Prostate CancerPrediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators
Introduction
Men with a suspicion of prostate cancer (PCa) based on elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE) generally receive a transrectal ultrasound-guided systematic biopsy (TRUS-Bx). Nowadays, multiparametric magnetic resonance imaging (mpMRI) is increasingly being used due to its high negative predictive value for clinically significant PCa of approximately 90% [1], [2], [3]. The European Association of Urology (EAU) PCa guidelines recommend performing prebiopsy mpMRI in men with a suspicion of PCa after previous negative TRUS-Bx [3], [4]. Since not all men with a clinical suspicion who receive mpMRI actually harbor high-grade PCa, a (targeted) biopsy following MRI could be avoided in some of these men using a risk calculator. The Rotterdam European Randomized Study of Screening for Prostate Cancer risk calculators (ERSPC-RCs) are well-validated models that help avoid 20–33% of unnecessary TRUS-Bx [5], [6], [7], [8], [9], [10], [11], [12], [13]. In the present study, we aim to construct MRI-ERSPC-RCs for patient selection for (targeted) biopsy following mpMRI by adding the Prostate Imaging Reporting and Data System (PI-RADS) score and age as parameters to the ERSPC-RC3 (in biopsy-naïve men) and ERSPC-RC4 (in previously biopsied men).
Section snippets
Study population
A total of 1353 consecutive men with a clinical suspicion of PCa (no prior PCa diagnosis), who received mpMRI and subsequent TRUS-Bx and/or targeted biopsy (TBx) between 2012 and 2017, were included in the prospective institutional review board–approved databases of five institutions in Düsseldorf (n = 723), Rotterdam (n = 178), The Hague (n = 210), Amsterdam (n = 160), and Den Bosch (n = 82). Subgroups of the institutional cohorts from Düsseldorf, Rotterdam, and The Hague were reported previously [14],
Patient characteristics
Table 1 shows the patient characteristics of all 1353 men with a clinical suspicion of PCa who received mpMRI and subsequent biopsy between 2012 and 2017 in the five institutions. Median age, PSA, and prostate volume were 66 (interquartile range [IQR] 60–71) yr, 8.7 (IQR 6.1–12.9) ng/ml, and 49.7 (36.0–70.0) ml, respectively. DRE values were missing in 33% (441/1353) men. A total of 82% (1114/1353) men had an overall PI-RADS score of ≥3. TRUS-Bx and MRI-TBx were performed with a median number
Discussion
Risk-based patient selection for TRUS-Bx has been adopted in daily clinical practice, either by clinical judgment or by the use of risk calculators. Using a multivariable risk calculator similar to the original ERSPC-RCs has been shown to reduce the percentage of unnecessary TRUS-Bx by 20–33% in several external validation studies [7], [8], [9], [10], [11], [12], [13]. Nowadays, mpMRI is increasingly performed, especially in men with a sustained suspicion of PCa after previous negative TRUS-Bx
Conclusions
Multivariable risk-based patient selection for biopsy after mpMRI can avoid unnecessary systematic and/or TBx, even after risk stratification before MRI. In the present study, we adjust the multiple externally validated ERSPC-RC-3 (for biopsy-naïve men) and ERSPC-RC-4 (for previously biopsied men) by incorporating the overall PI-RADS score and age. Although the ability of the MRI-ERSPC-RC3 for biopsy-naïve men to avoid biopsies remains questionable, application of the MRI-ERSPC-RC4 in
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