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Abstract To evaluate if follow-up mpMRI scans of patients in PI-RADS category 3 are safe enough to omit or delay prostate biopsy in the future and to determine an optimal control interval. This retrospective single center study includes consecutive PI-RADS category 3 patients with one or more follow-up mpMRI (T2WI, DWI, DCE) and subsequent MRI-targeted and systematic TRUS-guided biopsy between 2012 and 2018. Primary study objective was the verification of a significant PI-RADS category upgrade in follow-up mpMRI in patients with subsequent PCA positive biopsy versus patients with negative biopsy. Further objectives were development of the PI-RADS category and clinical parameters between initial and follow-up mpMRI in the context of histopathologic results and time interval. Eighty-nine patients (median PSA 6.6 ng/ml; PSAD 0.13 ng/ml/ml) were finally included (follow-up period 31 ± 18 months). 19 cases had PCA (median PSA 7.8 ng/ml; PSAD 0.14 ng/ml/ml). 4 cases had csPCA (median PSA 5.4 ng/ml; PSAD 0.13 ng/ml/ml) for which there was a significant PI-RADS upgrade after 12–24 months (mean 3.75; p = 0.01) compared to patients without PCA (mean 2.74). Without PCA the mean PI-RADS category decreased after 25–36 months (mean 2.74; p = 0.02). Clinical parameters did not change significantly except a PSAD increase for PCA patients after 24 months. Patients within PI-RADS category 3 may not need prompt biopsy since those with PCA reliably demonstrate a PI-RADS category upgrade in follow-up mpMRI after 12–24 months. PI-RADS 3 patients with negative biopsy do not benefit from follow-up mpMRI earlier than 24 months.

This is a data article from the original publication “Reasons for missing clinically significant prostate cancer by targeted magnetic resonance imaging/ultrasound fusion-guided biopsy” [1]. From January 2014 to April 2019 a sample collective of 785 patients with 3T multiparametric magnetic resonance imaging (mp-MRI) of the prostate and subsequent combined systematic biopsy (SB) and magnetic resonance imaging/ultrasound (US) fusion-guided biopsy (TB) was retrospectively analyzed. Prostate cancer (PCa) detection by TB and/or additional SB was analyzed.

Background: This study aimed to validate a previously published risk model (RM) which combines clinical and multiparametric MRI (mpMRI) parameters to predict extraprostatic extension (EPE) of prostate cancer (PC) prior to radical prostatectomy (RP)., Materials and Methods: A previously published RM combining clinical with mpMRI parameters including European Society of Urogenital Radiology (ESUR) classification for EPE was retrospectively evaluated in a cohort of two urological university hospitals in Germany. Consecutive patients (n = 205, January 2015 -June 2021) with available preoperative MRI images, clinical information including PSA, prostate volume, ESUR classification for EPE, histopathological results of MRI-fusion biopsy and RP specimen were included. Validation was performed by receiver operating characteristic analysis and calibration plots. The RM's performance was compared to ESUR criteria., Results: Histopathological T3 stage was detected in 43% of the patients (n = 89); 45% at Essen and 42% at Düsseldorf. Discrimination performance between pT2 and pT3 of the RM in the entire cohort was AUC = 0.86 (AUC = 0.88 at site 1 and AUC = 0.85 at site 2). Calibration was good over the entire probability range. The discrimination performance of ESUR classification alone was comparable (AUC = 0.87)., Conclusions: The RM showed good discriminative performance to predict EPE for decision-making for RP as a patient-tailored risk stratification. However, when experienced MRI reading is available, standardized MRI reading with ESUR scoring is comparable regarding information outcome. A main limitation is the potentially limited transferability to other populations because of the high prevalence of EPE in our subgroups., (© 2024. The Author(s).)

