively; all p < 0.05). No association between FH, adverse pathologic features, and biochemical recurrence was observed (all p > 0.05). ConclusionsPatients with FH on AS are at an increased risk of reclassification. Negative MRI, low disease volume, and low PSAD identify men with FH and a low risk of reclassification. Nonetheless, sample size and wide CIs entail caution in drawing conclusions based on these results. Patient summaryWe tested the impact of family history in men on active surveillance for localized prostate cancer. A significant risk of reclassification, but not adverse oncologic outcomes after deferred treatment, prompts the need for cautious discussion with these patients, without precluding initial expectant management.

974. Correlation of Magnetic Resonance Imaging (MRI) and Bone Histopathology in the Diagnosis of Foot Osteomyelitis in Diabetic Patients.

Abstract Background Inaccurate diagnosis of osteomyelitis (OM) in the setting of foot infection may lead to inappropriate therapy. Recommended imaging to discern OM is magnetic resonance imaging (MRI), but studies have shown varied sensitivity and specificity. The goal of our study is to determine the accuracy of MRI by comparing with bone biopsy histopathology. Methods Retrospective chart review of adult patients with diabetes mellitus and foot infection with concern for OM. They had MRI with contrast and subsequent bone biopsy, resection or amputation with histologic examination. A second, blinded musculoskeletal radiologist reviewed all reports in which there was diagnostic uncertainty. Exclusion criteria: foot tumor or recent foot surgery or injury. Results 63 eligible patients with 87 episodes of foot infection (50 males, 13 females, mean age 55 years) met study criteria. Time gap between biopsy and MRI was mean 6 days (range 0 to 23 days). 72 MRIs were positive (including 7 highly suspicious MRI reads), 11 negative and 4 indeterminate. 53 of the histologic results were positive for OM and 34 were negative. Two scenarios were created by placing 4 indeterminate MRI reads as positive in scenario 1 and negative in scenario 2. In scenario 1, there was only 1 false negative MRI but 24 false positives. In scenario 2, there were 2 false negative MRI and 21 false positives. Out of 74 bone specimens of those not on recent antimicrobial therapy, bone cultures were positive for pathogenic organisms on 22 specimens without histologic evidence of OM. Conclusion In both the above scenarios, sensitivity was high. Specificity was found to be lower than the reported specificity of MRI in the diagnosis of diabetic foot OM, which has been reported as 40% to 100%. Our data demonstrate that MRI is useful to rule out OM if negative but performs poorly in ruling in OM. Bone specimen for histopathology is essential to confirm the diagnosis. Bone culture is helpful to guide antimicrobial therapy rather than diagnosing OM. Prospective studies are warranted. Disclosures All Authors: No reported disclosures.

Optimizing multiparametric magnetic resonance imaging-targeted biopsy and detection of clinically significant prostate cancer: the role of perilesional sampling.

The added-value of systematic biopsy (SB) in patients undergoing magnetic resonance imaging(MRI)-targeted biopsy(TB) remains unclear and the spatial distribution of positive cores relative to the MRI lesion has been poorly studied. The aim of this study was to determine the utility of perilesional biopsy in detecting clinically significant prostate cancer(csPCa). We enrolled 505 consecutive patients that underwent SB and TB for suspicious MRI lesions (PI-RADS score 3-5) at Jules Bordet Institute between June 2016 and January 2022. Patient-specific tridimensional prostate maps were reviewed to determine the distance between systematic cores containing csPCa and the MRI index lesion. Primary outcomes were the cancer detection rate (CDR) per patient and the cumulative cancer distribution rate of positive cores for each 5 mm interval from the MRI index lesion. The secondary outcome was the identification of risk groups for the presence of csPCa beyond a 10 mm margin using the chi-square automated interaction detector (CHAID) machine learning algorithm. Overall, the CDR for csPCa of TB, SB, and combined method were 32%, 25%, and 37%, respectively. While combined method detected more csPCa compared to TB (37% vs. 32%, p < 0.001), no difference was found when TB was associated with perilesional sampling within 10 mm (37% vs. 35%, p = 0.2). The cumulative cancer distribution rate for csPCa reached 86% for the 10 mm margin. The CHAID algorithm identified three risk groups: (1) PI-RADS3 ("low-risk"), (2) PI-RADS4 or PI-RADS5 and PSA density<0.15 ng/ml ("intermediate-risk"), and (3) PI-RADS 5 and PSA density≥0.15 ng/ml ("high-risk"). The risk of missing csPCa was 2%, 8%, and 29% for low-, intermediate- and high-risk groups, respectively. Avoiding biopsies beyond a 10 mm margin prevented the detection of 19% of non-csPCa. Perilesional biopsy template using a 10 mm margin seems a reasonable alternative to the combined method with a comparable detection of csPCa. Our risk stratification may further enhance the selection of patients.

