Publications by authors named "Francesco Giganti"

82 Publications

Mapping Contemporary Biopsy Zones to Traditional Prostatic Anatomy: The Key to Understanding Relationships Between Prostate Cancer Topography, Magnetic Resonance Imaging Conspicuity, and Clinical Risk.

Eur Urol 2021 May 28. Epub 2021 May 28.

UCL Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/j.eururo.2021.05.017DOI Listing
May 2021

Prostate minimally invasive procedures: complications and normal vs. abnormal findings on multiparametric magnetic resonance imaging (mpMRI).

Abdom Radiol (NY) 2021 May 11. Epub 2021 May 11.

Department of Radiological Sciences, University of California, Irvine, Orange, CA, 92868-3201, USA.

Minimally invasive alternatives to traditional prostate surgery are increasingly utilized to treat benign prostatic hyperplasia and localized prostate cancer in select patients. Advantages of these treatments over prostatectomy include lower risk of complication, shorter length of hospital stay, and a more favorable safety profile. Multiparametric magnetic resonance imaging (mpMRI) has become a widely accepted imaging modality for evaluation of the prostate gland and provides both anatomical and functional information. As prostate mpMRI and minimally invasive prostate procedure volumes increase, it is important for radiologists to be familiar with normal post-procedure imaging findings and potential complications. This paper reviews the indications, procedural concepts, common post-procedure imaging findings, and potential complications of prostatic artery embolization, prostatic urethral lift, irreversible electroporation, photodynamic therapy, high-intensity focused ultrasound, focal cryotherapy, and focal laser ablation.
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http://dx.doi.org/10.1007/s00261-021-03097-6DOI Listing
May 2021

Understanding PI-QUAL for prostate MRI quality: a practical primer for radiologists.

Insights Imaging 2021 May 1;12(1):59. Epub 2021 May 1.

Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK.

Prostate magnetic resonance imaging (MRI) of high diagnostic quality is a key determinant for either detection or exclusion of prostate cancer. Adequate high spatial resolution on T2-weighted imaging, good diffusion-weighted imaging and dynamic contrast-enhanced sequences of high signal-to-noise ratio are the prerequisite for a high-quality MRI study of the prostate. The Prostate Imaging Quality (PI-QUAL) score was created to assess the diagnostic quality of a scan against a set of objective criteria as per Prostate Imaging-Reporting and Data System recommendations, together with criteria obtained from the image. The PI-QUAL score is a 1-to-5 scale where a score of 1 indicates that all MR sequences (T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced sequences) are below the minimum standard of diagnostic quality, a score of 3 means that the scan is of sufficient diagnostic quality, and a score of 5 implies that all three sequences are of optimal diagnostic quality. The purpose of this educational review is to provide a practical guide to assess the quality of prostate MRI using PI-QUAL and to familiarise the radiologist and all those involved in prostate MRI with this scoring system. A variety of images are also presented to demonstrate the difference between suboptimal and good prostate MR scans.
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http://dx.doi.org/10.1186/s13244-021-00996-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088425PMC
May 2021

Update from the ReIMAGINE Prostate Cancer Screening Study NCT04063566: Inviting Men for Prostate Cancer Screening Using Magnetic Resonance Imaging.

Eur Urol Focus 2021 Apr 22. Epub 2021 Apr 22.

UCL Division of Surgical & Interventional Sciences, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.

ReIMAGINE Screening is a single-centre study assessing the feasibility of biparametric magnetic resonance imaging as a screening tool for prostate cancer. The study outcomes will take us a step towards more accurate and less harmful prostate cancer screening.
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http://dx.doi.org/10.1016/j.euf.2021.03.027DOI Listing
April 2021

Standardisation of prostate multiparametric MRI across a hospital network: a London experience.

Insights Imaging 2021 Apr 20;12(1):52. Epub 2021 Apr 20.

Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.

Objectives: National guidelines recommend prostate multiparametric (mp) MRI in men with suspected prostate cancer before biopsy. In this study, we explore prostate mpMRI protocols across 14 London hospitals and determine whether standardisation improves diagnostic quality.

