This surgery-in-motion contribution shows that transperineal magnetic resonance–ultrasound fusion guided biopsy in men with suspected prostate cancer is well tolerated using local anesthesia in an ...ambulatory setting. The detection rates of clinically significant cancer are high, and even without prophylactic antibiotics, the risk of infectious complication is low.
Transperineal magnetic resonance imaging–transrectal ultrasound fusion guided biopsy (MFGB) is an increasingly popular technique due to increasing rates of biopsy-related infections. However, its widespread implementation has been hampered by the supposed necessity of epidural or general anesthesia.
To demonstrate the technique, feasibility, and results of transperineal MFGB under local anesthesia, in an ambulatory setting without the administration of prophylactic antibiotics.
This single-center study enrolled consecutive biopsy-naïve men with a clinical suspicion of prostate cancer into a prospective database between November 2015 and November 2020. Men with Prostate Imaging Reporting and Data System (PI-RADS) version 2 scores 3–5 underwent transperineal MFGB.
Transperineal MFGB was performed in an ambulatory setting under local anesthesia by a single operator.
Procedure-associated adverse events were recorded. Patient discomfort during both the local anesthesia and the biopsy procedure was determined using a visual analogic scale (0–10). Detection rates of grade group (GG) ≥2 prostate cancer and the proportion of men with GG 1 cancer were assessed.
A total of 1097 eligible men underwent transperineal MFGB. The complication rate was 0.73% (8/1097); complications comprised five (0.46%) urinary tract infections including one hospitalization and three (0.27%) urinary retentions. In 735 men, the median pain scores were 2 (interquartile range IQR 2–3) for the local anesthesia procedure and 1 (IQR 0-2) for the biopsy. Prostate cancer was detected in 84% (926/1097) of men; 66% (723/1097) had GG ≥2 and 19% (203/1097) GG 1.
Transperineal MFGB can safely be performed as an outpatient procedure under local anesthesia in an ambulatory setting. The detection rate of clinically significant prostate cancer is high, and biopsy is well tolerated. Although no antibiotic prophylaxis was used, the rate of infectious complications is practicably negligible.
This article shows how tissue samples (biopsies) can accurately be obtained from suspicious regions seen on prostate magnetic resonance imaging via needles inserted in the perineum (skin between the scrotum and the anus) in men with suspected prostate cancer. This technique appears to be very well tolerated under local anesthesia and has a lower risk of infection without antibiotic prophylaxis than the more common biopsy route through the rectum, with antibiotics.
Objectives
To investigate and compare the performance of different proposed diagnostic pathways in a cohort of biopsy-naïve men at risk for prostate cancer (PCa), in terms of biopsy avoidance, ...accurate diagnosis of clinically significant prostate cancer (csPCa), and reduction in overdiagnosis of clinically insignificant cancer (cisPCa), with particular focus on a recently suggested “risk-based” MRI-directed diagnostic pathway.
Methods
Single-center, retrospective cohort study, including 499 biopsy-naïve men at risk for PCa. All men underwent PI-RADS-compliant prostate MRI, transrectal ultrasound fusion-guided targeted (TBx), and systematic biopsy (SBx). Five diagnostic pathways were retrospectively evaluated and compared for. Outcome measures were biopsy avoidance, combined with missed csPCa and detected cisPCa. csPCa and cisPCa were defined as ISUP grade group ≥ 2 and grade = 1, respectively. Chi-square test was used for statistical analysis. Decision curve analyses were used to compare the benefits of the pathways across a range of biopsy thresholds.
Results
The prevalence (detection-focused reference pathway) of csPCa and cisPCa was 52.9% (264/499) and 23.0% (115/499). MRI-focused pathway (no biopsy in PI-RADS 1–2 men) did not significantly reduce ISUP ≥ 2 cancer detection (52.1% (260/499);
p
= 0.13), but significantly reduced ISUP 1 cancers diagnosed (20.6% (103/499);
p
< 0.01), and biopsy avoidance was 11.8% (59/499). The risk-based MRI-directed pathway (no biopsy in low-risk PI-RADS 1–3 men) resulted in a small reduction of ISUP ≥ 2 diagnosed (51.7% (258/499);
p
= 0.04), however non-significant when compared to MRI-focused pathway (
p
= 0.625). Moreover, the risk-based pathway further reduced detection of ISUP 1 (18.6% (93/499);
p
< 0.01), and biopsy avoidance was 19.2% (96/499). Decision curve analysis showed maximized net benefit of the risk-based pathway, for the range of threshold probabilities between 6.25 and 65%.
