Predictors of prostate cancer detection in MRI PI-RADS 3 lesions – Reality of a tertiary center
https://doi.org/10.4081/aiua.2023.11830
Accepted: November 2, 2023
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Introduction and objectives: The Prostate Imaging Reporting and Data System (PI-RADS) score reports the likelihood of a clinically significant prostate cancer (CsPCa) based on various multiparametric prostate magnetic resonance imaging (mpMRI) characteristics. The PI-RADS category 3 is an intermediate status, with an equivocal risk of malignancy. The PSA density (PSAD) has been proposed as a tool to facilitate biopsy decisions on PI-RADS category 3 lesions. The objective of this study is to determine the frequency of CsPCa, assess the diagnostic value of targeted biopsy and identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions. Methods: Between 1st January 2017 and 31st December 2022, a total of 1661 men underwent a prostate biopsy at our institution. Clinical and mpMRI data of men with PI-RADS 3 lesions was reviewed. The study population was divided into two groups: target group, including those submitted to systematic plus targeted biopsy versus non-target group when only systematic or saturation biopsy were performed. Patients with PI-RADS 3 lesions were divided into three categories based on pathological biopsy results: benign, clinically insignificant disease (score Gleason = 6 or International Society of Urologic Pathologic (ISUP) 1) and clinically significant cancer (score Gleason ≥ 7 (3+4) or ISUP ≥ 2) according to target and non-target group. Univariate and multivariate analyses were performed to identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions. Results: A total of 130 men with PIRADS 3 index lesions were identified. Pathologic results were benign in 77 lesions (59.2%), 19 (14.6%) were clinically insignificant (Gleason score 6) and 34 (26.2%) were clinically significant (Gleason score 7 or higher). Eighty-seven of the patients were included in the target group (66.9%) and 43 in the non-target group (33.1%). The CsPCa detection was higher in the non-target group (32.6%, n = 14 vs 23.0%, n = 20 respectively). When systematic and target biopsies were jointly performed, if the results of systematic biopsies are not considered and only the results of target biopsies are taken into account, a CsPCa diagnosis would be missed on 9 patients. The differences of insignificant cancer and CsPCa rates among the target or non-target group were not statistically significant (p = 0.50 and p = 0.24, respectively). on multivariate analysis, the abnormal DRE and lesions localized in Peripheral zone (PZ) were significantly associated with a presence of CsPCa in PI-RADS 3 lesions (oR = 3.61, 95% CI [1.22,10.72], p = 0.02 and oR = 3.31, 95% CI [1.35, 8.11], p = 0.01, respectively). A higher median PSAD significantly predisposed for CsPCa on univariate analyses (p = 0.05), however, was not significant in the multivariate analysis (p = 0.76). In our population, using 0.10 ng/ml/ml as a cut-off to perform biopsy, 41 patients would have avoided biopsy (31.5%), but 5 cases of CsPCa would not have been detected (3.4%). We could not identify any statistical significance between other clinical and imagiological variables and CsPCa detection. Conclusions: PI-RADS 3 lesions were associated with a low likelihood of CsPCa detection. A systematic biopsy associated or not with target biopsy is essential in PI-RADS 3 lesions, and targeted biopsy did not demonstrate to be superior in the detection of CsPCa. The presence of abnormal DRE and lesions localized in PZ potentially predict the presence of CsPCa in biopsied PI-RADS 3 lesions.
Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet. 2017; 389:815-22. DOI: https://doi.org/10.1016/S0140-6736(16)32401-1
Rouvière O, Puech P, Renard-Penna R, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol. 2019; 20:100-9. DOI: https://doi.org/10.1016/S1470-2045(18)30569-2
van der Leest M, Cornel E, Israël B, et al. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy naïve Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. Eur Urol. 2019; 75:570-8. DOI: https://doi.org/10.1016/j.eururo.2018.11.023
Drost FJH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 2019; 4:CD012663. DOI: https://doi.org/10.1002/14651858.CD012663.pub2
Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012; 22:746-57. DOI: https://doi.org/10.1007/s00330-011-2377-y
Turkbey B, Rosenkrantz AB, Haider MA, et al. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2. Eur Urol. 2019; 76:340-51. DOI: https://doi.org/10.1016/j.eururo.2019.02.033
EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6.
Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS Prostate Imaging - Reporting and Data System: 2015, Version 2. Eur Urol. 2016; 69:16-40. DOI: https://doi.org/10.1016/j.eururo.2015.08.052
Oerther B, Engel H, Bamberg F, Sigle A, Gratzke C, Benndorf M. Cancer detection rates of the PI-RADSv2.1 assessment categories: systematic review and meta-analysis on lesion level and patient level. Prostate Cancer Prostatic Dis. 2022; 25:256-63.
