MRI characteristics predict risk of pathological upgrade in patients with ISUP grade group 1 prostate cancer.

OBJECTIVE: This study aims to analyse multiparametric MRI (mpMRI) characteristics of patients diagnosed with ISUP grade group (GG) 1 prostate cancer (PC) on initial target plus systematic MRI/TRUS fusion-guided biopsy and investigate histopathological progression during follow-up. METHODS: A retrospective single-centre cohort analysis was conducted on consecutive patients with mpMRI visible lesions (PI-RADS ≥ 3) and detection of ISUP-1-PC at the time of initial biopsy. The study assessed clinical, mpMRI, and histopathological parameters. Subcohorts were analysed with (1) patients who had confirmed ISUP-1-PC and (2) patients who experienced histopathological upgrading to ISUP ≥ 2 PC during follow-up either at re-biopsy or radical prostatectomy (RP). RESULTS: A total of 156 patients (median age 65 years) between March 2014 and August 2021 were included. Histopathological upgrading to ISUP ≥ 2 was detected in 55% of patients during a median follow-up of 9.5 months (IQR 2.2-16.4). When comparing subgroups with an ISUP upgrade and sustained ISUP 1 PC, they differed significantly in contact length of the index lesion to the pseudocapsule, ADC value, PI-RADS category, and the MRI grading group (mGG) (p < 0.05). In the ISUP GG ≥ 2 subgroup, 91% of men had PI-RADS category 4 or 5 and 82% exhibited the highest mGG (mGG3). In multivariate analysis, mGG was the only independent parameter for predicting ISUP ≥ 2-PC in these patients. CONCLUSIONS: MRI reveals important information about PC aggressiveness and should be incorporated into clinical decision-making when ISUP-1-PC is diagnosed. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered. CLINICAL RELEVANCE STATEMENT: In cases with clear MRI characteristics for clinically significant prostate cancer (e.g., mGG 3 and/or PI-RADS 5, cT3, or clear focal PI-RADS 4 lesions on MRI) and ISUP GG 1 PC diagnosed on initial prostate biopsy, MRI findings should be incorporated into clinical decision-making and early re-biopsy (e.g., within 6 months) might be considered. KEY POINTS: MRI reveals important information about prostate cancer (PC) aggressiveness. MRI should be incorporated into clinical decision-making when ISUP GG 1 PC is diagnosed on initial prostate biopsy. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered.

Benefit of dynamic contrast-enhanced (DCE) imaging for prostate cancer detection depending on readers experience in prostate MRI.

AIM: To investigate the relevance of dynamic contrast enhanced imaging (DCE) within multiparametric magnetic resonance imaging (mpMRI) for the detection of clinically significant prostate cancer (csPC) depending on reader experience. MATERIALS AND METHODS: Consecutive patients with 3 T mpMRI and subsequent combined MRI/ultrasound fusion-guided targeted and systematic biopsy from January to September 2019 were included. All mpMRI examinations were read separately by two less experienced (R1; <500 prostate MRI) and two expert radiologists (R2; >5,000 prostate MRI) in consensus and blinded re-read as biparametric MRI (bpMRI). The primary endpoint was the performance comparison of mpMRI versus bpMRI of R1 and R2. RESULTS: Fifty-three of 124 patients had csPC (43%). The PI-RADS agreement of bpMRI and mpMRI was fair for R1 (κ = 0.373) and moderate for R2 (κ = 0.508). R1 assessed 11 csPC with PI-RADS ≤3 (20.8%) on mpMRI and 12 (22.6%) on bpMRI (R2: 1 [1.9%] and 6 [11.3%], respectively). Sensitivity for csPC of mpMRI was 79.3% (NPV 79.3%) for R1 and 98.1% (NPV 97.5%) for R2 (bpMRI: 77.4% [NVP 75.5%] and 86.8% [NPV 84.4%], respectively). Specificity of mpMRI for csPC was 59.2% for R1 and 54.9% for R2 (bpMRI: 52.1% and 53.5%, respectively). Overall accuracy of mpMRI was 79.8% for R1 compared to bpMRI 66.9% (p=0.017; R2: 87.1% and 81.5%; p=0.230). CONCLUSION: Prostate MRI benefits from reader experience. Less experienced readers missed a relevant proportion of csPC with mpMRI and even more with bpMRI. The overall performance of expert readers was comparable for mpMRI and bpMRI but DCE enabled detection of some further ISUP 2 PC.