Objective: This study aims to analyse multiparametric MRI (mpMRI) characteristics of patients diagnosed with ISUP grade group (GG) 1 prostate cancer (PC) on initial target plus systematic MRI/TRUS fusion-guided biopsy and investigate histopathological progression during follow-up., Methods: A retrospective single-centre cohort analysis was conducted on consecutive patients with mpMRI visible lesions (PI-RADS ≥ 3) and detection of ISUP-1-PC at the time of initial biopsy. The study assessed clinical, mpMRI, and histopathological parameters. Subcohorts were analysed with (1) patients who had confirmed ISUP-1-PC and (2) patients who experienced histopathological upgrading to ISUP ≥ 2 PC during follow-up either at re-biopsy or radical prostatectomy (RP)., Results: A total of 156 patients (median age 65 years) between March 2014 and August 2021 were included. Histopathological upgrading to ISUP ≥ 2 was detected in 55% of patients during a median follow-up of 9.5 months (IQR 2.2-16.4). When comparing subgroups with an ISUP upgrade and sustained ISUP 1 PC, they differed significantly in contact length of the index lesion to the pseudocapsule, ADC value, PI-RADS category, and the MRI grading group (mGG) (p < 0.05). In the ISUP GG ≥ 2 subgroup, 91% of men had PI-RADS category 4 or 5 and 82% exhibited the highest mGG (mGG3). In multivariate analysis, mGG was the only independent parameter for predicting ISUP ≥ 2-PC in these patients., Conclusions: MRI reveals important information about PC aggressiveness and should be incorporated into clinical decision-making when ISUP-1-PC is diagnosed. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered., Clinical Relevance Statement: In cases with clear MRI characteristics for clinically significant prostate cancer (e.g., mGG 3 and/or PI-RADS 5, cT3, or clear focal PI-RADS 4 lesions on MRI) and ISUP GG 1 PC diagnosed on initial prostate biopsy, MRI findings should be incorporated into clinical decision-making and early re-biopsy (e.g., within 6 months) might be considered., Key Points: MRI reveals important information about prostate cancer (PC) aggressiveness. MRI should be incorporated into clinical decision-making when ISUP GG 1 PC is diagnosed on initial prostate biopsy. In cases of specific MRI characteristics adverse to the histopathology, early re-biopsy might be considered., (© 2024. The Author(s).)

Background and Objective: The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) recommendations standardise the reporting of prostate magnetic resonance imaging (MRI) in patients on active surveillance (AS) for prostate cancer. An international consensus group recently updated these recommendations and identified the areas of uncertainty., Methods: A panel of 38 experts used the formal RAND/UCLA Appropriateness Method consensus methodology. Panellists scored 193 statements using a 1-9 agreement scale, where 9 means full agreement. A summary of agreement, uncertainty, or disagreement (derived from the group median score) and consensus (determined using the Interpercentile Range Adjusted for Symmetry method) was calculated for each statement and presented for discussion before individual rescoring., Key Findings and Limitations: Participants agreed that MRI scans must meet a minimum image quality standard (median 9) or be given a score of 'X' for insufficient quality. The current scan should be compared with both baseline and previous scans (median 9), with the PRECISE score being the maximum from any lesion (median 8). PRECISE 3 (stable MRI) was subdivided into 3-V (visible) and 3-NonV (nonvisible) disease (median 9). Prostate Imaging Reporting and Data System/Likert ≥3 lesions should be measured on T2-weighted imaging, using other sequences to aid in the identification (median 8), and whenever possible, reported pictorially (diagrams, screenshots, or contours; median 9). There was no consensus on how to measure tumour size. More research is needed to determine a significant size increase (median 9). PRECISE 5 was clarified as progression to stage ≥T3a (median 9)., Conclusions and Clinical Implications: The updated PRECISE recommendations reflect expert consensus opinion on minimal standards