Percutaneous Uterine Needle Biopsy with Microscopic and Array-CGH Analyses for Preoperative Sarcoma Diagnosis in Patients with Suspicious Myometrial Tumors on MRI: A Prospective Pilot Study (SARCGYN).

Unlike for soft tissue sarcomas, percutaneous biopsy is not validated for uterine myometrial tumors, leading to leiomyosarcoma inadvertent morcellation and overtreatment in childbearing patients. This study aimed to evaluate preoperative percutaneous uterine needle biopsy (PUB) with microscopic examination (M-PUB) and array-comparative genomic hybridization (MCGH-PUB). This was a prospective single-center cohort study including all consecutive patients who were candidates for hysterectomy because of suspected uterine leiomyosarcoma on magnetic resonance imaging (MRI) who received PUB. Microscopic and array-CGH analyses with genomic index (GI) counts were performed to guide the therapeutic strategy. Smooth-muscle tumors with suspect features with a GI above 15 were deemed malignant, as were tumors without microscopic malignant features with a complex genomic profile (GI above 30 or malignant profile). Preoperative diagnoses based on M-PUB and MCGH-PUB were compared with the postsurgical pathological specimen or follow-up. From November 2016 to February 2022, 34 patients were included. Based on the surgical specimen (N = 23) or follow-up (N = 11), final diagnoses were 11 sarcomas and 23 non-sarcomas. The median follow-up was 12 months (IQR 6-37). The diagnostic accuracies of M-PUB and MCGH-PUB were 94% and 100%, respectively. The sensitivity, specificity, and negative predictive value of MCGH-PUB were 100%, 100%, and 100%, respectively. A high GI was significantly associated with malignancy (P < 0.001). Genomic analyses allowed malignancy upgrades for four tumors. There were no complications and no dissemination along the biopsy track. MCGH-PUB is safe and accurate for preoperatively diagnosing uterine sarcomas and should be used routinely after suspicious MRI to tailor surgery.

Cerebrospinal Fluid Biomarkers for the Detection of Autoimmune Depression

The discovery of anti–NMDA receptor encephalitis in 2007 provided enormous boosts to immunological research in neurology and psychiatry. Anti–NMDA receptor encephalitis is associated with severe neurological and a plethora of psychiatric symptoms, including psychotic and affective phenomena (1,2). To date, several more well-characterized neuronal autoantibodies have been described (1,2). According to current international consensus criteria, a diagnosis of possible autoimmune encephalitis (AE) should be considered in the presence of a subacute neuropsychiatric syndrome (with severe working memory deficits, an altered mental state, or psychiatric symptoms) in combination with at least one further organic sign, such as inflammatory cerebrospinal fluid (CSF) changes with an increased white blood cell (WBC) count, suspicious magnetic resonance imaging (MRI) changes, epileptic seizures, or focal neurological signs (2).

Magnetic Resonance Imaging–targeted Prostate Biopsy Compared with Systematic Prostate Biopsy in Biopsy-naïve Patients with Suspected Prostate Cancer

