Transition Zone Lesions Research Articles

Detecting Clinically Significant Prostate Cancer in PI-RADS 3 Lesions Using T2w-Derived Radiomics Feature Maps in 3T Prostate MRI

Prostate Imaging Reporting and Data System version 2.1 (PI-RADS) category 3 lesions are a challenge in the clinical workflow. A better detection of the infrequently occurring clinically significant prostate cancer (csPCa) in PI-RADS 3 lesions is an important objective. The purpose of this study was to evaluate if feature maps calculated from T2-weighted (T2w) 3 Tesla (3T) MRI can help detect csPCa in PI-RADS category 3 lesions. In-house biparametric 3T prostate MRI examinations acquired between January 2019 and June 2023 because of elevated prostate-specific antigen (PSA) levels were retrospectively screened. Inclusion criteria were a PI-RADS 3 lesion and available results of an ultrasound-guided targeted and systematic biopsy. Exclusion criteria were a simultaneous PI-RADS category 4 or 5 lesion and hip replacement. Target lesions with the International Society of Urological Pathology (ISUP) grade group 1 were rated clinically insignificant PCa (ciPCa) and ≥2 csPCa. This resulted in 52 patients being included in the final analysis, of whom 11 (21.1%), 8 (15.4%), and 33 (63.5%) patients had csPCa, ciPCa, and no PCa, respectively, with the latter two groups being combined as non-csPCa. Eight of the csPCas were located in the peripheral zone (PZ) and three in the transition zone (TZ). In the non-csPCa group, 29 were located in the PZ and 12 in the TZ. Target lesions were marked with volumes of interest (VOIs) on axial T2w images. Axial T2w images were then converted to 93 feature maps. VOIs were copied into the maps, and feature quantity was retrieved directly. Features were tested for significant differences with the Mann–Whitney U-test. Univariate models for single feature performance and bivariate models implementing PSA density (PSAD) were calculated. Ten map-derived features differed significantly between the csPCa and non-csPCa groups (AUCs: 0.70–0.84). The diagnostic performance for TZ lesions (AUC: 0.83–1.00) was superior to PZ lesions (AUC: 0.74–0.85). In the bivariate models, performance in the PZ improved with AUCs >0.90 throughout. Parametric feature maps alone and as bivariate models with PSAD can (?) noninvasively identify csPCa in PI-RADS 3 lesions and could serve as a quantitative tool reducing ambiguity in PI-RADS 3 lesions.

Prostate cancer lesions in transition zone exhibit a higher propensity for pathological upgrading in radical prostatectomy.

The varying malignancy and lethality of different grades of prostate cancer (PCa) highlight the importance of accurate diagnosis. This study aims to evaluate the upgrading of transition zone (TZ) prostate cancer biopsies and identify factors to improve TZ biopsy accuracy. This retrospective study included 217 patients who underwent laparoscopic radical prostatectomy after 12 + X cores transperineal transrectal ultrasound-magnetic resonance imaging (MRI)-guided targeted prostate biopsy from 2018 to 2021 in our center. Patients with TZ lesions showed a higher incidence of International Society of Urological Pathology (ISUP) grade upgrading from 1 to higher grade compared to peripheral zone lesions (16.9% vs. 5.0%, p = 0.005). Multivariate analysis confirmed TZ lesions as an independent risk factor (OR: 4.594, 97.5% CI: 1.569-15.238, p = 0.008) for upgrading from 1 to higher. Additionally, the number of positive biopsy cores (OR: 0.586, 97.5% CI: 0.336-0.891, p = 0.029) and anterior TZ lesion location (OR: 10.797, 97.5% CI: 1.503-248.727, p = 0.048) were independent factors for the upgrading in TZ patients. This study found that PCa lesions located in the TZ, particularly the anterior TZ, have a higher risk of ISUP grade upgrading. This elevated risk arises from the insufficient distribution of biopsy cores around the TZ lesion. The findings underscore the importance of having an adequate number of biopsy cores around the lesion area to improve the accuracy of ISUP grade assessments.

Comparison of the incidence of clinically significant prostate cancer in patients with isolated peripheral versus transitional zone PIRADS 3 lesions.

We sought to investigate the association between isolated PIRADS 3 lesions of the transitional zone (TZ) versus the peripheral zone (PZ) and the incidence of clinically significant prostate cancer (csPCa) on systematic and targeted prostate biopsy (SB, TB). We retrospectively reviewed our tertiary institutional database of patients who underwent mpMRI-fusion followed by TB + SB between 2016 and 2021. We compared the incidence of csPCa (Gleason Grade Group ⩾ 2) in patients with solitary TZ-only PIRADS 3 and PZ-only PIRADS 3 on SB and TB. We excluded patients with (1)known PCa, (2)PIRADS 4-5 and/or (3)lesions in both TZ and PZ. T-tests, Chi-square tests, were conducted to compare between the groups. Of 1913 patients, we identified 110 with PZ-only and 38 with TZ-only PIRADS 3 lesions. 73 patients in PZ-only and 19 in TZ-only met inclusion criteria. No statistically significant differences were observed between PZ and TZ groups in terms of age, median prostate-specific antigen (PSA), prostate volume, median PSA-density, or median number of targeted cores obtained, all with p > 0.05.On SB, the incidence of csPCA was higher in patients with PZ rather than TZ PIRADS-3 lesions (10/73 vs 1/19, p = 0.28). Similarly, csPCA was more common in TB of PZ versus TZ PIRADS 3 lesions (7/73 vs 0/19, p = 0.33). Based on these results, the positive predictive values of PIRADS3 as a marker of csPCA were 5.3% and 0% for TZ lesions on SB versus TB, respectively, compared to 17.7% and 9.6% in the PZ. PIRADS 3 lesions are rarely associated with csPCA on SB and TB, particularly when located in the TZ, which is an important factor to consider when deciding on a biopsy in patients with isolated TZ lesions.

Determinants of decision-making in biopsy of PI-RADS 3 transition zone lesions.