Multiparametric MRI characteristics of prostatitis and atrophy in the peripheral zone in men without prostate cancer.

PURPOSE: To analyse multiparametric magnetic resonance imaging (mpMRI) characteristics and appearance of histopathologically proven non-cancerous intraprostatic findings focussing on quantity of prostatitis and atrophy in the peripheral zone. METHOD: In this retrospective analysis consecutive patients with mpMRI followed by MRI/TRUS-fusion biopsy comprising targeted (TB) and systematic biopsy (SB) cores without prostate cancer (PC) at histopathology were included. Subgroup analysis was performed in younger men (≤50 years). The proportions of prostatitis and atrophy were quantified for each biopsy core based on histopathology. MRI findings in the peripheral zone (PZ) and index lesions (IL, most suspicious/representative lesion) were characterized regarding changes in T2w, ADC value, and enhancement of dynamic contrast enhancement (DCE) and correlated with quantity of prostatitis and atrophy. RESULTS: Seventy-two patients were analysed. The median baseline characteristics were PSA 5.4 ng/ml (4.0-7.9), PI-RADS classification 3 (2-4), prostate volume 43 ml (33-57), and PSA density 0.13 ng/ml2 (0.10-0.19). Prostatitis was found in 44 % (n = 32) and atrophy in 65 % (n = 47) of cases. The quantity of atrophy demonstrated a significant correlation to T2w changes, ADC increase and DCE enhancement (p = 0.05, p = 0.05, p = 0.01), whereas quantity of prostatitis did not show any significant correlation to the MRI changes (p = 0.68, p = 0.58, p = 0.95). Quantity of prostatitis and atrophy increased with PI-RADS classification. Younger men had lower PSA (4.4 vs. 7.8 ml/ng; p < 0.001), smaller prostate volume (40 vs. 59 ml; p = 0.001), and lower PI-RADS classification (2-3 vs. 3-4; p = 0.005) and prostatitis and atrophy were less frequently observed (p ≤ 0.01, p = 0.03). CONCLUSIONS: Quantity of atrophy and prostatitis had different influence on MRI characteristics and increased within higher PI-RADS classification. Younger men had diffuse hypointense changes at T2w images, but less quantity of prostatitis and atrophy.

Pre-operative magnetic resonance imaging can predict prostate cancer with risk for positive surgical margins.

PURPOSE: Analysis of patients with pre-operative 3 T multiparametric prostate MRI (mpMRI) to determine reliable MRI-based risk predictors of patients at risk for positive surgical margins (PSM) in robotic assisted radical prostatectomy (RPE). METHODS: Consecutive patients with 3 T mpMRI and subsequent RPE from 01/2015 to 12/2018 were retrospectively included. Patients were compared regarding clinical and MRI related parameters such as length of capsular tumor contact (LCC) and distance to the membranous urethra (UD). RESULTS: Forty-nine of 179 patients (27%) had PSM in 70 different localizations, with the majority located at the capsule (57%, 40/70), mostly apical and/or posterior. The second most often PSM occurred at the apical urethra (22%, 15/70). PCA was visible on mpMRI at the localization of PSM in 93% at the capsule and in 80% at the urethra. PSA, PI-RADS classification, extraprostatic extension (EPE), and seminal vesicles infiltration (SVI) on MRI were significantly higher / more frequent in patients with PSM. LCC (AUC 0.710), EPE (AUC 0.693), and UD (1-AUC 0.673) predicted PSM (overall). An UD of ≤ 3.5 mm showed the highest accuracy of 95% (J = 0.946) for PSM at the urethra and a LCC of ≥ 22.5 mm with 77% (J = 0.378) for PSM at the capsule. CONCLUSION: PSM occurred mostly in the apex and/or posteriorly at the capsule or at the apical urethra. LCC was the best MRI predictor for PSM at the capsule and UD for tumors with PSM at the apical urethra. Using these MRI parameters readers might pre-operatively determine PCA localizations at risk for PSM.

