Prostate Imaging for Local Recurrence Reporting and Data System for Biparametric Magnetic Resonance Imaging: A Proposal.

We investigated a novel dedicated Prostate Imaging for Local Recurrence Reporting and Data System (PI-RRADS) in biochemical recurrence after radiotherapy (RT) and rad- ical prostatectomy (RP) evaluating biparametric magnetic resonance imaging (bpMRI) exams, at 3T MRI of 55 patients. Associating bpMRI and biochemical recurrence data, we calculated bpMRI diagnostic accuracy. Four probability categories, from 1 (very low) to 4 (very high), were distinguished. In 20 patients with radiotherapy, 25% and 75% of lesions were reported as PI-RRADS 3, and 4, respectively. In 35 patients with radi- cal prostatectomy, 7.7% of lesions were included in PI-RRADS 1-2, whereas 40.4% and 51.9% in PI-RRADS 3 and 4 categories, respectively. Excellent agreement and significant correlation between bpMRI and biochemical recurrence were found. BpMRI showed sensitivity, specificity, positive predictive value, negative predictive value, false-posi- tive value, false-negative value, and total diagnostic accuracy of 96.15%, 86.7%, 97.4 %, 81.25%, 13.3%, 3.8% and 94.6%, respectively. BpMRI-based PI-RRADS allows the detection and localization local recurrence in biochemical recurrence after RT and RP contributing in clinical management and treatment.

S-PI-RADS and PI-RRADS for Biparametric MRI in the Detection of Prostate Cancer and Post-treatment Local Recurrence.

The application of biparametric magnetic resonance imaging (bpMRI) [T2-weighted (T2W) and diffusion weighted imaging (DWI)/apparent diffusion coefficient (ADC)] using dedicated structured methods, such as Simplified Prostate Imaging Reporting and Data System (S-PI-RADS) for the detection, categorization, and management of prostate cancer (PCa) is reported. Also, Prostate Imaging Reporting for Local Recurrence and Data System (PI-RRADS) for the detection and assessment of the probability of local recurrence after radiotherapy (RT) or radical prostatectomy (RP) in patients with biochemical recurrence (BCR) is proposed. Both S-PI-RADS and PI-RRADS assign to DWI/ADC a main role for the above purpose. S-PI-RADS identifies four categories and, on the basis of the qualitative and quantitative analysis of the restricted diffusion on ADC map and lesion volume, distinguishes two categories of lesions: category 3 (moderately homogeneous hypointense on ADC map) and category 4 (markedly homogeneous or inhomogeneous hypointense on ADC map). Ιn category 3, two subcategories (3a: volume <0.5 cm3 and 3b: volume ≥0.5 cm3) suggesting clinical management. PI-RRADS distinguishes four assessment categories and suggests the stratification of the probability (ranging from very low for category 1 to very high for category 4) of local disease recurrence. In clinical practice, S-PI-RADS and PI-RRADS, based on bpMRI represent a potential valid approach that may facilitates the detection and management of PCa and for detecting local recurrence after treatment improving communication with other professionals.

Lesion Volume in a Bi- or Multivariate Prediction Model for the Management of PI-RADS v2.1 Score 3 Category Lesions.