BackgroundIt remains uncertain whether transrectal ultrasound (TRUS)-guided systematic biopsies can be omitted and rely solely on multiparametric magnetic resonance imaging–targeted biopsies (MRI-TBx) in biopsy-naïve men suspected of prostate cancer (PCa). ObjectiveTo compare PCa detection in biopsy-naïve men between systematic biopsy and MRI-TBx. Design, setting, and participantsA prospective cohort study was conducted in a Dutch teaching hospital. Consecutive patients with suspected PCa, no history of biopsy, and no clinical suspicion of metastasis underwent both TRUS-guided systematic biopsies and MRI-TBx by multiparametric magnetic resonance imaging (mpMRI)-ultrasound fusion, including sham biopsies in case of negative mpMRI. Outcome measurements and statistical analysisClinically significant PCa (csPCa), defined as group ≥2 on the International Society of Urological Pathology grading, was detected. Results and limitationsThe overall prevalence of csPCa, irrespective of biopsy technique, was 37.4% (132/353) in our population. MRI-TBx were performed in 263/353 (74.5%) patients with suspicious mpMRI (Prostate Imaging Reporting and Data System [PI-RADS] ≥3). The detection rates for csPCa were 39.5% for MRI-TBx and 42.9% for systematic biopsies. The added values, defined as the additional percentages of patients with csPCa detected by adding one biopsy technique, were 8.7% for the systematic biopsies and 5.3% for MRI-TBx. In patients with nonsuspicious mpMRI, five cases (6%) of csPCa were found by systematic biopsies. ConclusionsThis study in biopsy-naïve patients suspected for PCa showed that systematic biopsies have added value to MRI-TBx alone in patients with mpMRI PI-RADS >2. Patient summaryWe studied magnetic resonance imaging (MRI)-guided prostate biopsy for diagnosing prostate cancer and compared it with the standard method of prostate biopsy. Standard systematic biopsies cannot be omitted in patients with suspicious MRI, as they add to the detection of significant prostate cancer.

Designing and Implementing a Population-based Organised Prostate Cancer Testing Programme

BackgroundEuropean guidelines recommend that well-informed men at elevated risk of having prostate cancer (PCa) should be offered prostate-specific antigen (PSA) testing with risk-stratified follow-up. The Swedish National Board of Health and Welfare recommends against screening for PCa but supports regional implementation of organised prostate cancer testing (OPT). ObjectiveTo report the process for designing and implementing OPT programmes. Design, setting, and participantsPopulation-based OPT programmes in two Swedish regions, designed to include men aged between 50 and 74 yr, launched in September 2020 for 50-yr-old men. Outcome measurements and statistical analysisThe number of men invited, the participation rate, and the numbers of magnetic resonance imaging (MRI) scans, urological visits, and biopsies from September 2020 to June 2021 were recorded. Results and limitationsTwo Swedish regions co-designed an OPT programme with a risk-stratified diagnostic algorithm based on prostate-specific antigen (PSA), PSA density, MRI findings, and age. An automated administrative system was developed on a nationwide web-based platform. Invitation letters and test results are automatically generated and sent out by post. Men with PSA ≥3ng/ml, a suspicious MRI lesion, and/or PSA density ≥0.15 ng/ml/cm3 are referred for a prostate biopsy. Test results are registered for quality control and research. By June 2021, a total of 16 515 men were invited, of whom 6309 (38%) participated; 147 had an MRI scan and 39 underwent prostate biopsy. The OPT framework, algorithm, and diagnostic pathways have been working well. ConclusionsWe designed and implemented a framework for OPT with a high grade of automation. The framework and organisational experiences may be of value for others who plan a programme for early detection of PCa. Patient summaryWe describe the implementation of an organised testing programme for early detection of prostate cancer in two Swedish regions. This model is the first of its kind and may serve as a template for similar programmes.

Prostate Cancer Patients Under Active Surveillance with a Suspicious Magnetic Resonance Imaging Finding Are at Increased Risk of Needing Treatment: Results of the Movember Foundation’s Global Action Plan Prostate Cancer Active Surveillance (GAP3) Consortium

