How MRI is changing prostate cancer management: a focus on early detection and active surveillance: Comment l'IRM est en train de révolutionner la prise en charge du cancer de la prostate : focus sur la détection précoce et la surveillance active.

The last decade has witnessed major changes in prostate cancer management. Among these, the advent of magnetic resonance imaging (MRI), by allowing the visualisation of the cancerous lesion inside the prostatic gland, opened new management horizons. We conducted a narrative review of the literature published since 2010, focusing on the place of MRI in the early detection, active surveillance and prostate cancer screening settings. Multiparametric magnetic resonance imaging (mpMRI), interpreted using the PI-RADS scoring system, has allowed a shift from systematic to mpMRI-targeted biopsies, supported by level I evidence. Studies are ongoing to evaluate the role of MRI as a triage and screening tool. The integration of mpMRI has allowed for a better selection of active surveillance candidates, reducing the risk of misclassification. The PRECISE recommendations have been created to assess the likelihood of radiological change over time from the previous or baseline mpMRI scan, and serial mpMRI appears promising to reduce the need for repeat biopsy in active surveillance. Growing evidence supports the use of MRI at all stages of the prostate cancer pathway, relying on images of optimal diagnostic quality and experience in prostate MRI reporting and biopsy targeting. © 2022 Elsevier Masson SAS. All rights reserved.

Fiard G ，Giganti F 《PROGRES EN UROLOGIE》

Magnetic Resonance Imaging-Targeted Biopsy and Pretherapeutic Prostate Cancer Risk Assessment: a Systematic Review: Biopsie ciblée par Imagerie par résonance magnétique et évaluation pré-thérapeutique du risque de cancer de la prostate : revue systématiqu

Multiparametric magnetic resonance imaging (MRI) has been included in prostate cancer (PCa) diagnostic pathway and may improve disease characterization. The aim of this systematic review is to assess the added value of MRI-targeted biopsy (TB) in pre-therapeutic risk assessment models over existing tools based on systematic biopsy (SB) for localized PCa. A systematic search was conducted using Pubmed (Medline), Scopus and ScienceDirect databases according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We included studies through October 2021 reporting on TB in pretherapeutic risk assessment models. We identified 24 eligible studies including 24'237 patients for the systematic review. All included studies were retrospective and conducted in patients undergoing radical prostatectomy. Nine studies reported on the risk of extraprostatic extension, seven on the risk of lymph node invasion, three on the risk of biochemical recurrence and nine on the improvement of PCa risk stratification. Overall, the combination of TB with imaging, clinical and biochemical parameters outperformed current pretherapeutic risk assessment models. External validation studies are lacking for certain endpoints and the absence of standardization among TB protocols, including number of TB cores and fusion systems, may limit the generalizability of the results. TB should be incorporated in pretherapeutic risk assessment models to improve clinical decision making. Further high-quality studies are required to determine models' generalizability while there is an urgent need to reach consensus on a standardized TB protocol. Long-term outcomes after treatment are also awaited to confirm the superiority of such models over classical risk classifications only based on SB. © 2022 Elsevier Masson SAS. All rights reserved.

Diamand R ，Mjaess G ，Ploussard G ，Fiard G ，Oderda M ，Lefebvre Y ，Sirtaine N ，Roumeguère T ，Peltier A ，Albisinni S ... -  《PROGRES EN UROLOGIE》

Prostate Indeterminate Lesions on Magnetic Resonance Imaging-Biopsy Versus Surveillance: A Literature Review.

The indeterminate multiparametric prostate magnetic resonance image (mpMRI) lesion is one which cannot be classified as "positive" or "negative" for suspected cancer. Currently, there is no consensus on how to manage patients with indeterminate mpMRIs where areas cannot be classified as positives or negatives (Prostate Imaging Reporting and Data System [PI-RADS] 3 or Likert 3). To define the concept of indeterminate lesion and describe the management strategies that may be adopted for these patients. A literature search of the PubMed database was performed including the search terms "prostate indeterminate lesions", "PI-RADS 3", "Likert 3", "magnetic resonance imaging", and "prostate cancer". There is no universally accepted definition of what constitutes an indeterminate lesion on mpMRI. This is partly due to the experience of the reporting radiologist and their willingness to call a lesion indeterminate, knowing that this may have consequences for biopsy decisions. This is also partly due to the significant variation in mpMRI acquisition parameters used between different sites. Strategies for managing the indeterminate lesion include: (1) biopsy, where there is a highly variable prevalence of prostate cancer (PCa), reflecting the differences in clinically significant PCa definitions, mpMRI protocols and interobserver variability in characterization of indeterminate lesions and (2) surveillance, where early results suggest that this strategy may be of value for some selected patients with prostate-specific antigen (PSA) monitoring and/or interval mpMRI. The use of prebiopsy MRI, in conjunction with traditional clinical parameters and secondary biomarkers-nomograms, may allow a more accurate selection of patients who can avoid biopsy. A strategy of close surveillance based on PSA monitoring and interval mpMRI is a feasible management option for motivated patients with indeterminate mpMRI. This surveillance strategy could result in fewer men needing to undergo biopsy, and although early results are promising, long-term results for such a strategy are awaited. In some patients who have an MRI scan of their prostate, the scan may identify an area which may or may not contain cancer. This area is typically called the "indeterminate" lesion. In this report, we attempted to define the concept of indeterminate lesion on multiparametric magnetic resonance (mpMRI) and described the strategies that may be performed for these patients. The use of mpMRI in conjunction with traditional clinical parameters may allow more accurate risk stratification and assessment of the need for prostate biopsy.