Methods: An MRI physicist facilitated mpMRI set-up across several regional hospitals, working together with experienced uroradiologists who judged diagnostic quality. Radiologists from the 14 hospitals participated in the assessment and optimisation of prostate mpMRI image quality, assessed according to both PiRADSv2 recommendations and on the ability to "rule in" and/or "rule out" prostate cancer. Image quality and sequence parameters of representative mpMRI scans were evaluated across 23 MR scanners. Optimisation visits were performed to improve image quality, and 2 radiologists scored the image quality pre- and post-optimisation.

Results: 20/23 mpMRI protocols, consisting of 111 sequences, were optimised by modifying their sequence parameters. Pre-optimisation, only 15% of T2W images were non-diagnostic, whereas 40% of ADC maps, 50% of high b-value DWI and 41% of DCE-MRI were considered non-diagnostic. Post-optimisation, the scores were increased with 80% of ADC maps, 74% of high b-value DWI and 88% of DCE-MRI to be partially or fully diagnostic. T2W sequences were not optimised, due to their higher baseline quality scores.

Conclusions: Targeted intervention at a regional level can improve the diagnostic quality of prostate mpMRI protocols, with implications for improving prostate cancer detection rates and targeted biopsies.
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http://dx.doi.org/10.1186/s13244-021-00990-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058121PMC
April 2021

The Importance of Being PRECISE in Prostate Magnetic Resonance Imaging and Active Surveillance.

Eur Urol 2021 Apr 3;79(4):560-563. Epub 2021 Feb 3.

Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/j.eururo.2021.01.016DOI Listing
April 2021

Mixed acinar and macrocystic ductal prostatic adenocarcinoma.

Lancet Oncol 2021 01;22(1):e37

Department of Urology, University College London Hospital NHS Foundation Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK.

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http://dx.doi.org/10.1016/S1470-2045(20)30435-6DOI Listing
January 2021

Let's Follow the Golden Mean: Using Magnetic Resonance Imaging to Determine the Need for Biopsy in Men on Active Surveillance.

Eur Urol Oncol 2021 Apr 23;4(2):235-236. Epub 2020 Dec 23.

Division of Surgery & Interventional Science, University College London, London, UK; Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/j.euo.2020.11.009DOI Listing
April 2021

Prostate Cancer Undetected by mpMRI: Tumor Conspicuity is Reliant Upon Optimal Scan Timing and Quality.

Urology 2021 Feb 2;148:316-317. Epub 2020 Dec 2.

UCL Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/j.urology.2020.11.037DOI Listing
February 2021

False Positive Multiparametric Magnetic Resonance Imaging Phenotypes in the Biopsy-naïve Prostate: Are They Distinct from Significant Cancer-associated Lesions? Lessons from PROMIS.

Eur Urol 2021 01 10;79(1):20-29. Epub 2020 Oct 10.

UCL Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.

Background: False positive multiparametric magnetic resonance imaging (mpMRI) phenotypes prompt unnecessary biopsies. The Prostate MRI Imaging Study (PROMIS) provides a unique opportunity to explore such phenotypes in biopsy-naïve men with raised prostate-specific antigen (PSA) and suspected cancer.

Objective: To compare mpMRI lesions in men with/without significant cancer on transperineal mapping biopsy (TPM).

Design, Setting, And Participants: PROMIS participants (n=235) underwent mpMRI followed by a combined biopsy procedure at University College London Hospital, including 5-mm TPM as the reference standard. Patients were divided into four mutually exclusive groups according to TPM findings: (1) no cancer, (2) insignificant cancer, (3) definition 2 significant cancer (Gleason ≥3+4 of any length and/or maximum cancer core length ≥4mm of any grade), and (4) definition 1 significant cancer (Gleason ≥4+3 of any length and/or maximum cancer core length ≥6mm of any grade).

Outcome Measurements And Statistical Analysis: Index and/or additional lesions present in 178 participants were compared between TPM groups in terms of number, conspicuity, volume, location, and radiological characteristics.