Cancer rates for Prostate Imaging-Reporting and Data System (PI-RADS) 3 lesions are low. We aimed to determine the clinical and magnetic resonance imaging (MRI) parameters that can provide risk stratification for PI-RADS 3 transition zone (TZ) lesions to guide decision for biopsy, which can improve the cost-effectiveness of resource utilisation. The MRI scans of all patients who underwent MRI-ultrasound fusion targeted biopsy from 1 May 2016 to 31 December 2022 were retrospectively assessed by two board-certified abdominal radiologists. The following data were collected and analysed serum prostate-specific antigen, Prostatic Health Index (PHI), prostate volume, histological results, lesion size, location, diffusion-weighted imaging (DWI) parameter scores and overall PI-RADS score. Two hundred and fourteen TZ lesions were included. Among 131 PI-RADS 3 lesions, those with marked restricted diffusion (DWI score ≥4), diameter ≥1 cm, prostrate-specific antigen density (PSAD) ≥0.11 and PHI ≥34 were more likely to contain clinically significant prostate cancer (csPCa; P = 0.04, 0.02, 0.049 and 0.05, respectively), with areas under the receiver operating characteristics curve of 0.9, 0.76, 0.84 and 0.80, respectively. Apical lesions were more likely to contain csPCa compared to midgland or basal lesions (P = 0.01). Clinical parameters (PSAD and PHI) and MRI features (lesion size, DWI score, lesion location) can be used to risk stratify PI-RADS 3 TZ lesions and guide decision for targeted biopsy.

The impact of benign tissue within cancerous regions in the prostate: Characterizing sparse and dense prostate cancers on whole-mount histopathology and on multiparametric MRI

PurposeTo establish the incidence, size, zonal location and Gleason Score(GS)/Gleason Grade Group(GG) of sparse versus dense prostate cancer (PCa) lesions and to identify the imaging characteristics of sparse versus dense cancers on multiparametric MRI (mpMRI). MethodsSeventy-six men with untreated PCa were scanned prior to prostatectomy with endorectal-coil 3 T MRI including T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced MRI. Cancerous regions were outlined and graded on the whole-mount, processed specimens, with tissue compositions estimated. Regions with cancer comprising <50 % and ≥ 50 % of the tissue were considered sparse and dense respectively. Regions of interest (ROI) were manually drawn on T2-weighted MRI. Within each patient, area-weighted ROI averages were calculated for each imaging measure for each tissue type, GS/GG, and sparse/dense composition. ResultsA large number of cancer regions were identified on histopathology (n = 1193: 939 (peripheral zone (PZ)) and 254 (transition zone (TZ))). Thirty-seven percent of these lesions were sparse. Sparse lesions were primarily low-grade with the majority of PZ and 100 % of TZ sparse lesions ≤GS3 + 3/GG1. Dense lesions were significantly larger than sparse lesions in both PZ and TZ, p < 0.0001. On imaging, 246/45 PZ and 109/8 TZ dense/sparse 2D cancerous ROIs were drawn. Sparse GS3 + 3 and sparse ≥GS3 + 4 cancers did not have significantly different MRI intensities to dense GS3 + 3 cancers, while sparse GS3 + 3/GG1 cancers differed from benign, p < 0.05. ConclusionHistopathologically identified prostate cancer lesions were sparse in 37 % of cases. Sparse cancers were entirely low grade in TZ and predominantly low-grade in PZ and generally small, thus likely posing lower risk for spread and progression than dense lesions. Sparse lesions were not distinguishable from dense lesions on mpMRI, but could be distinguished from benign tissues.

Optimizing prostate cancer detection in transition zone: an analysis of apparent diffusion coefficient values in prostate magnetic resonance imaging evaluation with Prostate Imaging Reporting and Data System (PI-RADS) assessment.

Multiparametric magnetic resonance imaging (mpMRI) is increasingly used for the early detection of clinically significant prostate cancer (csPCa). However, the achievement of accurate detection rates, particularly for transition zone (TZ) lesions, remains challenging. We investigated the relationship between apparent diffusion coefficient (ADC) values in Prostate Imaging Reporting and Data System (PI-RADS) 3-5 lesions and csPCa within the TZ. We retrospectively evaluated TZ lesions in patients who underwent 3.0 Tesla MRI followed by MRI-targeted/transrectal ultrasound fusion biopsies (MRI-FBx). Fusion biopsies were performed for potentially cancerous lesions, defined as lesions with PI-RADS scores 3-5. We analyzed 196 lesions for which fusion biopsies were performed. The overall prostate cancer (PCa) detection rate was 53.6% (105/196); csPCa constituted 33.7% (66/196) of cases. The minimum ADC value was significantly lower for patients with csPCa (484.9±112.3 µm2/s) than for patients with benign histology or non-csPCa (P<0.001). Older age, higher initial prostate-specific antigen level, larger region of interest, and minimum and mean ADC values were associated with the presence of csPCa. Multivariate analysis indicated that only the minimum ADC value was an independent predictor of csPCa. Using a cutoff minimum ADC value <561 µm2/s to detect csPCa in TZ lesions increased the detection rate to 57.4% (54/94). The minimum ADC value provides substantial additional information regarding the presence of csPCa in the TZ, potentially improving the detection rates for lesions rated as PI-RADS 3-5 and informing the need for follow-up biopsies in areas that are initially cancer-free.

Diagnostic performance of ADC and ADCratio in MRI-based prostate cancer assessment: Asystematic review and meta-analysis.