Schoots IG, Padhani AR. Risk-adapted biopsy decision based on prostate magnetic resonance imaging and prostate specific antigen density for enhanced biopsy avoidance in first prostate cancer diagnostic evaluation. BJU Int. 2021; 127:175-8. DOI: https://doi.org/10.1111/bju.15277
Maggi M, Panebianco V, Mosca A, et al. Prostate Imaging Reporting and Data System 3 Category Cases at Multiparametric Magnetic Resonance for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus. 2020; 6:463-78.
Maggi M, Panebianco V, Mosca A, et al. Prostate Imaging Reporting and Data System 3 Category Cases at Multiparametric Magnetic Resonance for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus. 2020; 6:463-78. DOI: https://doi.org/10.1016/j.euf.2019.06.014
Ullrich T, Quentin M, Arsov C, et al. Risk Stratification of Equivocal Lesions on Multiparametric Magnetic Resonance Imaging of the Prostate. J Urol. 2018; 199:691-8. DOI: https://doi.org/10.1016/j.juro.2017.09.074
Park KJ, Choi SH, Lee JS, et al. Risk Stratification of Prostate Cancer According to PI-RADS® Version 2 Categories: Meta Analysis for Prospective Studies. J Urol. 2020; 204:1141-9. DOI: https://doi.org/10.1097/JU.0000000000001306
Hansen NL, Barrett T, Lloyd T, et al. Optimising the number of cores for magnetic resonance imaging - guided targeted and systematic transperineal prostate biopsy. BJU Int. 2020; 125:260-9. DOI: https://doi.org/10.1111/bju.14865
Cash H, Günzel K, Maxeiner A, et al. Prostate cancer detection on transrectal ultrasonography-guided random biopsy despite negative real-time magnetic resonance imaging/ultrasonography fusionguided targeted biopsy: reasons for targeted biopsy failure. BJU Int. 2016; 118:35-43. DOI: https://doi.org/10.1111/bju.13327
Wegelin O, Exterkate L, van der Leest M, et al. The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies. Eur Urol. 2019; 75:582-90. DOI: https://doi.org/10.1016/j.eururo.2018.11.040
Venderink W, van Luijtelaar A, Bomers JGR, et al. Results of Targeted Biopsy in Men with Magnetic Resonance Imaging Lesions Classified Equivocal, Likely or Highly Likely to Be Clinically Significant Prostate Cancer. Eur Urol. 2018; 73:353-60. DOI: https://doi.org/10.1016/j.eururo.2017.02.021
Sheridan AD, Nath SK, Syed JS, et al. Risk of Clinically Significant Prostate Cancer Associated With Prostate Imaging Reporting and Data System Category 3 (Equivocal) Lesions Identified on Multiparametric Prostate MRI. AJR Am J Roentgenol. 2018; 210:347-57. DOI: https://doi.org/10.2214/AJR.17.18516
Radtke JP, Wiesenfarth M, Kesch C, et al. Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for Advanced Risk Modeling of Prostate Cancer—Patient-tailored Risk Stratification Can Reduce Unnecessary Biopsies. Eur Urol. 2017; 72:888-96. DOI: https://doi.org/10.1016/j.eururo.2017.03.039
Liddell H, Jyoti R, Haxhimolla HZ. mp-MRI Prostate Characterised PIRADS 3 Lesions are Associated with a Low Risk of Clinically Significant Prostate Cancer - A Retrospective Review of 92 Biopsied PIRADS 3 Lesions. Curr Urol. 2015; 8:96-100. DOI: https://doi.org/10.1159/000365697
Yang S, Zhao W, Tan S, et al. Combining clinical and MRI data to manage PI-RADS 3 lesions and reduce excessive biopsy. Transl Androl Urol. 2020; 9:1252-61. DOI: https://doi.org/10.21037/tau-19-755
Galosi AB, Palagonia E, Scarcella S, et al. Detection limits of significant prostate cancer using multiparametric MR and digital rectal examination in men with low serum PSA: Up-date of the Italian Society of Integrated Diagnostic in Urology. Arch Ital Urol Androl. 2021; 93:92-100. DOI: https://doi.org/10.4081/aiua.2021.1.92
Oerther B, Engel H, Bamberg F, et al. Cancer detection rates of the PI-RADSv2.1 assessment categories: systematic review and metaanalysis on lesion level and patient level. Prostate Cancer Prostatic Dis. 2022; 25:256-63. DOI: https://doi.org/10.1038/s41391-021-00417-1
Schoots IG. MRI in early prostate cancer detection: how to manage indeterminate or equivocal PI-RADS 3 lesions? Transl Androl Urol. 2018; 7:70-82. DOI: https://doi.org/10.21037/tau.2017.12.31
Copyright (c) 2023 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
Downloads
Citations