Results And Limitations: Most lesions were located in the peripheral zone. More men with significant cancer had two or more lesions than those without significant disease (67% vs 37%; p< 0.001). In the former group, index lesions were larger (mean volume 0.68 vs 0.50 ml; p< 0.001, Wilcoxon test), more conspicuous (Likert 4-5: 79% vs 22%; p< 0.001), and diffusion restricted (mean apparent diffusion coefficient [ADC]: 0.73 vs 0.86; p< 0.001, Wilcoxon test). In men with Likert 3 index lesions, logPSA density and index lesion ADC were significant predictors of definition 1/2 disease in a logistic regression model (mean cross-validated area under the receiver-operator characteristic curve: 0.77 [95% confidence interval: 0.67-0.87]).

Conclusions: Significant cancer-associated MRI lesions in biopsy-naïve men have clinical-radiological differences, with lesions seen in prostates without significant disease. MRI-calculated PSA density and ADC could predict significant cancer in those with indeterminate MRI phenotypes.

Patient Summary: Magnetic resonance imaging (MRI) lesions that mimic prostate cancer but are, in fact, benign prompt unnecessary biopsies in thousands of men with raised prostate-specific antigen. In this study we found that, on closer look, such false positive lesions have different features from cancerous ones. This means that doctors could potentially develop better tools to identify cancer on MRI and spare some patients from unnecessary biopsies.
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http://dx.doi.org/10.1016/j.eururo.2020.09.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772750PMC
January 2021

Imaging quality and prostate MR: it is time to improve.

Br J Radiol 2021 Feb 11;94(1118):20200934. Epub 2020 Nov 11.

Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK.

The Prostate Imaging Reporting and Data System (PI-RADS) guidelines set out the minimal technical requirements for the acquisition of multiparametric MRI (mpMRI) of the prostate. However, the rapid diffusion of this technique has inevitably led to variability in scan quality among centres across the UK and the world. Suboptimal image acquisition reduces the sensitivity and specificity of this technique for the detection of clinically significant prostate cancer and results in clinicians losing confidence in the technique.Two expert panels, one from the UK and one from the European Society of Urogenital Radiology (ESUR)/EAU Section of Urologic Imaging (ESUI), have stressed the importance to establish quality criteria for the acquisition of mpMRI of the prostate. A first attempt to address this issue has been the publication of the Prostate Imaging Quality (PI-QUAL) score, which assesses the mpMRI quality against a set of objective criteria (PI-RADS guidelines) together with criteria obtained from the image.PI-QUAL represents the first step towards the standardisation of a scoring system to assess the quality of prostate mpMRI prior to reporting and allows clinicians to have more confidence in using the scan to determine patient care. Further refinements after robust consensus among experts at an international level need to be agreed before its widespread adoption in the clinical setting.
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http://dx.doi.org/10.1259/bjr.20200934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934318PMC
February 2021

Natural history of prostate cancer on active surveillance: stratification by MRI using the PRECISE recommendations in a UK cohort.

Eur Radiol 2021 Mar 30;31(3):1644-1655. Epub 2020 Sep 30.

Division of Surgery & Interventional Science, University College London, 3rd Floor, Charles Bell House, 43-45 Foley St., London, W1W 7TS, UK.

Objectives: The PRECISE recommendations for magnetic resonance imaging (MRI) in patients on active surveillance (AS) for prostate cancer (PCa) include repeated measurement of each lesion, and attribution of a PRECISE radiological progression score for the likelihood of clinically significant change over time. We aimed to compare the PRECISE score with clinical progression in patients who are managed using an MRI-led AS protocol.

Methods: A total of 553 patients on AS for low- and intermediate-risk PCa (up to Gleason score 3 + 4) who had two or more MRI scans performed between December 2005 and January 2020 were included. Overall, 2161 scans were retrospectively re-reported by a dedicated radiologist to give a PI-RADS v2 score for each scan and assess the PRECISE score for each follow-up scan. Clinical progression was defined by histological progression to ≥ Gleason score 4 + 3 (Gleason Grade Group 3) and/or initiation of active treatment. Progression-free survival was assessed using Kaplan-Meier curves and log-rank test was used to assess differences between curves.