To identify factors influencing the diagnostic performance of the quantitative imaging biomarkers ADC and ADCratio in prostate cancer (PCa) detection. A systematic literature search was conducted in Embase, Medline and Web of Science, for studies evaluating ADC values and ADCratio for PCa diagnosis, using the same patient cohorts and using histopathological references as ground truth. Pooled sensitivities, specificities, summary ROC curves and AUCs were calculated from constructed contingency data tables. Diagnostic performance (AUC) was quantitatively pooled using a bivariate mixed effects model. For identifying influencing factors, subgroup analysis, publication bias and heterogeneity assessment were investigated. Thirteen studies, involving 1038 patients and 1441 lesions, were included. For ADC, the pooled sensitivity and specificity was 80% (95% CI: 74-85%) and 78% (95% CI: 70-85%), respectively. For ADCratio pooled sensitivity and specificity was 80% (95% CI: 74-84%) and 80% (95% CI: 71-87%). Summary ROC analysis revealed AUCs of 0.86 (95% CI: 0.83-0.89) and 0.86 (95% CI: 0.83-0.89), respectively. Meta-regression showed heterogeneity between both imaging biomarkers. Subgroup analysis showed that ADCratio improved diagnostic performance in comparison to ADC when including both peripheral and transitional zone lesions (AUC: 0.87 [95% CI: 0.84-0.90] and 0.82 [95% CI: 0.79-0.85], respectively). Both ADC and ADCratio imaging biomarkers showed good and comparable diagnostic performance in PCa diagnosis. However, ADCratio shows better diagnostic performance than ADC in diagnosing transition zone cancers. In quantitative MRI-based PCa diagnosis, the imaging biomarker ADCratio is useful in challenging MRI readings of lesions. Understanding the performance of quantitative imaging biomarkers better can aid diagnostic MRI protocols, enhancing the precision of PCa assessments. MRI diffusion-weighted imaging-based ADC and ADCratio have comparable diagnostic performance in PCa assessment. In contrast to ADC, the ADCratio improves diagnostic performance, when assessing whole gland lesions. Compared to ADCratio, the ADC demonstrates enhanced diagnostic performance when evaluating peripheral zone lesions.

PI-RADS Upgrading Rules: Impact on Prostate Cancer Detection and Biopsy Avoidance of MRI-Directed Diagnostic Pathways.

BACKGROUND. PI-RADS incorporates rules by which ancillary sequence findings upgrade a dominant score to a higher final category. Evidence on the upgrading rules' impact on diagnostic pathways remains scarce. OBJECTIVE. The purpose of this article was to evaluate the clinical net benefit of the PI-RADS upgrading rules in MRI-directed diagnostic pathways. METHODS. This study was a retrospective analysis of a prospectively maintained clinical registry. The study included patients without known prostate cancer who underwent prostate MRI followed by prostate biopsy from January 2016 to May 2020. Clinically significant prostate cancer (csPCa) was defined as International Society of Urological Pathology (ISUP) grade group 2 and higher. csPCa detection was compared between dominant (i.e., no upgrade rule applied) and upgraded lesions. Decision-curve analysis was used to compare the net benefit, considering the trade-off of csPCa detection and biopsy avoidance, of MRI-directed pathways in scenarios considering and disregarding PI-RADS upgrading rules. These included a biopsy-all pathway, MRI-focused pathway (no biopsy for PI-RADS ≤ 2), and risk-based pathway (use of PSA density ≥ 0.15 ng/mL2 to select patients with PI-RADS ≤ 3 for biopsy). RESULTS. The sample comprised 716 patients (mean age, 64.9 years; 93 with a PI-RADS ≤ 2 examination, 623 with total of 780 PI-RADS ≥ 3 lesions). Frequencies of csPCa were not significantly different between dominant and upgraded PI-RADS 3 transition zone lesions (20% vs 19%, respectively), dominant and upgraded PI-RADS 4 transition zone lesions (33% vs 26%), and dominant and upgraded PI-RADS 4 peripheral zone lesions (58% vs 45%) (p > .05). In the biopsy-all, per-guideline MRI-focused, MRI-focused disregarding upgrading rules, per-guideline risk-based, and risk-based disregarding upgrading rules pathways, csPCa frequency was 53%, 52%, 51%, 52%, and 48% and biopsy avoidance was 0%, 13%, 16%, 19%, and 25%, respectively. Disregarding upgrading rules yielded 5.5 and 1.9 biopsies avoided per missed csPCa for MRI-focused and risk-based pathways, respectively. At probability thresholds for biopsy selection of 7.5-30.0%, net benefit was highest for the per-guideline risk-based pathway. CONCLUSION. Disregarding PI-RADS upgrading rules reduced net clinical bene fit of the risk-based MRI-directed diagnostic pathway when considering trade-offs between csPCa detection and biopsy avoidance. CLINICAL IMPACT. This study supports the application of PI-RADS upgrading rules to optimize biopsy selection, particularly in risk-based pathways.

Clinical risk prediction model and external validation of positive surgical margin in laparoscopic radical prostatectomy based on MRI lesion location.

To clarify the composition of lesions in different magnetic resonance imaging (MRI) partitions of positive surgical margins (PSM) after laparoscopic radical prostatectomy, explore the influence of lesion location on PSM, and construct a clinical prediction model to predict the risk of PSM. This retrospective cohort study included 309 patients who underwent laparoscopic radical prostatectomy from 2018 to 2021 in our center was performed. 129 patients who met the same criteria from January to September 2022 were external validation cohorts. The incidence of PSM in transition zone (TZ) lesions was higher than that in peripheral zone (PZ) lesions. The incidence of PSM in the middle PZ was lower than that in other regions. Prostate specific antigen (PSA), clinical T-stage, the number of positive cores, international society of urological pathology (ISUP) grade (biopsy), MRI lesion location, extracapsular extension, seminal vesicle invasion (SVI), pseudo-capsule invasion (PCI), long diameter of lesions, lesion volume, lesion volume ratio, PSA density were related to PSM. MRI lesion location and PCI were independent risk factors for PSM. Least absolute shrinkage and selection operator (LASSO) regression was used to construct a clinical prediction model for PSM, including five variables: the number of positive cores, SVI, MRI lesion location, long diameter of lesions, and PSA. The positive rate of surgical margin in middle PZ was significantly lower than that in other regions, and MRI lesion location was an independent risk factor for PSM.