BackgroundThe inclusion criterion for active surveillance (AS) is low- or intermediate-risk prostate cancer. The predictive value of the presence of a suspicious lesion at magnetic resonance imaging (MRI) at the time of inclusion is insufficiently known. ObjectiveTo evaluate the percentage of patients needing active treatment stratified by the presence or absence of a suspicious lesion at baseline MRI. Design, setting, and participantsA retrospective analysis of the data from the multicentric AS GAP3 Consortium database was conducted. The inclusion criteria were men with grade group (GG) 1 or GG 2 prostate cancer combined with prostate-specific antigen <20 ng/ml. We selected a subgroup of patients who had MRI at baseline and for whom MRI results and targeted biopsies were used for AS eligibility. Suspicious MRI was defined as an MRI lesion with Prostate Imaging Reporting and Data System (PI-RADS)/Likert ≥3 and for which targeted biopsies did not exclude the patient for AS. Outcome measurements and statistical analysisThe primary outcome was treatment free survival (FS). The secondary outcomes were histological GG progression FS and continuation of AS (discontinuation FS). Results and limitationsThe study cohort included 2119 patients (1035 men with nonsuspicious MRI and 1084 with suspicious MRI) with a median follow-up of 23 (12–43) mo. For the whole cohort, 3-yr treatment FS was 71% (95% confidence interval [CI]: 69–74). For nonsuspicious MRI and suspicious MRI groups, 3-yr treatment FS rates were, respectively, 80% (95% CI: 77–83) and 63% (95% CI: 59–66). Active treatment (hazard ratio [HR] = 2.0, p < 0.001), grade progression (HR = 1.9, p < 0.001), and discontinuation of AS (HR = 1.7, p < 0.001) were significantly higher in the suspicious MRI group than in the nonsuspicious MRI group. ConclusionsThe risks of switching to treatment, histological progression, and AS discontinuation are higher in cases of suspicious MRI at inclusion. Patient summaryAmong men with low- or intermediate-risk prostate cancer who choose active surveillance, those with suspicious magnetic resonance imaging (MRI) at the time of inclusion in active surveillance are more likely to show switch to treatment than men with nonsuspicious MRI.

Evaluation of the Predictive Role of Blood-Based Biomarkers in the Context of Suspicious Prostate MRI in Patients Undergoing Prostate Biopsy.

The aim of this study was to assess the predictive value of pre-biopsy blood-based markers in patients undergoing a fusion biopsy for suspicious prostate magnetic resonance imaging (MRI). We identified 365 consecutive patients who underwent MRI-targeted and systematic prostate biopsy for an MRI scored Prostate Imaging–Reporting and Data System Version (PI-RADS) ≥ 3. We evaluated the neutrophil/lymphocyte ratio (NLR), derived neutrophil/lymphocyte ratio (dNLR), platelet/lymphocyte ratio (PLR), systemic immune inflammation index (SII), lymphocyte/monocyte ratio (LMR,) de Ritis ratio, modified Glasgow Prognostic Score (mGPS), and prognostic nutrition index (PNI). Uni- and multivariable logistic models were used to analyze the association of the biomarkers with biopsy findings. The clinical benefits of biomarkers implemented in clinical decision-making were assessed using decision curve analysis (DCA). In total, 69% and 58% of patients were diagnosed with any prostate cancer and Gleason Grade (GG) ≥ 2, respectively. On multivariable analysis, only high dNLR (odds ratio (OR) 2.61, 95% confidence interval (CI) 1.23–5.56, p = 0.02) and low PNI (OR 0.48, 95% CI 0.26–0.88, p = 0.02) remained independent predictors for GG ≥ 2. The logistic regression models with biomarkers reached AUCs of 0.824–0.849 for GG ≥ 2. The addition of dNLR and PNI did not enhance the net benefit of a standard clinical model. Finally, we created the nomogram that may help guide biopsy avoidance in patients with suspicious MRI. In patients with PI-RADS ≥ 3 lesions undergoing MRI-targeted and systematic biopsy, a high dNLR and low PNI were associated with unfavorable biopsy outcomes. Pre-biopsy blood-based biomarkers did not, however, significantly improve the discriminatory power and failed to add a clinical benefit beyond standard clinical factors.

Clinical implementation of pre-biopsy magnetic resonance imaging pathways for the diagnosis of prostate cancer.