Results: Overall, 165/553 (30%) patients experienced the primary outcome of clinical progression (median follow-up, 74.5 months; interquartile ranges, 53-98). Of all patients, 313/553 (57%) did not show radiological progression on MRI (PRECISE 1-3), of which 296/313 (95%) had also no clinical progression. Of the remaining 240/553 patients (43%) with radiological progression on MRI (PRECISE 4-5), 146/240 (61%) experienced clinical progression (p < 0.0001). Patients with radiological progression on MRI (PRECISE 4-5) showed a trend to an increase in PSA density.

Conclusions: Patients without radiological progression on MRI (PRECISE 1-3) during AS had a very low likelihood of clinical progression and many could avoid routine re-biopsy.

Key Points: • Patients without radiological progression on MRI (PRECISE 1-3) during AS had a very low likelihood of clinical progression and many could avoid routine re-biopsy. • Clinical progression was almost always detectable in patients with radiological progression on MRI (PRECISE 4-5) during AS. • Patients with radiological progression on MRI (PRECISE 4-5) during AS showed a trend to an increase in PSA density.
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http://dx.doi.org/10.1007/s00330-020-07256-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880925PMC
March 2021

PI-RADS Version 2.1: A Critical Review, From the Special Series on Radiology Reporting and Data Systems.

AJR Am J Roentgenol 2021 01 19;216(1):20-32. Epub 2020 Nov 19.

Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.

PI-RADS version 2.1 updates the technical parameters for multiparametric MRI (mpMRI) of the prostate and revises the imaging interpretation criteria while maintaining the framework introduced in version 2. These changes have been considered an improvement, although some issues remain unresolved, and new issues have emerged. Areas for improvement discussed in this review include the need for more detailed mpMRI protocols with optimization for 1.5-T and 3-T systems; lack of validation of revised transition zone interpretation criteria and need for clarifications of the revised DWI and dynamic contrast-enhanced imaging criteria and central zone (CZ) assessment; the need for systematic evaluation and reporting of background changes in signal intensity in the prostate that can negatively affect cancer detection; creation of a new category for lesions that do not fit into the PI-RADS assessment categories (i.e., PI-RADS M category); inclusion of quantitative parameters beyond size to evaluate lesion aggressiveness; adjustments to the structured report template, including standardized assessment of the risk of extraprostatic extension; development of parameters for image quality and performance control; and suggestions for expansion of the system to other indications (e.g., active surveillance and recurrence).
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http://dx.doi.org/10.2214/AJR.20.24495DOI Listing
January 2021

Prostate cancer measurements on serial MRI during active surveillance: it's time to be PRECISE.

Br J Radiol 2020 Dec 21;93(1116):20200819. Epub 2020 Sep 21.

Division of Surgery & Interventional Science, University College London, London, UK.

Objective: The PRECISE criteria for reporting multiparametric MRI in patients on active surveillance (AS) for prostate cancer (PCa) score the likelihood of clinically significant change over time using a 1-5 scale, where 4 or 5 indicates radiological progression. According to the PRECISE recommendations, the index lesion size can be reported using different definitions of volume (planimetry or ellipsoid formula) or by measuring one or two diameters. We compared different measurements using planimetry as the reference standard and stratified changes according to the PRECISE scores.

Methods: We retrospectively analysed 196 patients on AS with PCa confirmed by targeted biopsy who had two MR scans (baseline and follow-up). Lesions were measured on weighted imaging (WI) according to all definitions. A PRECISE score was assessed for each patient.

Results: The ellipsoid formula exhibited the highest correlation with planimetry at baseline (ρ = 0.97) and follow-up (ρ = 0.98) imaging, compared to the biaxial measurement and single maximum diameter. There was a significant difference ( < 0.001) in the yearly percentage volume change between radiological regression/stability (PRECISE 2-3) and progression (PRECISE 4-5) for planimetry (39.64%) and for the ellipsoid formula (46.78%).