Are T2WI PI-RADS sub-scores of transition zone prostate lesions biased by DWI information? A multi-reader, single-center study

PurposeAccording to PI-RADS v2.1, T2-weighted imaging (T2WI) is the dominant sequence for transition zone (TZ) lesions. This study aimed to assess, whether diffusion-weighted imaging (DWI) information influences the assignment of T2WI scores. MethodOut of 283 prostate MRI examinations with correlated biopsy results, fourty-four patients were selected retrospectively: first, 22 patients with a TZ lesion with T2WI and DWI scores ≥ 4, to represent lesions with unequivocal suspicion on T2WI and DWI. Second, 22 additional patients with TZ lesions of similar T2WI appearance but with corresponding DWI score ≤ 3 were added as control. Four residents and one board-certified radiologist each performed two assessments of the included patients: First, only T2WI was available (T2-only read); second, both T2WI and DWI sequences were available (biparametric read). Lesion scores were assessed using Wilcoxon signed-rank test, inter-reader agreement using weighted kappa and Kendall's W statistics, and sensitivity/specificity using McNemar test. ResultsThe T2WI scores were significantly different between the T2-only and biparametric read for 3 out of 4 residents (p ≤ 0.049) but not for the radiologist. The overall PI-RADS scores derived from the two reading sessions differed considerably for 35/220 cases (all readers pooled). Inter-reader agreement was fair for the T2WI and overall PI-RADS scores (mean kappa 0.27–0.30) and moderate for the DWI scores (mean kappa 0.43). ConclusionsFor inexperienced readers, assessment of T2WI is variable and potentially biased by availability of DWI information, which can lead to changes of overall PI-RADS score and consequently clinical management. Assessment of T2WI should be performed before reviewing DWI to ensure non-biased interpretation of TZ lesions in the dominant sequence.

Peritumoral Radiomics Strategy Based on Ensemble Learning for the Prediction of Gleason Grade Group of Prostate Cancer

To develop and evaluate a peritumoralradiomic-based machine learning model to differentiate low-Gleason grade group (L-GGG) and high-GGG (H-GGG) prostate lesions. In this retrospective study, a total of 175 patients with prostate cancer (PCa) confirmed by puncture biopsy were recruited and included 59 patients with L-GGG and 116 patients with H-GGG. The original PCa regions of interest (ROIs) were delineated on T2-weighted (T2WI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps, and then centra-tumoral and peritumoral ROIs were defined. Features were meticulously extracted from each ROI to establish radiomics models, employing distinct sequence datasets. Peritumoral radiomics models were specifically developed for both the peripheral zone (PZ) and transitional zone (TZ), utilizing dedicated PZ and TZ datasets, respectively. The performances of the models were evaluated by using the receiver operating characteristic (ROC) curve and precision-recall curve. The classification model with combined peritumoral features based on T2+DWI+ADC sequence dataset demonstrated superior performance compared to the original tumor and centra-tumoral classification models. It achieved an area under the ROC curve (AUC) of 0.850 [95% confidence interval, 0.849, 0.860] and an average accuracy of 0.950. The combined peritumoral model outperformed the regional peritumoral models with AUC of 0.85 versus 0.75 for PZ lesions and 0.88 versus 0.69 for TZ lesions, respectively. The peritumoral classification models exhibit greater efficacy in predicting PZ lesions as opposed to TZ lesions. The peritumoral radiomics features showed excellent performance in predicting GGG in PCa patients and might be a valuable addition to the non-invasive assessment of PCa aggressiveness.

Value of synthetic MRI quantitative parameters in preprocedural evaluation for TRUS/MRI fusion-guided biopsy of the prostate.

Transrectal ultrasonography (TRUS)/magnetic resonance imaging (MRI) fusion-guided biopsy has a high clinical application value. However, this technique has some limitations, which limit its use in routine clinical practice. Therefore, the selection of suitable proatate lesions for this technique is worthy of our attention. Synthetic MRI (SyMRI) is capable of quantifying multiple relaxation parameters, which might have potential value in preprocedural evaluation for TRUS/MRI fusion-guided biopsy of the prostate. The aim of our study is to examine the value of SyMRI quantitative parameters in preprocedural evaluation for TRUS/MRI fusion-guided biopsy of the prostate. We prospectively selected 148 lesions in 137 patients who underwent prostate biopsy in our hospital. Next, 2-4 needles of TRUS/MRI fusion-guided biopsy combined with 10 needles of system biopsy(SB) were used as the protocol for prostate biopsy. Before biopsy, the MAGiC sequences of the MRI images of the enrolled patients underwent post-processing, and the longitudinal relaxation time (T1), transverse relaxation time (T2), and proton density (PD) were extracted. The biopsy pathology results were used as a gold standard to compare the differences in SyMRI quantitative parameters between benign and malignant prostate lesions in the peripheral and transitional zones. The receiver operating characteristic (ROC) curves were plotted to confirm the optimal SyMRI quantitative parameter for prostate lesion benignancy/malignancy performance, and the cutoff values of these parameters were used for grouping the lesions. The single-needle biopsy prostate cancer (PCa)-positivity rates (number of positive biopsy needles/total biopsy needles) and PCa overall detection rates by TRUS/MRI fusion-guided biopsy and SB were compared in different subgroups. The T1 and T2 values can determine the benignancy/malignancy of prostate transition lesions(p < 0.01), and the T2 value has a greater diagnostic performance (p = 0.0376). The T2 value can determine the benignancy/malignancy of prostate peripheral lesions. The optimal diagnostic cutoff values for T2 were 77 and 81 ms, respectively. The single-needle PCa positivity rate of TRUS/MRI fusion-guided biopsy was higher than SB for any prostate lesions in different subgroups (p < 0.01). However, only in the subgroup of transition zone lesions with T2 ≤ 77 ms, the PCa overall detection rate of TRUS/MRI fusion-guided biopsy was significantly higher than that of SB (p = 0.031). SyMRI-T2 value can provide a theoretical basis for the selection of suitable lesions for TRUS/MRI fusion-guided biopsy.

Prospective Evaluation of PI-RADS Version 2.1 for Prostate Cancer Detection and Investigation of Multiparametric MRI-derived Markers.