Gómez Rivas J ，Giganti F ，Álvarez-Maestro M ，Freire MJ ，Kasivisvanathan V ，Martinez-Piñeiro L ，Emberton M ... -  《European Urology Focus》

Diagnostic Accuracy and Prognostic Value of Serial Prostate Multiparametric Magnetic Resonance Imaging in Men on Active Surveillance for Prostate Cancer.

Multiparametric magnetic resonance imaging (MRI) is increasingly utilized to improve the detection of clinically significant prostate cancer. Evidence for serial MRI in men on active surveillance (AS) is lacking. To evaluate the role of MRI in detecting Gleason grade group (GG) ≥2 disease in confirmatory and subsequent surveillance biopsies for men on AS. This was a single-center study of men with low-risk prostate cancer enrolled in an AS cohort between 2006 and 2018. All men were diagnosed by systematic biopsy and underwent MRI prior to confirmatory ("MRI1") and subsequent surveillance ("MRI2") biopsies. MRI lesions were scored with Prostate Imaging Reporting and Data System (PI-RADS) version 2. The primary outcome was biopsy upgrade to GG ≥ 2 prostate cancer, and the secondary outcome was definitive treatment. Test characteristics for PI-RADS score were calculated. Multivariable logistic and Cox proportional hazard regression models were used to determine the associations between PI-RADS score change and outcomes, on a per-examination basis. Of 125 men with a median follow-up of 78 mo, 38% experienced an increase in PI-RADS scores. The sensitivity and positive predictive value of PI-RADS ≥3 for GG ≥ 2 disease improved from MRI1 to MRI2 (from 85% to 91% and from 26% to 49%, respectively). An increase in PI-RADS scores from MRI1 to MRI2 was associated with GG ≥ 2 (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.7-13.2) compared with PI-RADS 1-3 on both MRI scans. Men with PI-RADS 4-5 lesions on both MRI scans had a higher likelihood of GG ≥ 2 than patients with PI-RADS 1-3 lesions on both (OR 3.3, 95% CI 1.3-8.6). Importantly, any increase in PI-RADS scores was independently associated with definitive treatment (hazard ratio 3.9, 95% CI 1.3-11.9). This study was limited by its retrospective, single-center design. The prognostic value of MRI improves with serial examination and provides additional risk stratification. Validation in other cohorts is needed. We looked at the role of serial prostate magnetic resonance imaging in men with low-risk prostate cancer on active surveillance at the University of California, San Francisco. We found that both consistently visible and increasingly suspicious lesions were associated with biopsy upgrade and definitive treatment.

Chu CE ，Cowan JE ，Lonergan PE ，Washington SL 3rd ，Fasulo V ，de la Calle CM ，Shinohara K ，Westphalen AC ，Carroll PR ... -  《European Urology Oncology》

Standardized Magnetic Resonance Imaging Reporting Using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation Criteria and Magnetic Resonance Imaging/Transrectal Ultrasound Fusion with Transperineal Saturation Biopsy to Select Men

Contemporary selection criteria for men with prostate cancer (PC) suitable for active surveillance (AS) are unsatisfactory, leading to high disqualification rates based on tumor misclassification. Conventional biopsy protocols are based on standard 12-core transrectal ultrasound (TRUS) biopsy. To assess the value of magnetic resonance imaging (MRI)/TRUS fusion biopsy over 4-yr follow-up in men on AS for low-risk PC. Between 2010 and 2018, a total of 273 men were included. Of them, 157 men with initial 12-core TRUS biopsy and 116 with initial MRI/TRUS fusion biopsy were followed by systematic and targeted transperineal MRI/TRUS fusion biopsies based on Prostate Cancer Research International Active Surveillance criteria. MRI from follow-up MRI/TRUS fusion biopsy was assessed using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system. AS-disqualification rates for patients on AS initially diagnosed by either 12-core TRUS biopsy or by MRI/TRUS fusion biopsy were compared using Kaplan-Meier estimates, log-rank tests, and regression analyses. We also analyzed the influence of negative primary MRI and PRECISE scoring to predict AS disqualification using Kaplan-Meier estimates, log-rank tests, and receiver operating characteristic (ROC) curve analysis. Of men diagnosed by 12-core TRUS biopsy, 59% were disqualified from AS based on the results of subsequent MRI/TRUS fusion biopsy. In the initial MRI fusion biopsy cohort, upgrading occurred significantly less frequently (19%, p<0.001). ROC curve analyses demonstrated good discrimination for the PRECISE score with an area under the curve of 0.83. No men with a PRECISE score of 1 or 2 (demonstrating absence or downgrading of lesions in follow-up MRI) were disqualified from AS. In our cohort, a negative baseline MRI scan was not a predictor of nondisqualification from AS. Limitations include transperineal approach and extended systematic biopsies used with MRI/TRUS fusion biopsy, which may not be representative of other centers. MRI/TRUS fusion biopsies allow a reliable risk classification for patients who are candidates for AS. The application of the PRECISE scoring system demonstrated good discrimination. In this study, we investigated the value of multiparametric magnetic resonance imaging (MRI) and MRI/transrectal ultrasound (TRUS) fusion biopsies for the assessment of active surveillance (AS) reliability using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation criteria. Standard TRUS biopsies lead to significant underestimation of prostate cancer. In contrast, MRI/TRUS fusion biopsies allowed for a more reliable risk classification. For appropriate inclusion into AS, men should receive either an initial or a confirmatory MRI/TRUS fusion biopsy.

Dieffenbacher S ，Nyarangi-Dix J ，Giganti F ，Bonekamp D ，Kesch C ，Müller-Wolf MB ，Schütz V ，Gasch C ，Hatiboglu G ，Hauffe M ，Stenzinger A ，Duensing S ，Schlemmer HP ，Moore CM ，Hohenfellner M ，Radtke JP ... -  《European Urology Focus》