ObjectiveTo assess the outcomes of pre‐biopsy magnetic resonance imaging (MRI) pathways, as a tool in biopsy‐naïve men with suspicion of prostate cancer, in routine clinical practice. Secondary outcomes included a comparison of transrectal MRI‐directed biopsy (TR‐MRDB) and transperineal (TP)‐MRDB in men with suspicious MRI.Patients and MethodsWe retrospectively assessed a two‐centre cohort of consecutive biopsy‐naïve men with suspicion of prostate cancer who underwent a Prostate Imaging‐Reporting and Data System version 2 (PI‐RADS v2) compliant pre‐biopsy MRI in a single, high‐volume centre between 2015 and 2019 (Centre 1). Men with suspicious MRI scans underwent TR‐MRDB in Centre 1 and TP‐MRDB with additional random biopsies (RB) in Centre 2. The MRI and histopathology were assessed in the same institution (Centre 1). Outcomes included: (i) overall detection rates of Grade Group (GG) 1, GG ≥2, and GG ≥3 cancer in men with suspicious MRI; (ii) Biopsy‐avoidance due to non‐suspicious MRI; and (iii) Cancer detection rates and biopsy‐related complications between TR‐ and TP‐MRDB. To reduce confounding bias for MRDB comparisons, inverse probability weighting (IPW) was performed for age, digital rectal examination, prostate‐specific antigen (PSA), prostate volume, PSA density, and PI‐RADS category.ResultsOf the 2597 men included, the overall GG 1, GG ≥2, and GG ≥3 prevalence was 8% (210/2597), 27% (697/2597), and 15% (396/2597), respectively. Biopsy was avoided in 57% (1488/2597) of men. After IPW, the GG 1, GG ≥2 and GG ≥3 detection rates after TR‐ and TP‐MRDB were comparable at 24%, 57%, and 32%; and 18%, 64%, and 38%, respectively; with mean differences of −5.7% (95% confidence interval [CI] −13% to 1.4%), 6.1% (95% CI −2.1% to 14%), and 5.7% (95% CI −1.7% to 13%). Complications were similar in TR‐MRDB (0.50%) and TP‐MRDB with RB (0.62%; mean difference 0.11%, 95% CI −0.87% to 1.1%).ConclusionThis high‐volume, two‐centre study shows pre‐biopsy MRI as a decision tool is implementable in daily clinical practice. Compared to recent trials, a substantially higher biopsy avoidance rate was achieved without compromising GG ≥2/GG ≥3 detection and coinciding with lower over detection rates of GG 1 cancer. Prostate cancer detection and complication rates were comparable for TR‐ and TP‐MRDB.

Diagnostic Accuracy of Microultrasound in Patients with a Suspicion of Prostate Cancer at Magnetic Resonance Imaging: A Single-institutional Prospective Study

BackgroundMultiparametric magnetic resonance imaging (MRI) represents the gold standard for the diagnosis of clinically significant prostate cancer (csPCa). The search for alternative diagnostic techniques is still ongoing. ObjectiveTo determine the accuracy of microultrasound (microUS) for the diagnosis of csPCa within prospectively collected cohort of patients with a suspicion of prostate cancer (PCa) according to MRI. Design, setting, and participantsA total of 320 consecutive patients with at least one Prostate Imaging Reporting and Data System (PIRADS) ≥3 lesion according to MRI were prospectively enrolled. InterventionAll patients received microUS before prostate biopsy using the ExactVu system; the Prostate Risk Identification using microUS (PRI-MUS) protocol was used to identify targets. The urologists were blinded to MRI results until after the microUS targeting was completed. All patients received both targeted (based on either microUS or MRI findings) and randomized biopsies. Outcome measurements and statistical analysisThe sensitivity and specificity of microUS to determine the presence of csPCa (defined as at least one core with a Gleason score ≥7 PCa) were determined. Multivariable logistic regression analysis was fitted to determine the predictors of csPCa. Results and limitationsClinically significant PCa was diagnosed in 116 (36.3%) patients. The sensitivity and negative predictive value of microUS for csPCa diagnosis were 89.7% and 81.5%, while specificity and positive predictive value were 26.0% and 40.8%, respectively. A combination of microUS-targeted and randomized biopsies would allow diagnosing the same proportion of csPCa as that diagnosed by an approach combining MRI-targeted and randomized biopsies (n = 113; 97.4%), with only three (2.6%) csPCa cases diagnosed by a microUS-targeted and three (2.6%) by an MRI-targeted approach. In a logistic regression model, an increasing PRI-MUS score was an independent predictor of csPCa (p ≤ 0.005). The main limitation of the current study is represented by the fact that all patients had suspicious MRI. ConclusionsMicroultrasound is a promising imaging modality for targeted prostate biopsies. Our results suggest that a microUS-based biopsy strategy may be capable of diagnosing the great majority of cancers, while missing only few patients with csPCa. Patient summaryAccording to our results, microultrasound (microUS) may represent an effective diagnostic alternative to magnetic resonance imaging for the diagnosis of clinically significant prostate cancer, providing high sensitivity and a high negative predictive value. Further randomized studies are needed to confirm the potential role of microUS in the diagnostic pathway of patients with a suspicion of prostate cancer.