Conclusion
The risk-based MRI-directed pathway for prostate cancer diagnosis was optimal in balancing accurate diagnosis, reducing overdiagnosis, and maximizing biopsy avoidance. This substantial evidence should inform guideline recommendations towards using “risk-based” MRI-directed biopsy decisions in biopsy-naïve men at risk of significant prostate cancer.
Key Points
•
Our study recognizes the added value of prostate MRI and MR-targeted biopsies in order to propose clinical diagnostic pathways for prostate cancer, towards maximizing the potential avoidance of unnecessary biopsies, while maintaining optimal detection rate of clinically significant prostate cancer.
•
The risk-based MRI-directed pathway incorporates risk factors such as PSA density, digital rectal examination, and family history to further refine the initial stratification of patients based on PI-RADS scores.
•
In this study, the risk-based pathway had the most optimal performance in terms of combination of outcomes, with the highest rate of biopsy avoidance (19.2%), while keeping a high detection rate of clinically significant prostate cancer (51.7%), when compared to the reference standard (52.9%).
Artificial intelligence developments are essential to the successful deployment of community-wide, MRI-driven prostate cancer diagnosis. AI systems should ensure that the main benefits of biopsy ...avoidance are delivered while maintaining consistent high specificities, at a range of disease prevalences. Since all current artificial intelligence / computer-aided detection systems for prostate cancer detection are experimental, multiple developmental efforts are still needed to bring the vision to fruition. Initial work needs to focus on developing systems as diagnostic supporting aids so their results can be integrated into the radiologists’ workflow including gland and target outlining tasks for fusion biopsies. Developing AI systems as clinical decision-making tools will require greater efforts. The latter encompass larger multicentric, multivendor datasets where the different needs of patients stratified by diagnostic settings, disease prevalence, patient preference, and clinical setting are considered. AI-based, robust, standard operating procedures will increase the confidence of patients and payers, thus enabling the wider adoption of the MRI-directed approach for prostate cancer diagnosis.
Key Points
• AI systems need to ensure that the benefits of biopsy avoidance are delivered with consistent high specificities, at a range of disease prevalence.
• Initial work has focused on developing systems as diagnostic supporting aids for outlining tasks, so they can be integrated into the radiologists’ workflow to support MRI-directed biopsies.
• Decision support tools require a larger body of work including multicentric, multivendor studies where the clinical needs, disease prevalence, patient preferences, and clinical setting are additionally defined.
The optimal treatment for men with high-risk localized or locally advanced prostate cancer (PCa) remains unknown.
To perform a systematic review of the existing literature on the effectiveness of the ...different primary treatment modalities for high-risk localized and locally advanced PCa. The primary oncological outcome is the development of distant metastases at ≥5 yr of follow-up. Secondary oncological outcomes are PCa-specific mortality, overall mortality, biochemical recurrence, and need for salvage treatment with ≥5 yr of follow-up. Nononcological outcomes are quality of life (QoL), functional outcomes, and treatment-related side effects reported.
Medline, Medline In-Process, Embase, and the Cochrane Central Register of Randomized Controlled Trials were searched. All comparative (randomized and nonrandomized) studies published between January 2000 and May 2019 with at least 50 participants in each arm were included. Studies reporting on high-risk localized PCa (International Society of Urologic Pathologists ISUP grade 4–5 Gleason score {GS} 8–10 or prostate-specific antigen PSA >20 ng/ml or ≥ cT2c) and/or locally advanced PCa (any PSA, cT3–4 or cN+, any ISUP grade/GS) or where subanalyses were performed on either group were included. The following primary local treatments were mandated: radical prostatectomy (RP), external beam radiotherapy (EBRT) (≥64 Gy), brachytherapy (BT), or multimodality treatment combining any of the local treatments above (±any systemic treatment). Risk of bias (RoB) and confounding factors were assessed for each study. A narrative synthesis was performed.