Background Data regarding the prospective performance of Prostate Imaging Reporting and Data System (PI-RADS) version 2.1 alone and in combination with quantitative MRI features for prostate cancer detection is limited. Purpose To assess lesion-based clinically significant prostate cancer (csPCa) rates in different PI-RADS version 2.1 categories and to identify MRI features that could improve csPCa detection. Materials and Methods This single-center prospective study included men with suspected or known prostate cancer who underwent multiparametric MRI and MRI/US-guided biopsy from April 2019 to December 2021. MRI scans were prospectively evaluated using PI-RADS version 2.1. Atypical transition zone (TZ) nodules were upgraded to category 3 if marked diffusion restriction was present. Lesions with an International Society of Urological Pathology (ISUP) grade of 2 or higher (range, 1-5) were considered csPCa. MRI features, including three-dimensional diameter, relative lesion volume (lesion volume divided by prostate volume), sphericity, and surface to volume ratio (SVR), were obtained from lesion contours delineated by the radiologist. Univariable and multivariable analyses were conducted at the lesion and participant levels to determine features associated with csPCa. Results In total, 454 men (median age, 67 years [IQR, 62-73 years]) with 838 lesions were included. The csPCa rates for lesions categorized as PI-RADS 1 (n = 3), 2 (n = 170), 3 (n = 197), 4 (n = 319), and 5 (n = 149) were 0%, 9%, 14%, 37%, and 77%, respectively. csPCa rates of PI-RADS 4 lesions were lower than PI-RADS 5 lesions (P < .001) but higher than PI-RADS 3 lesions (P < .001). Upgraded PI-RADS 3 TZ lesions were less likely to harbor csPCa compared with their nonupgraded counterparts (4% [one of 26] vs 20% [20 of 99], P = .02). Predictors of csPCa included relative lesion volume (odds ratio [OR], 1.6; P < .001), SVR (OR, 6.2; P = .02), and extraprostatic extension (EPE) scores of 2 (OR, 9.3; P < .001) and 3 (OR, 4.1; P = .02). Conclusion The rates of csPCa differed between consecutive PI-RADS categories of 3 and higher. MRI features, including lesion volume, shape, and EPE scores of 2 and 3, predicted csPCa. Upgrading of PI-RADS category 3 TZ lesions may result in unnecessary biopsies. ClinicalTrials.gov registration no. NCT03354416 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Goh in this issue.

MP44-03 PI-RADS 5 LESIONS WITHIN THE TRANSITION ZONE ARE ASSOCIATED WITH DECREASED DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER VERSUS PERIPHERAL ZONE LESIONS IN PATIENTS UNDERGOING MRI FUSION PROSTATE BIOPSY

You have accessJournal of UrologyCME1 Apr 2023MP44-03 PI-RADS 5 LESIONS WITHIN THE TRANSITION ZONE ARE ASSOCIATED WITH DECREASED DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER VERSUS PERIPHERAL ZONE LESIONS IN PATIENTS UNDERGOING MRI FUSION PROSTATE BIOPSY Andrew Wood, Prajit Khooblall, Tarik Benidir, Jennifer Bullen, Ruben Olivares, Zeyad Schwen, Samuel Haywood, Eric Klein, Ryan Ward, Andrei Purysko, and Christopher Weigh Andrew WoodAndrew Wood More articles by this author , Prajit KhooblallPrajit Khooblall More articles by this author , Tarik BenidirTarik Benidir More articles by this author , Jennifer BullenJennifer Bullen More articles by this author , Ruben OlivaresRuben Olivares More articles by this author , Zeyad SchwenZeyad Schwen More articles by this author , Samuel HaywoodSamuel Haywood More articles by this author , Eric KleinEric Klein More articles by this author , Ryan WardRyan Ward More articles by this author , Andrei PuryskoAndrei Purysko More articles by this author , and Christopher WeighChristopher Weigh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003290.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: MRI-fusion targeted prostate biopsy (MRI-TBx) of Prostate Imaging Reporting and Data System (PI-RADS) lesions in both the peripheral zone (PZ) and transition zone (TZ) has become an integral part of prostate cancer (PCa) diagnosis. However, interpretation of the TZ remains challenging due to a markedly heterogeneous background and benign processes mimicking PCa. Our objective was to examine whether TZ, compared to PZ location, impacted odds of detecting clinically significant PCa (csPCa), defined as International Society of Urological Pathology (ISUP) grade group ≥2. METHODS: We performed a retrospective review of all patients who underwent MRI-TBx at a tertiary care center. Lesion level review was performed to compare MRI-TBx in lesions located in the TZ vs. PZ. The primary outcome of interest was detection of csPCa, however, detection of ISUP grade group 1 PCa (GG1 PCa) was also examined. Multivariable (MV) logistic regression analyses were performed to assess for predictors of csPCa detection. RESULTS: 1464 lesions from 1087 patients were included in the analysis. 31.3% of lesions were located in the TZ. Overall, TZ lesions were significantly less likely to harbor csPCa as compared with those in the PZ (26.9% vs 34.3%, p=0.017). When stratified by PI-RADS score, only PI-RADS 5 lesions demonstrated a significant difference in detection of csPCa between TZ and PZ lesions (40.1% vs. 66.8%, p<0.001). Additionally, PI-RADS 5 lesions in the TZ were significantly more likely to harbor GG1 PCa (39.4% vs. 20.3%, p<0.001). On MV analysis, TZ location remained an independent predictor of csPCa within PI-RADS 5 lesions (OR=0.35, p<0.001). CONCLUSIONS: PI-RADS 5 lesions in the TZ have 65% lower odds of harboring csPCa and are more likely to harbor GG1 PCa than those in the PZ. This has important implications for both risk stratification and consideration of further workup in patients with negative or low-grade pathology on MRI-TBx of PI-RADS 5 lesions. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e611 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Wood More articles by this author Prajit Khooblall More articles by this author Tarik Benidir More articles by this author Jennifer Bullen More articles by this author Ruben Olivares More articles by this author Zeyad Schwen More articles by this author Samuel Haywood More articles by this author Eric Klein More articles by this author Ryan Ward More articles by this author Andrei Purysko More articles by this author Christopher Weigh More articles by this author Expand All Advertisement PDF downloadLoading ...

