Risk Stratification Among Men With Prostate Imaging Reporting and Data System version 2 Category 3 Transition Zone Lesions: Is Biopsy Always Necessary?

Abstract

OBJECTIVE The objective of our study was to determine the clinical and MRI characteristics of clinically significant prostate cancer (PCA) (Gleason score ≥ 3 + 4) in men with Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) category 3 transition zone (TZ) lesions. MATERIALS AND METHODS From 2014 to 2016, 865 men underwent prostate MRI and MRI/ultrasound (US) fusion biopsy (FB). A subset of 90 FB-naïve men with 96 PI-RADSv2 category 3 TZ lesions was identified. Patients were imaged at 3 T using a body coil. Images were assigned a PI-RADSv2 category by an experienced radiologist. Using clinical data and imaging features, we performed univariate and multivariate analyses to identify predictors of clinically significant PCA. RESULTS The mean patient age was 66 years, and the mean prostate-specific antigen density (PSAD) was 0.13 ng/mL2. PCA was detected in 34 of 96 (35%) lesions, 14 of which (15%) harbored clinically significant PCA. In univariate analysis, DWI score, prostate volume, and PSAD were significant predictors (p < 0.05) of clinically significant PCA with a suggested significance for apparent diffusion coefficient (ADC) and prostate-specific antigen value (p < 0.10). On multivariate analysis, PSAD and lesion ADC were the most important covariates. The combination of both PSAD of 0.15 ng/mL2 or greater and an ADC value of less than 1000 mm2/s yielded an AUC of 0.91 for clinically significant PCA (p < 0.001). If FB had been restricted to these criteria, only 10 of 90 men would have undergone biopsy, resulting in diagnosis of clinically significant PCA in 60% with eight men (9%) misdiagnosed (false-negative). CONCLUSION The yield of FB in men with PI-RADSv2 category 3 TZ lesions for clinically significant PCA is 15% but significantly improves to 60% (AUC > 0.9) among men with PSAD of 0.15 ng/mL2 or greater and lesion ADC value of less than 1000 mm2/s.

Detection rate of clinically significant prostate cancer in magnetic resonance imaging and ultrasonography‐fusion transperineal targeted biopsy for lesions with a prostate imaging reporting and data system version 2 score of 3–5

“…PI‐RADS category 3–5 warrant a repeat biopsy for patients with prior negative biopsies according to the American Urological Association and the Society of Abdominal Radiology . However, increasing evidence shows that lesions with PI‐RADS category 3 should be monitored without immediate biopsy to avoid unnecessary biopsy . In combination with additional clinical parameters, such as previous biopsy history, PV and PI‐RADS score, nomograms have yielded higher CSPC detection rates …”

“…8 However, increasing evidence shows that lesions with PI-RADS category 3 should be monitored without immediate biopsy to avoid unnecessary biopsy. [9][10][11][12] In combination with additional clinical parameters, such as previous biopsy history, PV and PI-RADS score, nomograms have yielded higher CSPC detection rates. 13,14 In the present retrospective study, we analyzed the usefulness of clinical parameters to predict biopsy results based on the CSPC detection rate of real-time MRI/US rigid fusion guided targeted biopsies at Tokyo Metropolitan Police Hospital, Tokyo, Japan.…”

Modified MR dispersion imaging in prostate dynamic contrast‐enhanced MRI

“…MRI‐positive lesions were defined to be true positive if they were in the same quadrant (left and right, anterior and posterior) and in the appropriate segment (base, midgland, and apex) on both mp‐MRI and histopathology and false positive if no corresponding lesions were found on the histopathology. Lesions with GS ≥ 7 ( n = 49) were defined as clinically significant PCa (CS‐PCa) with higher rates of adverse outcomes in comparison to GS = 6 ( n = 21) and false positives ( n = 24). A detailed information regarding locations (transition vs. peripheral zones), sizes (pathology diameter ≥ 1 cm vs. <1 cm), and Gleason scores (GS ≥ 7 vs. GS = 6) for MRI‐positive lesions is illustrated in Fig.…”

Multivariate risk prediction tools including MRI for individualized biopsy decision in prostate cancer diagnosis: current status and future directions

“…In such a scenario, at first the mpMRI could be circumvented using DRE to the roughly estimate prostate volume. Subsequently, mpMRI could only be utilized in men that most likely have an elevated PSA not related to BPH [37][38][39][40][41].…”