The Prostate Imaging-Reporting and Data System (PI-RADS) v2 analysis system for multiparametric magnetic resonance imaging (mpMRI) detection of prostate cancer (PCa) is based on PI-RADS v1, ...accumulated scientific evidence, and expert consensus opinion.
To summarize the accuracy, strengths and weaknesses of PI-RADS v2, discuss pathway implications of its use and outline opportunities for improvements and future developments.
For this consensus expert opinion from the PI-RADS steering committee, clinical studies, systematic reviews, and professional guidelines for mpMRI PCa detection were evaluated. We focused on the performance characteristics of PI-RADS v2, comparing data to systems based on clinicoradiologic Likert scales and non–PI-RADS v2 imaging only. Evidence selections were based on high-quality, prospective, histologically verified data, with minimal patient selection and verifications biases.
It has been shown that the test performance of PI-RADS v2 in research and clinical practice retains higher accuracy over systematic transrectal ultrasound (TRUS) biopsies for PCa diagnosis. PI-RADS v2 fails to detect all cancers but does detect the majority of tumors capable of causing patient harm, which should not be missed. Test performance depends on the definition and prevalence of clinically significant disease. Good performance can be attained in practice when the quality of the diagnostic process can be assured, together with joint working of robustly trained radiologists and urologists, conducting biopsy procedures within multidisciplinary teams.
It has been shown that the test performance of PI-RADS v2 in research and clinical practice is improved, retaining higher accuracy over systematic TRUS biopsies for PCa diagnosis.
Multiparametric magnetic resonance imaging (MRI) and MRI-directed biopsies using the Prostate Imaging-Reporting and Data System improves the detection of prostate cancers likely to cause harm, and at the same time decreases the detection of disease that does not lead to harms if left untreated. The keys to success are high-quality imaging, reporting, and biopsies by radiologists and urologists working together in multidisciplinary teams.
Multiparametric magnetic resonance imaging (MRI) and MRI-directed biopsies using the Prostate Imaging-Reporting and Data System improves the detection of prostate cancers likely to cause harm, and at the same time decreases the detection of disease that does not lead to harm if left untreated. The keys to success are high-quality imaging, reporting, and biopsies by radiologists and urologists working together in multidisciplinary teams.
The significance of the oral manifestations of HIV has been widely recognised since the start of the epidemic. It is estimated that more than 38 million people are living with HIV currently, with ...more than a third presenting with oral manifestations. Access to optimum clinical management and effective treatment in resource‐rich countries has led to a remarkable decrease in some of the oral manifestations in the HIV population but this is not mirrored in developing countries, where most HIV‐positive patients reside. In this paper, a review of the literature since the start of the HIV infection in different parts of the world is presented to highlight the current significance of the oral conditions in this population. Oral candidiasis was repeatedly reported as the most encountered oral manifestation of HIV in different countries, including in studies on groups on anti‐retroviral therapy. Over time salivary gland disease was reported less in developed countries but was encountered more in developing countries. There is evidence to show that the prevalence of oral warts increased with the establishment of anti‐retroviral therapy. A review of the worldwide prevalence of HIV‐related oral conditions indicates that except for oral hairy leucoplakia, the prevalence of all other nine commonly reported oral conditions remained the same or increased over time. Oral opportunistic infections in HIV‐infected patients are an ongoing clinical burden mainly in developing countries. Maintaining research in the subject and improving access to HIV treatment will help address the oral health inequalities around the world.
Diffusion-weighted (DW) magnetic resonance (MR) imaging is emerging as a powerful clinical tool for directing the care of patients with cancer. Whole-body DW imaging is almost at the stage where it ...can enter widespread clinical investigations, because the technology is stable and protocols can be implemented for the majority of modern MR imaging systems. There is a continued need for further improvements in data acquisition and analysis and in display technologies. Priority areas for clinical research include clarification of histologic relationships between tissues of interest and DW MR imaging biomarkers at diagnosis and during therapy response. Because whole-body DW imaging excels at bone marrow assessments at diagnosis and for therapy response, it can potentially address a number of unmet clinical and pharmaceutical requirements. There are compelling needs to document and understand how common and novel treatments affect whole-body DW imaging results and to establish response criteria that can be tested in prospective clinical studies that incorporate measures of patient benefit.
Objective
To comprehensively review the literature on the integration of MRI as a diagnostic tool in prostate cancer screening and offer practical recommendations for optimising its use.
Methods
...Existing research studies, clinical guidelines and expert opinions were reviewed to support the optimisation standards for MRI use in screening. Consolidated screening principles were used to make appropriate recommendations regarding the integration of MRI into the diagnostic pathway.