Overall, 90 studies met the inclusion criteria. RoB and confounding factors revealed high RoB for selection, performance, and detection bias, and low RoB for correction of initial PSA and biopsy GS. When comparing RP with EBRT, retrospective series suggested an advantage for RP, although with a low level of evidence. Both RT and RP should be seen as part of a multimodal treatment plan with possible addition of (postoperative) RT and/or androgen deprivation therapy (ADT), respectively. High levels of evidence exist for EBRT treatment, with several randomized clinical trials showing superior outcome for adding long-term ADT or BT to EBRT. No clear cutoff can be proposed for RT dose, but higher RT doses by means of dose escalation schemes result in an improved biochemical control. Twenty studies reported data on QoL, with RP resulting mainly in genitourinary toxicity and sexual dysfunction, and EBRT in bowel problems.
Based on the results of this systematic review, both RP as part of multimodal treatment and EBRT + long-term ADT can be recommended as primary treatment in high-risk and locally advanced PCa. For high-risk PCa, EBRT + BT can also be offered despite more grade 3 toxicity. Interestingly, for selected patients, for example, those with higher comorbidity, a shorter duration of ADT might be an option. For locally advanced PCa, EBRT + BT shows promising result but still needs further validation. In this setting, it is important that patients are aware that the offered therapy will most likely be in the context a multimodality treatment plan. In particular, if radiation is used, the combination of local with systemic treatment provides the best outcome, provided the patient is fit enough to receive both. Until the results of the SPCG15 trial are known, the optimal local treatment remains a matter of debate. Patients should at all times be fully informed about all available options, and the likelihood of a multimodal approach including the potential side effects of both local and systemic treatment.
We reviewed the literature to see whether the evidence from clinical studies would tell us the best way of curing men with aggressive prostate cancer that had not spread to other parts of the body such as lymph glands or bones. Based on the results of this systematic review, there is good evidence that both surgery and radiation therapy are good treatment options, in terms of prolonging life and preserving quality of life, provided they are combined with other treatments. In the case of surgery this means including radiotherapy (RT), and in the case of RT this means either hormonal therapy or combined RT and brachytherapy.
High-risk and locally advanced prostate cancer (PCa) patients are likely to undergo multimodality treatment. Patients should at all times be fully informed about all available options and the likelihood of a multimodal approach, including the potential side effects of both local and systemic treatment.
For high-risk localized and locally advanced PCa, both radical prostatectomy as part as multimodal therapy and external beam radiotherapy (EBRT) + long-term androgen deprivation therapy (ADT) can be recommended as primary treatment.
For high-risk localized PCa, EBRT + BT can also be offered despite a less favorable toxicity profile. In selected high-risk PCa patients, a shorter duration of ADT might be considered.
Until the results of the SPCG15 trial are known, the optimal local treatment remains a matter of debate.
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•Prostate MRI effectively detects cribriform growth in prostate cancer.•Lower ADC values are associated with any and large cribriform patterns.•Adverse MRI parameters indicate ...prostate cancer with cribriform pattern.
Cribriform pattern has recently been recognized as an important independent risk factor for prostate cancer (PCa) outcome. This study aimed to identify the association of quantifiable prostate magnetic resonance imaging (MRI) parameters with any and large cribriform pattern at radical prostatectomy (RP) specimens.
Preoperative prostate MRI’s from 188 men undergoing RP between 2010 and 2018 were retrospectively acquired. RP specimens of the patients were revised for Gleason score (GS), and presence of any and large cribriform pattern. MRI parameters such as MRI visibility, PI-RADS score, lowest apparent diffusion coefficient (ADC) value, lesion size, and radiologic extra-prostatic extension (EPE) were reviewed. The association of prostate MRI parameters for presence of any and large cribriform pattern at RP was analysed using logistic regression.
116/188 (61.7%) PCa patients had any cribriform and 36/188 (19.1%) large cribriform pattern at RP. 171/188 (91.0%) men had MRI-visible lesions; 111/116 (95.7%) tumours with any and 36/36 (100%) with large cribriform pattern were visible at MRI. PCa with any and large cribriform pattern both had lower ADC values than those without (p < 0.001). In adjusted analysis, lowest ADC value was as an independent predictor for any cribriform (Odds Ratio (OR) 0.2, 95% Confidence Interval (CI) 0.1–0.8; p = 0.01) and large cribriform pattern (OR 0.2, 95% CI 0.1–0.7; p = 0.01), while other parameters were not.