MP55-10 LOWER RATES OF CLINICALLY-SIGNIFICANT PROSTATE CANCER ARE PRESENT IN PI-RADS 4 AND 5 LESIONS IN THE TRANSITIONAL ZONE THAN PERIPHERAL ZONE

You have accessJournal of UrologyCME1 Apr 2023MP55-10 LOWER RATES OF CLINICALLY-SIGNIFICANT PROSTATE CANCER ARE PRESENT IN PI-RADS 4 AND 5 LESIONS IN THE TRANSITIONAL ZONE THAN PERIPHERAL ZONE Jessica Shannon, Sabrina L. Noyes, Andrew Moriarity, Grand Rapids, Mi, Ji Qi, Bruce Lyu, Brian R Lane, and For the Michigan Urological Surgery Improvement Collaborative Jessica ShannonJessica Shannon More articles by this author , Sabrina L. NoyesSabrina L. Noyes More articles by this author , Andrew MoriarityAndrew Moriarity More articles by this author , Grand RapidsGrand Rapids More articles by this author , Mi Mi More articles by this author , Ji QiJi Qi More articles by this author , Bruce LyuBruce Lyu More articles by this author , Brian R LaneBrian R Lane More articles by this author , and For the Michigan Urological Surgery Improvement CollaborativeFor the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003308.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is limited data comparing prostate cancer (PC) detection rates in lesions identified within the peripheral zone (PZ) and transitional zone (TZ) on prostate MRI (pMRI). We compared the diagnostic performance of PIRADSv2 for detecting clinically significant (CS) PC in the PZ and TZ. METHODS: Data were queried from the Michigan Urological Surgery Improvement Collaborative (MUSIC) and Spectrum Health EMR to identify patients undergoing MRI assessed using PIRADS v2 by Advanced Radiology Services physicians between June 2016 and September 2022. All patients identified as having one or more PIRADS 4 or 5 lesions were included if they underwent targeted biopsy within 12 months of the MRI. The primary outcome was CSPC defined as GG2 or greater in biopsy of the targeted lesion. RESULTS: A total of 322 lesions in 224 patients were identified, with mean age 67 years, mean PSA 7.1 ng/ml, and mean prostate volume 63.4 cm3. Overall detection of PC was 75.2%, CSPC was 47.2%, and predominant pattern 4-5 (GG3-GG5) was 47.2%. 131 lesions were in the TZ and 191 in the PZ. CSPC was detected in 41.2% of TZ lesions and 51.3% of PZ lesions (p=0.075). CSPC detection was significantly higher for PI-RADS 4 lesions in the PZ compared to TZ (44.7% vs. 29.4%, p=0.034) and trended towards significance in PI-RADS 5 lesions (70.0% vs. 54.0%, p=0.0823). For GG3-GG5 PC, there was also a significant difference seen with PI-RADS 4 (8.8% vs. 20.6%, p=0.033) and a trend with PI-RADS 5 lesions (12.7% vs. 24.0%, p=0.117). CONCLUSIONS: Overall detection of PC was consistent with prior literature for PI-RADS 4 and 5 lesions. Lesions in the TZ were more likely to be benign or low-grade PC. This is important information for clinicians managing patients with TZ lesions and may suggest re-consideration of the precise features leading to PI-RADS assignments in the TZ in subsequent revisions. Source of Funding: The corresponding author would like to thank the Betz Family Endowment for Cancer Research for their continued support. Funding was provided in part by the Spectrum Health Foundation. Funding was provided in part by the Value Partnerships program at Blue Cross Blue Shield of Michigan. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e767 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Shannon More articles by this author Sabrina L. Noyes More articles by this author Andrew Moriarity More articles by this author Grand Rapids More articles by this author Mi More articles by this author Ji Qi More articles by this author Bruce Lyu More articles by this author Brian R Lane More articles by this author For the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP44-10 THE VALUE OF DYNAMIC CONTRAST ENHANCEMENT FOR RISK-STRATIFICATION AND PROSTATE CANCER DETECTION ON MULTIPARAMETRIC PROSTATE MRI