Phase I Trial of MRI-Guided Prostate Cancer Lattice Extreme Ablative Dose (LEAD) Boost Radiation Therapy

A phase I clinical trial was designed to test the feasibility and toxicity of administering high-dose spatially fractionated radiation therapy to magnetic resonance imaging (MRI)-defined prostate tumor volumes, in addition to standard treatment. We enrolled 25 men with favorable to high-risk prostate cancer and 1 to 3 suspicious multiparametric MRI (mpMRI) gross tumor volumes (GTVs). The mpMRI-GTVs were treated on day 1 with 12 to 14 Gy via dose cylinders using a lattice extreme ablative dose technique. The entire prostate, along with the proximal seminal vesicles, was then treated to 76 Gy at 2 Gy/fraction. For some high-risk patients, the distal seminal vesicles and pelvic lymph nodes received 56 Gy at 1.47 Gy/fraction concurrently in 38 fractions. The total dose to the lattice extreme ablative dose cylinder volume(s) was 88 to 90 Gy (112-123 Gy in 2.0 Gy equivalents, assuming an α-to-β ratio of 3). Dosimetric parameters were satisfactorily met. Median follow-up was 66 months. There were no grade 3 acute/subacute genitourinary or gastrointestinal adverse events. Maximum late genitourinary toxicity was grade 1 in 15 (60%), grade 2 in 4 (16%), and grade 4 in 1 (4%; sepsis after a posttreatment transurethral resection). Maximum late gastrointestinal toxicity was grade 1 in 11 (44%) and grade 2 in 4 (16%). Two patients experienced biochemical failure. External beam radiation therapy delivered with an upfront spatially fractionated, stereotactic high-dose mpMRI-GTV boost is feasible and was not associated with any unexpected events. The technique is now part of a follow-up phase II randomized trial.

Accuracy of MRI-directed ultrasound and subsequent ultrasound-guided biopsy for suspicious breast MRI findings

To determine the accuracy of magnetic resonance imaging (MRI)-directed breast ultrasound and subsequent ultrasound-guided biopsy, and to evaluate patient and lesion factors associated with the detection of an ultrasound correlate for MRI findings. Health Insurance Portability and Accountability Act (HIPAA)-compliant, institutional review board-approved retrospective review of 7,332 consecutive contrast-enhanced MRI examinations from 1 January 2009 to 30 March 2012 was performed to identify MRI-detected lesions that underwent MRI-directed ultrasound, ultrasound-guided core-needle biopsy (USG-CNB), and follow-up MRI after benign biopsy. Examinations were reviewed in consensus. USG-CNB was considered accurate if the biopsy clip was within 1 cm of the MRI lesion on follow-up MRI. Medical records were reviewed for histopathology, patient demographics, and follow-up imaging. MRI-directed ultrasound was performed on 522 patients with MRI-detected findings. A presumed ultrasound correlate was identified in 298 cases and 221 (73.4%) underwent biopsy. Follow-up MRI after USG-CNB was performed for 90 benign concordant biopsied lesions. Seven lesions were excluded because the biopsy marker was not visible on the subsequent MRI examination. Of the remaining 83 lesions, the biopsy marker was accurate in 72 (87%) lesions on follow-up MRI and 11 were considered inaccurate (13%). Of these 11 lesions, five were considered benign based on stability/resolution at follow-up MRI, while six underwent subsequent tissue diagnosis (mean time to tissue diagnosis: 13 months), with 1/6 (16.7%) malignancies. Although MRI-directed ultrasound is a reliable and accurate method to evaluate MRI findings, a 13% inaccuracy rate for MRI-directed ultrasound-guided biopsy was found. Therefore, for cases with uncertain MRI-directed ultrasound correlation, MRI-guided biopsy should be performed for accurate and timely diagnosis.