Single center analysis of an advisable control interval for follow-up of patients with PI-RADS category 3 in multiparametric MRI of the prostate.

To evaluate if follow-up mpMRI scans of patients in PI-RADS category 3 are safe enough to omit or delay prostate biopsy in the future and to determine an optimal control interval. This retrospective single center study includes consecutive PI-RADS category 3 patients with one or more follow-up mpMRI (T2WI, DWI, DCE) and subsequent MRI-targeted and systematic TRUS-guided biopsy between 2012 and 2018. Primary study objective was the verification of a significant PI-RADS category upgrade in follow-up mpMRI in patients with subsequent PCA positive biopsy versus patients with negative biopsy. Further objectives were development of the PI-RADS category and clinical parameters between initial and follow-up mpMRI in the context of histopathologic results and time interval. Eighty-nine patients (median PSA 6.6 ng/ml; PSAD 0.13 ng/ml/ml) were finally included (follow-up period 31 ± 18 months). 19 cases had PCA (median PSA 7.8 ng/ml; PSAD 0.14 ng/ml/ml). 4 cases had csPCA (median PSA 5.4 ng/ml; PSAD 0.13 ng/ml/ml) for which there was a significant PI-RADS upgrade after 12-24 months (mean 3.75; p = 0.01) compared to patients without PCA (mean 2.74). Without PCA the mean PI-RADS category decreased after 25-36 months (mean 2.74; p = 0.02). Clinical parameters did not change significantly except a PSAD increase for PCA patients after 24 months. Patients within PI-RADS category 3 may not need prompt biopsy since those with PCA reliably demonstrate a PI-RADS category upgrade in follow-up mpMRI after 12-24 months. PI-RADS 3 patients with negative biopsy do not benefit from follow-up mpMRI earlier than 24 months.

Data on the detection of clinically significant prostate cancer by magnetic resonance imaging (MRI)-guided targeted and systematic biopsy.

This is a data article from the original publication "Reasons for missing clinically significant prostate cancer by targeted magnetic resonance imaging/ultrasound fusion-guided biopsy" [1]. From January 2014 to April 2019 a sample collective of 785 patients with 3T multiparametric magnetic resonance imaging (mp-MRI) of the prostate and subsequent combined systematic biopsy (SB) and magnetic resonance imaging/ultrasound (US) fusion-guided biopsy (TB) was retrospectively analyzed. Prostate cancer (PCa) detection by TB and/or additional SB was analyzed.

Comparison of 3 T mpMRI and pelvic CT examinations for detection of lymph node metastases in patients with prostate cancer.

PURPOSE: This study investigates preoperative lymph node metastases (LNM) detection accuracy by MRI and CT in patients with prostate cancer (PCA). METHODS: All patients with preoperative MRI, CT or both and subsequent radical prostatectomy (RPE) and lymphadenectomy (LA) were included in this retrospective cohort study. Prostate specific antigen (PSA), PI-RADS, ISUP grade group, clinical and pathological tumor (T) stage was compared between negative and positive nodal (N) stage. LNM were assessed with size and localization and weather they were preoperatively detected or not. In patients with preoperative CT and MRI, the results were compared intermodally. The reference standard was the histopathological results after RPE and LA. RESULTS: A total of 228 patients were analysed including 24 patients with confirmed LNM (N1; 11%). PSA (median 9.7 vs. 14 ng/ml), PI-RADS (median 4 vs. 5), ISUP (median 2 vs. 4), and cT/pT-stage (median T2 vs. T3) was significantly higher in patients with LNM. No LNM were found in patients with ISUP-1-PCA. MRI was able to detect 67% of patients with LNM. Lymph node metastases presented on MRI predominantly small, round-shaped, located parailiacally with a minimum SAD of 4 mm (vs. CT SAD of 8 mm). In comparison, MRI was superior to CT in the detection of LNM (sensitivity 81% vs. 33%; specificity 99% vs. 97). CONCLUSION: LNM were very rare in patients with PSA < 10 ng/ml, PI-RADS ≤ 4, and ≤ cT2. MRI could detect LNM up to 4 mm with a moderate sensitivity and high specificity. Thus, MRI might optimise the preoperative diagnostic and therapy planning of patients with PCA, whereas CT was clearly limited for N-stage assessment.