You have accessJournal of UrologyCME1 Apr 2023MP44-10 THE VALUE OF DYNAMIC CONTRAST ENHANCEMENT FOR RISK-STRATIFICATION AND PROSTATE CANCER DETECTION ON MULTIPARAMETRIC PROSTATE MRI Eric Li, Mohammad Siddiqui, Jonathan Aguiar, Parth Shah, Ashorne Mahenthiran, Jasmine Lin, Moataz Soliman, Sai Kumar, Mary Kate Keeter, Clayton Neill, Xinlei Mi, Quan Mai, Edward Schaeffer, Ashley Ross, and Hiten Patel Eric LiEric Li More articles by this author , Mohammad SiddiquiMohammad Siddiqui More articles by this author , Jonathan AguiarJonathan Aguiar More articles by this author , Parth ShahParth Shah More articles by this author , Ashorne MahenthiranAshorne Mahenthiran More articles by this author , Jasmine LinJasmine Lin More articles by this author , Moataz SolimanMoataz Soliman More articles by this author , Sai KumarSai Kumar More articles by this author , Mary Kate KeeterMary Kate Keeter More articles by this author , Clayton NeillClayton Neill More articles by this author , Xinlei MiXinlei Mi More articles by this author , Quan MaiQuan Mai More articles by this author , Edward SchaefferEdward Schaeffer More articles by this author , Ashley RossAshley Ross More articles by this author , and Hiten PatelHiten Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003290.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Positive dynamic contrast enhancement (DCE) on multiparametric prostate MRI (mpMRI) upgrades peripheral zone (PZ) lesions on diffusion weighted imaging (DWI) from PIRADS 3 to 4, whereas these lesions would remain PIRADS 3 for biparametric MRI. It remains unclear if the rate of clinically significant prostate cancer (csPCa, Gleason Grade Group [GG] ≥2) differs for patients with DCE upgraded lesions (3+) compared to lesions rated 3 by DWI with negative DCE (3-), or 4 by DWI. METHODS: Biopsy naïve men presenting with elevated PSA and pre-biopsy MRI from 2018-2022 were identified. Clinicopathologic and MRI data including highest PIRADS lesion and scoring in individual MRI series were obtained. Patients with PIRADS 1 or 2 or transitional zone lesions as their highest PIRADS lesion were excluded. Patients with multiple lesions were included, and categorized by their highest PIRADS lesion. T-test, Chi-squared, and multivariable logistic regression were performed. RESULTS: 2468 men underwent mpMRI, and 1021 patients who underwent prostate biopsy had PZ lesions as their highest PIRADS lesion. csPCa detection rates for PIRADS 3-, 3+ and 4 were 19%, 31%, and 58%, respectively (p=0.01 for 3- vs 3+; p<0.001 for 3+ vs 4). On multivariable analysis, older age, Black race, PHI>36, PSAD>0.16, and highest PIRADS were significant predictors of csPCa. There was a significant difference in csPCa detection comparing 3+ to 3- (OR 1.94, 95% CI 1.13-3.34, p<0.001) and comparing 4 to 3+ (OR 2.38, 95% CI 1.52-3.78, p<0.001). AUCs for csPCa detection were similar for models classifying patients based on biparametric or multiparametric interpretation of PIRADS (82.0% vs. 81.9%). CONCLUSIONS: Patients with PZ lesions upgraded from PIRADS 3 to 4 by DCE have a csPCa detection rate that is higher than those rated as DWI 3 with negative DCE, but lower than those rated as DWI 4. Overall discrimination for biparametric and multiparametric MRI were similar, but DCE findings may aid in individualized cancer risk-stratification and diagnostic decisions. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e614 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Li More articles by this author Mohammad Siddiqui More articles by this author Jonathan Aguiar More articles by this author Parth Shah More articles by this author Ashorne Mahenthiran More articles by this author Jasmine Lin More articles by this author Moataz Soliman More articles by this author Sai Kumar More articles by this author Mary Kate Keeter More articles by this author Clayton Neill More articles by this author Xinlei Mi More articles by this author Quan Mai More articles by this author Edward Schaeffer More articles by this author Ashley Ross More articles by this author Hiten Patel More articles by this author Expand All Advertisement PDF downloadLoading ...

MP38-19 FOCAL THERAPY CANDIDACY: AN EVALUATION OF INITIAL AND CONTINUED ELIGIBILITY FOR FOCAL THERAPY IN AN ACTIVE SURVEILLANCE COHORT

You have accessJournal of UrologyCME1 Apr 2023MP38-19 FOCAL THERAPY CANDIDACY: AN EVALUATION OF INITIAL AND CONTINUED ELIGIBILITY FOR FOCAL THERAPY IN AN ACTIVE SURVEILLANCE COHORT Alexander P. Kenigsberg, Daniel Nemirovsky, Neil Mendhiratta, Zoe Blake, Jacob J. Enders, Samuel A. Gold, Michael B. Rothberg, Daniel Nethala, Brad Wood, Baris Turkbey, Sandeep Gurram, and Peter A. Pinto Alexander P. KenigsbergAlexander P. Kenigsberg More articles by this author , Daniel NemirovskyDaniel Nemirovsky More articles by this author , Neil MendhirattaNeil Mendhiratta More articles by this author , Zoe BlakeZoe Blake More articles by this author , Jacob J. EndersJacob J. Enders More articles by this author , Samuel A. GoldSamuel A. Gold More articles by this author , Michael B. RothbergMichael B. Rothberg More articles by this author , Daniel NethalaDaniel Nethala More articles by this author , Brad WoodBrad Wood More articles by this author , Baris TurkbeyBaris Turkbey More articles by this author , Sandeep GurramSandeep Gurram More articles by this author , and Peter A. PintoPeter A. Pinto More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003276.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal Therapy (FT) for Gleason grade group (GG) 1 prostate cancer (PCa) is controversial, given almost all of these patients are suitable active surveillance (AS) candidates. Little is known about how many AS GG 1 patients retain focal therapy eligibility (FTE) over time. The objective of this study is to evaluate initial and long-term FTE for patients with GG1 disease. METHODS: A prospectively maintained AS cohort was retrospectively queried for patients initiated on AS between 2009 and 2020 with GG1 PCa. Patients with a unilateral, biopsy-concordant, MRI-visible PIRADS or PIRADS-equivalent 2-5 lesions amenable to hemiablation who had a PSA<20, <4 positive systematic biopsy cores were considered FTE. Patients who remained GG1 were considered to have maintained FTE. Those who progressed were reassessed at time of progression for FTE. Patients with ≥GG4 disease, bilateral GG≥2, or MRI-invisible GG≥2 lost FTE. Univariate and multivariate analyses were conducted to evaluate factors associated with FTE. RESULTS: 282 GG1 PCa patients were identified, 164 of whom (58%) were FT candidates, with a mean follow-up of 4.9 years (range 1.0-13.4 years). 81/164 (49%) progressed to GG≥2 or higher on a subsequent biopsy. At the time of PCa upgrading, 36/164 (22%) of the FT candidate cohort lost FTE. Baseline characteristics are shown in Table 1. Patients who lost FTE trended toward increased PSA (6.3 vs 5.3, p=0.062 and MRI lesions (2.6 vs 2.0, p=0.007), and were more likely to have transitional or central zone (TZ/CZ) lesions (30.6% vs 14.1%, p=0.022) relative to those who maintained FTE. On logistic regression (Table 2), the number of MRI lesions and TZ/CZ lesions were associated with FTE loss (p=0.033 and 0.047, respectively). CONCLUSIONS: While approximately half of GG1 FT candidates demonstrate disease progression, almost 80% maintain FTE. Given the demonstrated safety of AS and relatively small number of patients who lose FTE while on surveillance, routine FT for GG1 disease would result in a large number of unnecessary procedures. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e532 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander P. Kenigsberg More articles by this author Daniel Nemirovsky More articles by this author Neil Mendhiratta More articles by this author Zoe Blake More articles by this author Jacob J. Enders More articles by this author Samuel A. Gold More articles by this author Michael B. Rothberg More articles by this author Daniel Nethala More articles by this author Brad Wood More articles by this author Baris Turkbey More articles by this author Sandeep Gurram More articles by this author Peter A. Pinto More articles by this author Expand All Advertisement PDF downloadLoading ...