and reporting criteria for prostate MRI in AS., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: Development of a color scheme representation to facilitate the interpretation of tri-exponential DWI data from abdominal organs, where multi-exponential behavior is more pronounced., Methods: Multi-exponential analysis of DWI data provides information about the microstructure of the tissue under study. The tri-exponential signal analysis generates numerous parameter images that are difficult to analyze individually. Summarized color images can simplify at-a-glance analysis. A color scheme was developed in which the slow, intermediate, and fast diffusion components were each assigned to a different red, green, and blue color channel. To improve the appearance of the image, histogram equalization, gamma correction, and white balance were used, and the processing parameters were adjusted. Examples of the resulting color maps of the diffusion fractions of healthy and pathological kidney and prostate are shown., Results: The color maps obtained by the presented method show the merged information of the slow, intermediate, and fast diffusion components in a single view. A differentiation of the different fractions becomes clearly visible. Fast diffusion regimes, such as in the renal hilus, can be clearly distinguished from slow fractions, such as in dense tumor tissue., Conclusion: Combining the diffusion information from tri-exponential DWI analysis into a single color image allows for simplified interpretation of the diffusion fractions. In the future, such color images may provide additional information about the microstructural nature of the tissue under study., (© 2024 The Author(s). Magnetic Resonance in Medicine published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Objectives: To investigate the specific strengths of MRI and PET components in 68 Ga-PSMA-11 PET/MRI for staging of patients with biochemically recurrent prostate cancer (PCa)., Methods: Patients with biochemical recurrence of PCa and contrast-enhanced whole-body 68 Ga-PSMA-11 PET/MRI including a dedicated pelvic multiparametric MRI were included in this retrospective study. Imaging datasets of MRI and PET were evaluated separately regarding local PCa recurrence (Tr), pelvic lymph node metastases (N1), distant lymph node metastases (M1a), bone metastases (M1b), and soft tissue metastases (M1c) according to PROMISE version 1. Data evaluation was performed patient- and region-/lesion-based. Cox regression revealed a PSA of 1.69 ng/mL as a cut-off for subgroup analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were evaluated for each image component. Differences in staging accuracy were assessed using the Wilcoxon and McNemar test., Results: Altogether 102 patients (mean aged 68 ± 8 years, median PSA 1.33 ng/mL) were included. PCa was found in 70/102 (68%) patients. Accuracy of MRI in the detection of Tr, N1, M + , M1a, and M1b was 100%, 79%, 90%, 97%, and 95% for PSA < 1.69 ng/mL and 100%, 87%, 87%, 91%, and 96% for PSA > 1.69 ng/mL. Accuracy of 68 Ga-PSMA-11 PET was 93%, 97%, 93%, 98%, and 100% for PSA < 1.69 ng/mL and 87%, 91%, 96%, 100%, and 96% for PSA > 1.69 ng/mL., Conclusions: Combined assessment of 68 Ga-PSMA-11 PET/MRI improves tumor localization in men with biochemical recurrence. The MRI detected local recurrence of PCa more often whereas 68  Ga-PSMA-11 PET detected lymph node metastases more often, especially for PSA < 1.69 ng/mL., Clinical Relevance Statement: This study gives a scientific baseline to improve the understanding and reading of 68 Ga-PSMA-11 PET/MRI imaging in patients with biochemically recurrent PCa by showing the specific strength of each imaging component., Key Points: • Combining the individual modality strengths of 68 Ga-PSMA-11 PET/MRI improves tumor localization in men with biochemical recurrence of prostate cancer. • MRI component of 68  Ga-PSMA-11 PET/MRI shows its strength in detecting local recurrence of prostate cancer, especially at PSA < 1.69 ng/mL. • 68  Ga-PSMA-11 PET component shows its strength in detecting local and distant lymph node metastases, especially at PSA < 1.69 ng/mL., (© 2023. The Author(s).)