The majority of PCa with cribriform pattern at RP were visible at MRI, and lowest ADC value was an independent predictor for both any and large cribriform pattern.
The computer-aided analysis of prostate multiparametric MRI (mpMRI) could improve significant-prostate-cancer (PCa) detection. Various deep-learning- and radiomics-based methods for significant-PCa ...segmentation or classification have been reported in the literature. To be able to assess the generalizability of the performance of these methods, using various external data sets is crucial. While both deep-learning and radiomics approaches have been compared based on the same data set of one center, the comparison of the performances of both approaches on various data sets from different centers and different scanners is lacking. The goal of this study was to compare the performance of a deep-learning model with the performance of a radiomics model for the significant-PCa diagnosis of the cohorts of various patients. We included the data from two consecutive patient cohorts from our own center (
= 371 patients), and two external sets of which one was a publicly available patient cohort (
= 195 patients) and the other contained data from patients from two hospitals (
= 79 patients). Using multiparametric MRI (mpMRI), the radiologist tumor delineations and pathology reports were collected for all patients. During training, one of our patient cohorts (
= 271 patients) was used for both the deep-learning- and radiomics-model development, and the three remaining cohorts (
= 374 patients) were kept as unseen test sets. The performances of the models were assessed in terms of their area under the receiver-operating-characteristic curve (AUC). Whereas the internal cross-validation showed a higher AUC for the deep-learning approach, the radiomics model obtained AUCs of 0.88, 0.91 and 0.65 on the independent test sets compared to AUCs of 0.70, 0.73 and 0.44 for the deep-learning model. Our radiomics model that was based on delineated regions resulted in a more accurate tool for significant-PCa classification in the three unseen test sets when compared to a fully automated deep-learning model.
Objectives
To assess the value of risk‐stratification based on magnetic resonance imaging (MRI) and prostate‐specific antigen density (PSA‐D) in reducing unnecessary biopsies without missing Gleason ...pattern 4 prostate cancer in men on active surveillance (AS).
Patients and Methods
In all, 210 men on AS with Gleason score 3 + 3 prostate cancer received a first MRI and if indicated Prostate Imaging Reporting and Data System (PI‐RADS) score ≥3 targeted biopsy (TBx) using MRI‐transrectal ultrasonography (TRUS) fusion. The MRI was performed 3 months after diagnosis (group A: n = 97), at confirmatory biopsy (group B: n = 39) or at surveillance biopsy after one or more repeat TRUS‐guided systematic biopsies (TRUS‐Bx) (group C: n = 74). The primary outcome was upgrading to Gleason score ≥3 + 4 prostate cancer based on MRI ± TBx in groups A, B and C. Biopsy outcomes were stratified for the overall PI‐RADS score and PSA‐D to identify a subgroup of men in whom a biopsy could have been avoided as no Gleason score upgrading was detected.
Results
In all, 134/210 (64%) men had a positive MRI and 51/210 (24%) men had Gleason score upgrading based on MRI‐TBx. The percentage of Gleason score upgrading based on MRI‐TBx was 23% (22/97), 23% (9/39) and 27% (20/74) in respectively groups A, B and C. Additional Gleason score upgrading detected by TRUS‐Bx occurred in 8% (3/39) of men in group B and 6% (1/17) of men who received TRUS‐Bx in group C. No Gleason score upgrading was detected by MRI‐TBx in men with a PI‐RADS score of 3 and a PSA‐D of <0.15 ng/mL2(n = 15), nor by TRUS‐Bx in men with a PI‐RADS score of 1–3 and a PSA‐D of <0.15 ng/mL2 (n = 15).
Conclusion
At least one out of five men on AS with Gleason score 3 + 3 prostate cancer at diagnostic TRUS‐Bx show Gleason score upgrading based on first MRI ± TBx at baseline, confirmatory or surveillance biopsy. Men with a PI‐RADS score of 1–3 and PSA‐D of <0.15 ng/mL2 did not show Gleason score upgrading at MRI ± TBx or TRUS‐Bx at each time point of surveillance. Thus risk‐stratification based on PI‐RADS and PSA‐D may reduce unnecessary follow‐up biopsy procedures in men on AS.