Results
To strike a balance between the potential benefits of early detection on mortality and minimising the harm of over-diagnosing indolent cancers, it is necessary to have a clear understanding of the context of MRI use. The key to optimisation is patient selections and MRI-targeted biopsies. For men at higher-than-average risk, it is essential to use screening-specific MRI protocols and establish accuracy levels and interpretation criteria. Optimisation of readings by the automation of data acquisition, image quality monitoring, post-processing, radiologist certification and deep-learning computer-aided software is needed. The optimal utilisation of MRI involves its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.
Conclusion
MRI in the prostate cancer screening pathway can bring substantial diagnostic benefits. By carefully considering its advantages, limitations and safety concerns and integrating it into a multistep diagnostic pathway, clinicians can improve outcomes while minimising harm to screening participants.
Clinical relevance statement
The manuscript discusses the role of MRI in prostate cancer screening, highlighting its potential to improve accuracy and reduce overdiagnosis. It emphasises the importance of optimising protocols and integrating MRI into a multistep diagnostic pathway for successfully delivering screening benefits.
Key Points
• Population screening for prostate cancer is a new indication for prostate MRI that allows the detection of high-risk cancers while reducing the need for biopsies and associated harm.
• To optimise prostate cancer screening using MRI, it is essential to redefine MRI protocols; establish accuracy levels, reliability and interpretation criteria; and optimise reading (including post-processing, image quality, radiologist certification, and deep-learning computer-aided software).
• The optimal utilisation of MRI for prostate cancer screening would involve its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.
The benefits and drawbacks of the dynamic contrast‐enhanced MRI sequence for prostate cancer diagnosis are increasingly being recognized, with many centers adopting the biparametric (bp) MRI approach ...as the default initial approach. The abandonment of the routine use of contrast medium requires an assessment of the loss of diagnostic power against the gains in operational logistics, costs, time, capacity, and side effects. It is the balance of these factors weighted against the clinical priorities of patients that determines which patient groups can safely avoid dynamic contrast enhancement. Although systematic reviews and individual studies are broadly supportive of the bpMRI approach, the pathway impacts for men with suspected cancer using the bpMRI approach are still not well documented for clinical practice. Robust prospectively acquired data for bpMRI regarding biopsy avoidance, detection of clinically significant and insignificant cancers, and for increasing the precision of tumor grade and volume are needed. There is a requirement for prospective, randomized, or blinded head‐to‐head, multicenter studies, addressing the noninferiority of biopsy yields prompted by bpMRI and multiparametric MRI approaches. These studies should more precisely define patient groups where the benefits and harms of contrast enhancement are aligned to their clinical priorities. Only then can we be confident in recommending bpMRI as an initial diagnostic approach for prostate cancer diagnosis.
Level of Evidence
1
Technical Efficacy Stage
5
The Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) was developed with a consensus-based process using a combination of published data, and expert observations and opinions. In the ...short time since its release, numerous studies have validated the value of PI-RADS v2 but, as expected, have also identified a number of ambiguities and limitations, some of which have been documented in the literature with potential solutions offered. To address these issues, the PI-RADS Steering Committee, again using a consensus-based process, has recommended several modifications to PI-RADS v2, maintaining the framework of assigning scores to individual sequences and using these scores to derive an overall assessment category. This updated version, described in this article, is termed PI-RADS v2.1. It is anticipated that the adoption of these PI-RADS v2.1 modifications will improve inter-reader variability and simplify PI-RADS assessment of prostate magnetic resonance imaging even further. Research on the value and limitations on all components of PI-RADS v2.1 is strongly encouraged.
The Prostate Imaging Reporting and Data System (PI-RADS) Committee, using a consensus-based process, has recommended several modifications to PI-RADS version 2 (v2), maintaining the framework of assigning scores to individual sequences and using these scores to derive an overall assessment category. The updated version is termed PI-RADS v2.1.
High-quality evidence shows that MRI in biopsy-naive men can reduce the number of men who need prostate biopsy and can reduce the number of diagnoses of clinically insignificant cancers that are ...unlikely to cause harm. In men with prior negative biopsy results who remain under persistent suspicion, MRI improves the detection and localization of life-threatening prostate cancer with greater clinical utility than the current standard of care, systematic transrectal US-guided biopsy. Systematic analyses show that MRI-directed biopsy increases the effectiveness of the prostate cancer diagnosis pathway. The incorporation of MRI-directed pathways into clinical care guidelines in prostate cancer detection has begun. The widespread adoption of the Prostate Imaging Reporting and Data System (PI-RADS) for multiparametric MRI data acquisition, interpretation, and reporting has promoted these changes in practice. The PI-RADS MRI-directed biopsy pathway enables the delivery of key diagnostic benefits to men suspected of having cancer based on clinical suspicion. Herein, the PI-RADS Steering Committee discusses how the MRI pathway should be incorporated into routine clinical practice and the challenges in delivering the positive health impacts needed by men suspected of having clinically significant prostate cancer.
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