Assessment of MRI-detected lesions on screening tomosynthesis in patients with newly diagnosed breast cancer

ObjectivesThe purpose of this study is to retrospectively evaluate the presence of screening digital breast tomosynthesis (DBT) correlates for suspicious lesions detected on pre-operative staging magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer. MethodsAfter approval from the institutional review board (IRB), screening DBTs on breast cancer patients with BI-RADS 4 or 5 staging MRI exams between 8/1/17 and 8/1/18 were assessed for presence of DBT correlates for suspicious MRI findings. The pathology of the index lesion, type of additional MRI finding (mass, non-mass enhancement, or focus), correlative finding on tomosynthesis (mass, asymmetry/focal asymmetry, distortion, or calcifications), size on MRI and tomosynthesis, breast density, and pathology of the additional lesion were recorded. The chi-square test of association was used unless otherwise specified. Confidence intervals for proportions were estimated using the Wilson's score method. Results17/70 (24%) of additional lesions seen on pre-operative MRI exams in patients with newly diagnosed cancer had a mammographic correlate on corresponding screening DBT. There was no significant relationship between the presence of a mammographic correlate and the type of MRI finding (mass, NME, or focus), breast density, size of lesion, pathology of index cancer, or pathology of the additional lesion (p≥ 0.05). Conclusions76% of additional lesions seen on pre-operative staging MRI in patients with newly diagnosed breast cancer are not seen retrospectively on screening DBT. Since about 24% of MRI-detected additional lesions may have a DBT correlate, DBT exams should be reviewed in patients recalled for further workup of findings seen on pre-operative MRI since this may facilitate DBT-guided biopsy of suspicious lesions, which is preferable to MRI-guided biopsy for cost and patient comfort reasons.

7P - Current diagnostic strategy for mammographic microcalcification without specific ultrasound abnormality

BackgroundStereotactic vacuum-assisted breast biopsy (SVAB) is widely used to evaluate predominantly mammograhic microcalcifications without specific ultrasound abnormalities. Recently however, there raise the problem that screening mammography detect the indolent low grade ductal carcinoma in situ (DCIS), and such diseases don’t necessarily have to be diagnosed by invasive SVAB examination. Moreover, breast magnetic resonance imaging (MRI) has increasingly been performed over the past 10 years and reveals high sensitivity for detecting breast cancer, especially tumor undetectable by ultrasound. The purpose of this study was to assess the optimal indications for SVAB. MethodsFive hundred and eighty-one patients with mammographic microcalcifications underwent SVAB between 2008 and 2014 in our hospital. All calcification lesions were classified into several groups according to the calcification categories (CC) and the presence of suspicions MRI abnormalities. We examined the rate of malignant disease in the subgroups. BI-RADS 4 and 5 MRI lesions were defined as suspicious MRI abnormality (SMA). We considered high grade DCIS and invasive ductal carcinoma (IDC) as worrisome disease ought to be diagnosed. ResultsThe rate of malignancy was 6.3 % in CC2, 14.3% in CC3, 30.3% in CC4, and 80.0% in CC5 altogether. Of 581 patients, two hundred and thirty-three patients were underwent contrast enhanced MRI. Among category 3 or 4 microcalcifications without SMA (134 lesions), results of SVAB revealed 22 malignant lesions (16.4%), including 21 low grade DCIS and only one high grade DCIS and no IDC. If the lesions were accompanied by SMA, the rate of malignancy in these categories was increased to 66.2% (51/77), including 8 high grade DCIS and 14 IDC. If the regions were classified to category 5, about three forth cases were accompanied by SMA (17/23). Half of the category 5 lesions without SMA was malignant (3/6), including one high grade DCIS. ConclusionsMammographic microcalcification classified as 3 or 4 without suspicious MRI abnormal lesion were not be recommended for stereotactic vacuum-assisted biopsies. Legal entity responsible for the studyNaoki Sato. FundingHas not received any funding. DisclosureThe author has declared no conflicts of interest.Table7PTableMRI (-)MRI (-)MRI (-)MRI (+)MRI (+)MRI (+)category 3category 4category 5category 3category 4category 5Benign753331760ADH400120Low grade DCIS138211186High grade DCIS101355IDC000688