Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway

Abstract

Multiparametric magnetic resonance imaging (MRI) of the prostate is now recommended as the initial diagnostic test for men presenting with suspected prostate cancer, with a negative MRI enabling safe avoidance of biopsy and a positive result enabling MRI-directed sampling of lesions. The diagnostic pathway consists of several steps, from initial patient presentation and preparation to performing and interpreting MR images, communicating the imaging findings, outlining the prostate and intra-prostatic target lesions, performing the biopsy, and assessing the cores. Each component of this pathway requires experienced clinicians, optimised equipment, good inter-disciplinary communication between specialists, and standardised workflows in order to achieve the expected outcomes. Assessment of quality and mitigation measures are essential for the success of the MRI-directed prostate cancer diagnostic pathway. Quality assurance processes including Prostate Imaging-Reporting and Data System (PI-RADS), template biopsy, and pathology guidelines help minimise variation and ensure optimisation of the diagnostic pathway. Quality control systems including the Prostate Imaging Quality (PI-QUAL) scoring system, patient-level outcomes (such as PI-RADS MRI score assignment and cancer detection rates), multidisciplinary meeting review and audits might also be used to provide consistency of outcomes and ensure that all the benefits of the MRI-directed pathway are achieved. Key points-Multiparametric magnetic resonance imaging (MRI) is now recommended as the initial diagnostic test for men presenting with suspected prostate cancer -A negative MRI enables patients to safely avoid biopsy, whereas a positive MRI prompts targeted biopsy and pathologically accurate tissue sampling.-The MRI-directed prostate cancer diagnostic pathway involves several steps including acquiring and interpreting MR images, communicating MRI findings, outlining suspicious target lesions, performing biopsy, and evaluating the cores.-All steps in the pathway are prone to variation; assessment and mitigation of poor quality and variance are essential for a successful delivery of the MRI-directed pathway -Quality assurance systems to minimise variation in performance and prevent poor quality include Prostate Imaging-Reporting and Data System (PI-RADS) imaging guidelines for radiologists, prostate biopsy templates, and International Society of Urological Pathology (ISUP) guidelines for histopathologists.-Quality control measures include checking MRI compliance with PI-RADS, image quality assessment with the Prostate Imaging Quality (PI-QUAL) scoring system, radiologist certification, multidisciplinary team meeting ( MDT) review and pathology re-review of images, and audits of cancer detection rates and biopsy core quality.

Picture Perfect: The Status of Image Quality in Prostate MRI

“…Finally, as shown in both this review and by Barrett and colleagues, 8 we have outlined some important questions for prostate MRI which centers could reflect on in order to ensure quality along the PCa diagnostic pathway (Table 3).…”

“…A recent review outlined the dual importance of both quality control (i.e., radiologists assessing scan quality as part of clinical practice) and quality assurance (i.e., the measures introduced to guarantee that scans are of the optimal quality). 8 The need for both initiatives has been recognized in the past and supported by a dedicated European working group 9 as well as a panel of experts in the United Kingdom. 10 Nevertheless, the heterogeneity of scanners and settings worldwide has made it "impossible to provide a tailored mpMRI prostate imaging protocol for every MR system," 11 rendering quality assurance difficult.…”

“…In prostate MRI, this is still an emerging focus. A recent review outlined the dual importance of both quality control (i.e., radiologists assessing scan quality as part of clinical practice) and quality assurance (i.e., the measures introduced to guarantee that scans are of the optimal quality) 8 . The need for both initiatives has been recognized in the past and supported by a dedicated European working group 9 as well as a panel of experts in the United Kingdom 10 .…”

Index lesion contouring on prostate MRI for targeted MRI/US fusion biopsy – Evaluation of mismatch between radiologists and urologists

“…However, the successful delivery of the MRI-directed diagnostic pathway requires a multidisciplinary cooperative effort and relies on several steps including MR image acquisition, image interpretation, index lesion definition, performance of the biopsy procedure and the histopathological analysis of biopsy specimen [5,6]. Each of these steps is influenced by several factors and potential sources of error can arise in this MRI-directed pathway at different stages and timepoints.…”

The added value of a deep learning-based computer-aided detection system on prostate cancer detection among readers with varying level of multiparametric MRI expertise

“…Efforts on improving the quality of prostate MRI exams are underway with the recently published guidelines such as PI-RADS v2.1 and prostate imaging quality (PI-QUAL) (2,16). However, the impact of this standardization attempt is likely to take effect in years in many institutions as the quality assurance and quality control steps are dependent on the collective effort of a multi-disciplinary team (17,18). On the other hand, AI could potentially aid in challenging cases (i.e., low quality MRI), if the training dataset consisted of images obtained from scanners with different magnetic strength (3T or 1.5T), MRI vendors, receiver coils (endorectal or surface) (19) (Figure 1).…”