Purpose: Patients with suspicion of clinically significant prostate cancer (csPC) on multiparametric prostate MRI (mpMRI) but negative or inconclusive MRI/US fusion-guided biopsy (FB) can be challenging in clinical practice. To assess the utility of MRI in-bore biopsy (IB) in patients with discordant imaging and histopathological findings after FB., Methods: Consecutive patients with Prostate Imaging Reporting and Data System (PI-RADS) category 4 or 5 on mpMRI at 3T after FB without histologically confirmed csPC who underwent IB between 01/2014 and 05/2022, were retrospectively included. The primary objective was to assess the detection rate of csPC. Secondary objectives were to analyze clinical parameters, MRI parameters, and lesion localization., Results: In the final cohort of 51 patients, the IB resulted in an overall detection rate of 71% for PC and 47% for csPC. Furthermore, in 55% of cases with initial low-grade PC, the Gleason score was upgraded after IB. CsPC was often detected apical and/or anterior. The detection rate for PC was 58% in PI-RADS category 4 and 94% in PI-RADS category 5 (csPC 39% and 61%, respectively). Patients with csPC had statistically significant smaller prostate volumes, a higher PI-RADS category, a higher prostate-specific antigen density (PSAD), and were older., Conclusions: For a relevant proportion of patients with PI-RADS category 4 or 5 and negative or inconclusive findings on previous FB, but with persistent suspicion of csPC, a subsequent IB verified the presence of csPC. Therefore, IB can be a backup in cases of uncertainty., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The harm-to-benefit ratio of prostate cancer (PCa) screening remains controversial mainly due to the unfavorable test characteristics of prostate-specific antigen (PSA) as a screening test., Methods: In this nonsystematic review, we present a current overview of the body of evidence on prostate cancer screening with a focus on the role of magnetic resonance imaging (MRI) of the prostate., Results: Evidence generated in large randomized controlled trials showed that PSA-based screening significantly decreases cancer-specific mortality. The main obstacle in developing and implementing PCa screening strategies is the resulting overdiagnosis and as a consequence overtreatment of indolent cancers. Opportunistic screening is characterized by an adverse benefit-to-harm ratio and should, therefore, not be recommended. The German Statutory Early Detection Program for prostate cancer, which consists of a digital rectal examination (DRE) as a stand-alone screening test, is not evidence-based, neither specific nor sensitive enough and results in unnecessary diagnostics. The European Commission recently urged member states to develop population-based and organized risk-adapted PSA-based screening programs, which are currently tested in the ongoing German PROBASE trial. Finetuning of the diagnostic pathway following PSA-testing seems key to improve its positive and negative predictive value and thereby making PCa screening more accurate. Incorporation of prostatic MRI into screening strategies leads to more accurate diagnosis of clinically significant prostate cancer, while diagnosis of indolent cancers is reduced. In the future, molecular liquid-based biomarkers have the potential to complement or even replace PSA in PCa screening and further personalize screening strategies. Active surveillance as an alternative to immediate radical therapy of demographically increasing PCa diagnoses can potentially further improve the benefit-to-harm ratio of organized screening., Conclusion: Early detection of PCa should be organized on a population level into personalized and evidence-based screening strategies. Multiparametric MRI of the prostate may play a key role in this setting., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Risk-adjusted screening for prostate cancer (PCa) aims to reduce harms by less frequent retesting, especially in men at a low risk of PCa. Definitions of low risk are based mainly on studies in men starting screening at age 55-60 yr., Objective: To identify men at age 45 yr with a low risk of PCa., Design, Setting, and Participants: A population-based, risk-adjusted PCa screening trial was conducted in Germany using baseline prostate-specific antigen (PSA) starting in young men (PROBASE)., Intervention: PSA measurements starting at the age of 45 yr., Outcome Measurements and Statistical Analysis: The incidence of PCa within 5 yr was assessed in men with screen-negative baseline PSA <1.5 ng/ml compared with