[Risk-adapted prostate cancer screening-update 2021]. / Risikoadaptierte Früherkennung des Prostatakarzinoms ­ Update 2021.

BACKGROUND: Prostate cancer (PCa) is the most common cancer and the second leading cause of cancer death in men in industrialized countries. There is no commonly accepted prostate cancer screening strategy. Based on the experience of various international screening studies, the German Prostate Cancer Early Detection Study Based on a Baseline PSA Value in Young Men (PROBASE) was established in 2014. OBJECTIVE: Based on the positive results of retrospective cohort analyses, the PROBASE study is designed to demonstrate that a screening strategy based on risk stratification by a baseline prostate-specific antigen (PSA) level at age 45 or 50 years may be an alternative to population-based screening. PROBASE is presented in the context of other risk-adapted screening studies. MATERIALS AND METHODS: There are basically several approaches to improve the population-based screening of PCa. Known risk factors for prostate cancer are age, a certain genetic predisposition (BRCA 1/2) and other germline mutations as well as individual somatic mutations. RESULTS: A total of 23,301 participants were randomized to study arm A. Baseline PSA testing in study arm A categorized 89.18% of participants into the low-risk group, 9.32% into the intermediate-risk group, and 1.48% into the high-risk group. Thus, the risk assignment exactly matched the previously reported distribution. DISCUSSION: Baseline PSA-dependent, risk-adapted PSA screening has the potential to reduce the high incidence of overdiagnosis and ultimately overtreatment of insignificant prostate cancers of population-based screening through extended testing intervals in the low-risk group. In parallel with PROBASE, several risk-adapted screening strategies are currently being tested worldwide; the evaluation of which is also awaited in several years.

Reasons for missing clinically significant prostate cancer by targeted magnetic resonance imaging/ultrasound fusion-guided biopsy.

OBJECTIVES: This study evaluates cases with clinically significant prostate cancer (csPCa) missed by targeted biopsy (TB) and analyzes the diagnostic impact of an additional systematic biopsy (SB) in a large patient collective. METHODS: Consecutive patients with a 3 T multiparametric prostate MRI (mpMRI) and a subsequent MRI/US fusion-guided TB plus 12-core US-guided SB from 01/2014 to 04/2019 were included in this study. Primary study endpoint was the analysis of cases with a csPCa missed by TB and detected by SB. Secondary study objectives were the PCa detection and the correlation with clinical and MRI parameters. RESULTS: In total 785 patients met the inclusion criteria. 342 patients had a csPCa (median PSAD 0.29 ng/mL/cm3). In 42 patients (13 %), a csPCa was detected only by SB. In 36 of these cases, the localization of the positive SB cores matched with the cancer suspicious region described on mpMRI (mCSR). Cases with a csPCA missed by TB showed either an insufficient MRI segmentation (prostate boundary correlation) (31 %) and/or insufficient lesion registration (lesion transfer, tracking, and/or matching) (48 %), a missed small lesion (14 %), or a failed center of a large lesion (10 %). Median PSAD of patients with non-significant PCa detected by SB was 0.15 ng/mL/cm3. CONCLUSIONS: Main reasons for missing a csPCa by TB were insufficient prostate segmentation or imprecise lesion registration within MRI/US fusion-guided biopsy. Consequently, verification of MRI quality, exact mCSR assessment, and advanced biopsy experience may improve accuracy. Altogether, an additional SB adds limited clinical benefit in men with PSAD ≤ 0.15 ng/mL/cm3.