OBJECTIVE: This study aimed at improving the discrimination of Prostate Imaging - Reporting and Data System version 2.1 (PI-RADS v2.1) score 3 suspicious prostate cancer lesions using lesion volume evaluation. MATERIAL AND METHODS: Two hundred five PI-RADS v2.1 score 3 lesions were submitted to transperineal MRI/TRUS fusion-targeted biopsy. The lesion volumes were estimated on diffusion-weighted imaging sequence and distributed in PI-RADS 3a (LV < 0.5 mL) and PI-RADS 3b (LV ≥ 0.5 mL) subcategories, using a 0.5 mL cutoff value. Data were retrospectively matched with histopathological findings from the biopsy. Assuming that lesions with LV < or ≥ 0.5 mL were respectively not eligible (benign and indolent PCa lesions) or eligible for biopsy (significant PCa lesions), the diagnostic accuracy of lesion volume in determining clinically significant PCa at biopsy was evaluated using a bi- or multivariate model. RESULTS: About 55.1% and 44.9% of lesions were distributed in subcategories 3a and 3b, respectively. The overall PI-RADS score 3 detection rate was 273%. 3.5% (1.95% of total), and 25% (11.7% of total) significant PCa were found in PI-RADS 3a and 3b subcategory, respectively. The method showed 85.2% sensitivity, 61.2% specificity, 25% positive predictive value, and 96.5% negative predictive value and avoided 55.1% of unnecessary biopsies. The diagnostic accuracy in determining significant PCa at biopsy was 73.2% or 86.5% depending on whether lesion volume was used alone or in combination with prostate volume and patient age in a multivariate model. CONCLUSION: 0.5 mL lesion volume cutoff value significantly discriminates fusion-targeted biopsy need in PI-RADS v2.1 score 3 lesions and its diagnostic accuracy improves when it combines with prostate volume and age in a multivariate model.

Oligometastatic Prostate Cancer: Is there a Role for Surgery? A Narrative Review.

Oligometastatic prostate cancer is commonly considered a transition between high metastatic and local- ized disease and includes a large spectrum of conditions with a polymorphic clinical behavior. The current management of these patients contemplates systemic therapy (i.e., androgen-deprivation drugs, chemothera- peutic drugs, or both treatments administered simultaneously) which have been shown to improve survival. Radiotherapy has also been introduced, into a multimodal setting, among the therapeutic treatments forpatients who are defined as oligometastatic prostate cancer according to Chemohormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer (CHAARTED) criteria.The role of surgical debulking in patients with oligometastatic prostate cancer has always been considered impracticable, both for a marginal therapeutic role and for the greater risk of sequelae and/or complications related to the procedure itself. Several authors have demonstrated some mechanisms by which the persistence of the primary tumor can facilitate the clinical progression of the disease itself and promote carcinogenesis, differentiation, migration, and angiogenesis in prostate cancer. From these studies emerges the hypothesis of a possible therapeutic advantage in oncological terms also for cytoreductive radical prostatectomy, in a multimodal therapy setting, compared to systemic therapy alone. The present review summarizes the main knowledge regarding the safety, feasibility, and oncological outcomes of cytoreductive radical prostatectomy in oligometastatic prostate cancer patients.

Simplified PI-RADS (S-PI-RADS) for biparametric MRI to detect and manage prostate cancer: What urologists need to know.

Biparametric magnetic resonance imaging (bpMRI) of the prostate has emerged as an alternative to multiparametric MRI (mpMRI) for the detection of clinically significant prostate cancer (csPCa). However, while the Prostate Imaging Reporting and Data System (PI-RADS) is widely known for mpMRI, a proper PI-RADS for bpMRI has not yet been adopted. In this review, we report the current status and the future directions of bpMRI, and propose a simplified PI-RADS (S-PI-RADS) that could help radiologists and urologists in the detection and management of PCa.

MRI apparent diffusion coefficient (ADC): A biomarker for prostate cancer after radiation therapy.

Prostate specific antigen (PSA) remains the most used test to assess the response after therapies including the radiation therapy (RT). Apparent diffusion coefficient (ADC) derived from the conventional diffusionweighted imaging (DWI), as a part of noncontrast or biparametric MRI (bpMRI) (T2-weighted and DWI), offers diagnostic accuracy and cancer detection rate equivalent to that of multiparametric MRI. Cellular changes induced by RT can be quali-qualitatively demonstrated as early as 3months after RT as an increase in the signal intensity of the tumor on the ADC map. ADC, in association with PSA, represents a potential biomarker imaging for evaluating treatment efficacy in PCa both during and shortly after RT.

Round table: arguments in supporting abbreviated or biparametric MRI of the prostate protocol.

Prostate Imaging Reporting and Data System (PI-RADS) version 2.1 update, in the attempt to improve clinical guidelines for multiparametric magnetic resonance imaging (mpMRI) of the prostate, has clear limitations. The role of dynamic contrast-enhanced sequences is not defined, precise guidance on the clinical management (biopsy or clinical surveillance) for score 3 lesions [equivocal for clinical significant prostate cancer (sPCa)] is not offered and criteria for lesions interpretation remain difficult and subjective. We report criteria and arguments in supporting the use of abbreviated or biparametric prostate MRI protocol in clinical practice for detection and management of PCa.