The evidence in the field of diagnosis, staging, and treatment of localised prostate cancer (PCa) is evolving rapidly. The 2024 European Association of Urology (EAU)-European Association of Nuclear ...Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.
The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines provide recommendations for the management of clinically localised prostate cancer (PCa). This paper aims to present a summary of the 2024 version of the EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on the screening, diagnosis, and treatment of clinically localised PCa.
The panel performed a literature review of all new data published in English, covering the time frame between May 2020 and 2023. The guidelines were updated, and a strength rating for each recommendation was added based on a systematic review of the evidence.
A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is considered, a combination of targeted and regional biopsies should be performed. Prostate-specific membrane antigen positron emission tomography imaging is the most sensitive technique for identifying metastatic spread. Active surveillance is the appropriate management for men with low-risk PCa, as well as for selected favourable intermediate-risk patients with International Society of Urological Pathology grade group 2 lesions. Local therapies are addressed, as well as the management of persistent prostate-specific antigen after surgery. A recommendation to consider hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term intensified hormonal treatment.
The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. These PCa guidelines reflect the multidisciplinary nature of PCa management.
This article is the summary of the guidelines for “curable” prostate cancer. Prostate cancer is “found” through a multistep risk-based screening process. The objective is to find as many men as possible with a curable cancer. Prostate cancer is curable if it resides in the prostate; it is then classified into low-, intermediary-, and high-risk localised and locally advanced prostate cancer. These risk classes are the basis of the treatments. Low-risk prostate cancer is treated with “active surveillance”, a treatment with excellent prognosis. For low-intermediary-risk active surveillance should also be discussed as an option. In other cases, active treatments, surgery, or radiation treatment should be discussed along with the potential side effects to allow shared decision-making.
Different nomograms exist for the preoperative prediction of pelvic lymph-node metastatic disease in individual patients with prostate cancer (PCa). These nomograms do not incorporate modern imaging ...techniques such as prostate-specific membrane antigen (PSMA) positron emission tomography (PET).
To determine the predictive performance of the Briganti 2017, Memorial Sloan Kettering Cancer Center (MSKCC), and Briganti 2019 nomograms with the addition of PSMA-PET in an international, multicenter, present-day cohort of patients undergoing robot-assisted radical prostatectomy (RARP) and extended pelvic lymph-node dissection (ePLND) for localized PCa.
All 757 eligible patients who underwent a PSMA-PET prior to RARP and ePLND in three reference centers for PCa surgery between January 2016 and November 2020 were included.
Performance of the three nomograms was assessed using the receiver operating characteristic curve–derived area under the curve (AUC), calibration plots, and decision curve analyses. Subsequently, recalibration and addition of PSMA-PET to the nomograms were performed.
Overall, 186/757 patients (25%) had pelvic lymph-node metastatic (pN1) disease on histopathological examination. AUCs of the Briganti 2017, MSKCC, and Briganti 2019 nomograms were 0.70 (95% confidence interval 95% CI: 0.64–0.77), 0.71 (95% CI: 0.65–0.77), and 0.76 (95% CI: 0.71–0.82), respectively. PSMA-PET findings showed a significant association with pN1 disease when added to the nomograms (p < 0.001). Addition of PSMA-PET substantially improved the discriminative ability of the models yielding cross-validated AUCs of 0.76 (95% CI: 0.70–0.82), 0.77 (95% CI: 0.72–0.83), and 0.82 (95% CI: 0.76–0.87), respectively. In decision curve analyses, the addition of PSMA-PET to the three nomograms resulted in increased net benefits.
The addition of PSMA-PET to the previously developed nomograms showed substantially improved predictive performance, which suggests that PSMA-PET is a likely future candidate for a modern predictive nomogram.
Different tools have been developed to individualize the prediction of prostate cancer spread to lymph nodes before surgery. We found that the inclusion of modern imaging (prostate-specific membrane antigen positron emission tomography) improved substantially the overall performance of these prediction tools.
The addition of prostate-specific membrane antigen positron emission tomography (PSMA-PET) to the previously developed nomograms for the prediction of pelvic lymph-node metastases showed substantially improved predictive performance, which suggests that PSMA-PET is a likely future candidate for a modern predictive nomogram.
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