Test-retest repeatability of ADC in prostate using the multi b-Value VERDICT acquisition

PurposeVERDICT (Vascular, Extracellular, Restricted Diffusion for Cytometry in Tumours) MRI is a multi b-value, variable diffusion time DWI sequence that allows generation of ADC maps from different b-value and diffusion time combinations. The aim was to assess precision of prostate ADC measurements from varying b-value combinations using VERDICT and determine which protocol provides the most repeatable ADC. Materials and MethodsForty-one men (median age: 67.7 years) from a prior prospective VERDICT study (April 2016–October 2017) were analysed retrospectively. Men who were suspected of prostate cancer and scanned twice using VERDICT were included. ADC maps were formed using 5b-value combinations and the within-subject standard deviations (wSD) were calculated per ADC map. Three anatomical locations were analysed per subject: normal TZ (transition zone), normal PZ (peripheral zone), and index lesions. Repeated measures ANOVAs showed which b-value range had the lowest wSD, Spearman correlation and generalized linear model regression analysis determined whether wSD was related to ADC magnitude and ROI size. ResultsThe mean lesion ADC for b0b1500 had the lowest wSD in most zones (0.18–0.58x10-4 mm2/s). The wSD was unaffected by ADC magnitude (Lesion: p = 0.064, TZ: p = 0.368, PZ: p = 0.072) and lesion Likert score (p = 0.95). wSD showed a decrease with ROI size pooled over zones (p = 0.019, adjusted regression coefficient = -1.6x10-3, larger ROIs for TZ versus PZ versus lesions). ADC maps formed with a maximum b-value of 500 s/mm2 had the largest wSDs (1.90–10.24x10-4 mm2/s). ConclusionADC maps generated from b0b1500 have better repeatability in normal TZ, normal PZ, and index lesions.

Extracapsular extension of transitional zone prostate cancer miss-detected by multiparametric magnetic resonance imaging.

To demonstrate the importance of extracapsular extension (ECE) of transitional zone (TZ) prostate cancer (PCa), examine the causes of its missed detection by Mp-MRI, and develop a new predictive model by integrating multi-level clinical variables. This retrospective study included 304 patients who underwent laparoscopic radical prostatectomy after 12 + X needle transperineal transrectal ultrasound (TRUS)-MRI-guided targeted prostate biopsy from 2018 to 2021 in our center was performed. In this study, the incidence rates of ECE were similar in patients with MRI lesions in the peripheral zone (PZ) and TZ (P = 0.66). However, the missed detection rate was higher in patients with TZ lesions than in those with PZ lesions (P < 0.05). These missed detections result in a higher positive surgical margin rate (P < 0.05). In patients with TZ lesions, detected MP-MRI ECE may have grey areas: the longest diameters of the MRI lesions were 16.5-23.5mm; MRI lesion volumes were 0.63-2.51ml; MRI lesion volume ratios were 2.75-8.86%; PSA were 13.85-23.05ng/ml. LASSO regression was used to construct a clinical prediction model for predicting the risk of ECE in TZ lesions from the perspective of MRI and clinical features, including four variables: the longest diameter of MRI lesions, TZ pseudocapsule invasion, ISUP grading of biopsy pathology, and number of positive biopsy needles. Patients with MRI lesions in the TZ have the same incidence of ECE as those with lesions in the PZ, but a higher missed detection rate.

Sub-differentiation of PI-RADS 3 lesions in TZ by advanced diffusion-weighted imaging to aid the biopsy decision process.

Performing biopsy for intermediate lesions with PI-RADS 3 has always been controversial. Moreover, it is difficult to differentiate prostate cancer (PCa) and benign prostatic hyperplasia (BPH) nodules in PI-RADS 3 lesions by conventional scans, especially for transition zone (TZ) lesions. The purpose of this study is sub-differentiation of transition zone (TZ) PI-RADS 3 lesions using intravoxel incoherent motion (IVIM), stretched exponential model, and diffusion kurtosis imaging (DKI) to aid the biopsy decision process. A total of 198 TZ PI-RADS 3 lesions were included. 149 lesions were BPH, while 49 lesions were PCa, including 37 non-clinical significant PCa (non-csPCa) lesions and 12 clinical significant PCa (csPCa) lesions. Binary logistic regression analysis was used to examine which parameters could predict PCa in TZ PI-RADS 3 lesions. The ROC curve was used to test diagnostic efficiency in distinguishing PCa from TZ PI-RADS 3 lesions, while one-way ANOVA analysis was used to examine which parameters were statistically significant among BPH, non-csPCa and csPCa. The logistic model was statistically significant (χ2 = 181.410, p<0.001) and could correctly classify 89.39% of the subjects. Parameters of fractional anisotropy (FA) (p=0.004), mean diffusion (MD) (p=0.005), mean kurtosis (MK) (p=0.015), diffusion coefficient (D) (p=0.001), and distribute diffusion coefficient (DDC) (p=0.038) were statistically significant in the model. ROC analysis showed that AUC was 0.9197 (CI 95%: 0.8736-0.9659). Sensitivity, specificity, positive predictive value and negative predictive value were 92.1%, 80.4%, 93.9% and 75.5%, respectively. FA and MK of csPCa were higher than those of non-csPCa (all p<0.05), while MD, ADC, D, and DDC of csPCa were lower than those of non-csPCa (all p<0.05). FA, MD, MK, D, and DDC can predict PCa in TZ PI-RADS 3 lesions and inform the decision-making process of whether or not to perform a biopsy. Moreover, FA, MD, MK, D, DDC, and ADC may have ability to identify csPCa and non-csPCa in TZ PI-RADS 3 lesions.