Prostate MRI and transperineal TRUS/MRI fusion biopsy for prostate cancer detection: clinical practice updates.

This narrative review summarizes the current knowledge about multiparametric and biparametric magnetic resonance imaging of the prostate. This is provided from both a radiological and a urological point of view analyzing the technical aspects of fusion-targeted biopsy using the transperineal approach. We report practical considerations concerning pure cognitive and software-assisted settings, discuss the principal transperineal fusion software now available, and debate the pros and cons of choosing one approach over the other.

Biparametric MRI and 41 sector map for MRI/Transrectal ultrasound fusion biopsy to increase diagnostic accuracy of prostate cancer.

Optimizing the number of prostate biopsy (PB) cores in the initial diagnosis of prostate cancer is still an open question. Increasing the number of cores can expectedly lead to a higher cancer detection rate but more frequent, and greater number of adverse effects should be considered. It is necessary to limit the number of PBs, obtained from tumor areas and areas with a high suspect of malignancy. Simplified Prostate Imaging Reporting and Data System (PIRADS) using biparametric MR imaging (bpMRI) protocol identifies 4 categories indicating the management for each one. We suggest targeted biopsy for category 3b [lesion with a volume ≥0.5 cc, homogeneous or inhomogeneous, mild/moderately or markedly hypointense on T2-weighted, hyperintense on high b value diffusion-weighted (DW) imaging and moderately hypointense on apparent diffusion coefficient (ADC) map] and category 4 (homogeneous or heterogeneous lesion intra- or extraglandular, mild/moderately or markedly hypointense on T2-weighted, hyperintense on high b value DW imaging and markedly hypointense on ADC map). For a precise localization of the suspected prostate lesions we used a model of 41 sectors/regions map. BpMRI/Transrectal ultrasound fusion-targeted biopsy and the 41 sectors map represent a valid alternative model to the core biopsy of 10-12 systematic transrectal or transperineal peripheral zone biopsies.

Biparametric MRI of the prostate.

Biparametric Magnetic Resonance Imaging (bpMRI) of the prostate combining both morphologic T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) is emerging as an alternative to multiparametric MRI (mpMRI) to detect, to localize and to guide prostatic targeted biopsy in patients with suspicious prostate cancer (PCa). BpMRI overcomes some limitations of mpMRI such as the costs, the time required to perform the study, the use of gadolinium-based contrast agents and the lack of a guidance for management of score 3 lesions equivocal for significant PCa. In our experience the optimal and similar clinical results of the bpMRI in comparison to mpMRI are essentially related to the DWI that we consider the dominant sequence for detection suspicious PCa both in transition and in peripheral zone. In clinical practice, the adoption of bpMRI standardized scoring system, indicating the likelihood to diagnose a clinically significant PCa and establishing the management of each suspicious category (from 1 to 4), could represent the rationale to simplify and to improve the current interpretation of mpMRI based on Prostate Imaging and Reporting Archiving Data System version 2 (PI-RADS v2). In this review article we report and describe the current knowledge about bpMRI in the detection of suspicious PCa and a simplified PI-RADS based on bpMRI for management of each suspicious PCa categories to facilitate the communication between radiologists and urologists.

Is contrast enhancement needed for diagnostic prostate MRI?

Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) provides clinical guidelines for multiparametric magnetic resonance imaging (mpMRI) [T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI)] of prostate. However, DCE-MRI seems to show a limited contribution in prostate cancer (PCa) detection and management. In our experience, DCE-MRI, did not show significant change in diagnostic performance in addition to DWI and T2WI [biparametric MRI (bpMRI)] which represent the predominant sequences to detect suspected lesions in peripheral and transitional zone (TZ). In this article we reviewed the role of DCE-MRI also indicating the potential contribute of bpMRI approach (T2WI and DWI) and lesion volume evaluation in the diagnosis and management of suspected PCa.