those with PSA 1.5-≤3.0 ng/ml., Results and Limitations: Of 23301 men who received a first PSA test at age 45 yr, 0.79% had a screen-positive PSA value of ≥3 ng/ml. Among the 89% of men who had a screen-negative baseline PSA value of <1.5 ng/ml, only 0.45% received a positive PSA test ≥3 ng/ml upon retesting after 5 yr. By contrast, for those with a screen-negative baseline PSA value of 1.5-3 ng/ml, 13% surpassed 3 ng/ml upon biennial testing within the next 4 yr. The incidence of PCa in subsequent screening rounds increased with increasing baseline PSA levels, from 0.13 per 1000 person-years for men with initial PSA level of <1.5 ng/ml to 8.0 per 1000 person-years for those with PSA levels of 1.5-3.0 ng/ml. A limitation is a follow-up time of only 5 yr, so far., Conclusions: Men with baseline PSA <1.5 ng/ml at age 45 yr are at a very low risk of PCa over the next 5 yr., Patient Summary: The PROBASE study showed that men with baseline prostate-specific antigen (PSA) <1.5 ng/ml at age 45 yr have a very low prostate cancer detection rate over 5 yr and do not need PSA retesting during this time., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Knowledge about anatomical details seems to facilitate the procedure and planning of prostatic artery embolization (PAE) in patients with symptomatic benign prostatic hyperplasia (BPS). The aim of our study was the pre-interventional visualization of the prostatic artery (PA) with MRA and the correlation of iliac elongation and bifurcation angles with technical success of PAE and technical parameters. MRA data of patients with PAE were analysed retrospectively regarding PA visibility, PA type, vessel elongation, and defined angles were correlated with intervention time, fluoroscopy time, dose area product (DAP), cumulative air kerma (CAK), contrast media (CM) dose and technical success of embolization. T-test, ANOVA, Pearson correlation, and Kruskal-Wallis test was applied for statistical analysis. Between April 2018 and March 2021, a total of 78 patients were included. MRA identified the PA origin in 126 of 147 cases (accuracy 86%). Vessel elongation affected time for catheterization of right PA (p = 0.02), fluoroscopy time (p = 0.05), and CM dose (p = 0.02) significantly. Moderate correlation was observed for iliac bifurcation angles with DAP (r = 0.30 left; r = 0.34 right; p = 0.01) and CAK (r = 0.32 left; r = 0.36 right; p = 0.01) on both sides. Comparing the first half and second half of patients, median intervention time (125 vs. 105 min.) and number of iliac CBCT could be reduced (p < 0.001). We conclude that MRA could depict exact pelvic artery configuration, identify PA origin, and might obviate iliac CBCT. Vessel elongation of pelvic arteries increased intervention time and contrast media dose while the PA origin had no significant influence on intervention time and/or technical success., (© 2024. The Author(s).)

Aim: To investigate the relevance of dynamic contrast enhanced imaging (DCE) within multiparametric magnetic resonance imaging (mpMRI) for the detection of clinically significant prostate cancer (csPC) depending on reader experience., Materials and Methods: Consecutive patients with 3 T mpMRI and subsequent combined MRI/ultrasound fusion-guided targeted and systematic biopsy from January to September 2019 were included. All mpMRI examinations were read separately by two less experienced (R1; <500 prostate MRI) and two expert radiologists (R2; >5,000 prostate MRI) in consensus and blinded re-read as biparametric MRI (bpMRI). The primary endpoint was the performance comparison of mpMRI versus bpMRI of R1 and R2., Results: Fifty-three of 124 patients had csPC (43%). The PI-RADS agreement of bpMRI and mpMRI was fair for R1 (κ = 0.373) and moderate for R2 (κ = 0.508). R1 assessed 11 csPC with PI-RADS ≤3 (20.8%) on mpMRI and 12 (22.6%) on bpMRI (R2: 1 [1.9%] and 6 [11.3%], respectively). Sensitivity for csPC of mpMRI was 79.3% (NPV 79.3%) for R1 and 98.1% (NPV 97.5%) for R2 (bpMRI: 77.4% [NVP 75.5%] and 86.8% [NPV 84.4%], respectively). Specificity of mpMRI for csPC was 59.2% for R1 and 54.9% for R2 (bpMRI: 52.1% and 53.5%, respectively). Overall accuracy of mpMRI was 79.8% for R1 compared to bpMRI 66.9% (p=0.017; R2: 87.1% and 81.5%; p=0.230)., Conclusion: Prostate MRI benefits from reader experience. Less experienced readers missed a relevant proportion of csPC with mpMRI and even more with bpMRI. The overall performance of expert readers was comparable for mpMRI and bpMRI but DCE enabled detection of some further ISUP 2 PC., (Copyright © 2023. Published by Elsevier Ltd.)