Conclusion: The ellipsoid formula could be used to monitor tumour growth during AS. Evidence of a significant yearly percentage volume change between radiological regression/stability (PRECISE 2-3) and progression (PRECISE 4-5) has been also observed.

Advances In Knowledge: The ellipsoid formula is a reasonable surrogate for planimetry in capturing tumour volume changes on WI in patients on imaging-led AS. This is also associated with radiological changes using the PRECISE recommendations.
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http://dx.doi.org/10.1259/bjr.20200819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716009PMC
December 2020

Three-dimensional Magnetic Resonance Imaging-based Printed Models of Prostate Anatomy and Targeted Biopsy-proven Index Tumor to Facilitate Patient-tailored Radical Prostatectomy-A Feasibility Study.

Eur Urol Oncol 2020 Aug 29. Epub 2020 Aug 29.

Department of Urology, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany; Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany. Electronic address:

In this prospective single-center feasibility study, we demonstrate that the use of three-dimensional (3D)-printed prostate models support nerve-sparing radical prostatectomy (RP) and intraoperative frozen sectioning (IFS) in ten men suffering from intermediate- and high-risk prostate cancer (PC), of whom seven harbored pT3 disease. Patient-specific 3D resin models were printed based on preoperative multiparametric magnetic resonance imaging (mpMRI) to provide an exact 3D impression of significant tumor lesions. RP and IFS were planned in a patient-tailored fashion. The 36-region Prostate Imaging Reporting and Data System (PI-RADS) v2.0 scheme was used to compare the MRI/3D print with whole-mount histopathology. In all cases, localization of the index lesion was correctly displayed by MRI and the 3D model. Localization of significant PC lesions correlated significantly (Pearson`s correlation coefficient of 0.88; p <  0.001). In addition, a significant correlation of the width, length, and volume of the tumor and prostate gland, derived from the printed model and histopathology, was found, using Pearson's correlation analyses and Bland-Altman plots. In conclusion, 3D-printed prostate models correlate well with final pathology and can be used to tailor RP. PATIENT SUMMARY: The use of three-dimensional (3D)-printed prostate models based on preoperative magnetic resonance imaging (MRI) may improve prostatectomy outcome. This study confirmed the accuracy of 3D-printed prostates compared with pathology from radical prostatectomy specimens. Thus, MRI-derived 3D-printed prostate models can assist in prostate cancer surgery.
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http://dx.doi.org/10.1016/j.euo.2020.08.004DOI Listing
August 2020

Active surveillance for low-risk prostate cancer - in pursuit of a standardized protocol.

Cent European J Urol 2020 25;73(2):123-126. Epub 2020 Jun 25.

Division of Urology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Introduction: Active surveillance (AS) is a management option recommended by most guidelines for low risk clinically-localized prostate cancer (LR-CLPC). Data shows that AS is being increasingly adopted into clinical practice worldwide. Our aim was to review the up-to date guidelines and observational studies in regards to AS in LR-CLRPC to gain insight into principles of contemporary clinical practice.

Material And Methods: Several guidelines on the management of low-risk prostate cancer were reviewed for evidence-based recommendations regarding the protocol of AS. We reviewed the available literature for most recent studies on AS in LR-CLPC.

Results: No uniform protocol of AS in LR-CLPC has been recommended up to date and available guidelines significantly differ in terms of protocol schedules and the role of particular tools in monitoring for disease progression. Nevertheless, recent studies on AS in LR-CLPC, in which various protocols were adopted, have demonstrated promising outcomes in regards to cancer-specific survival (99-100% at 5 years, 98.1-99.9% at 10 years, and 94.3-96% at 15 years), with high rates of men remaining within the protocols (23-39% at 10 years).

Conclusions: This article is a call for focusing further research on development and recommending a precise and standardized, evidence-based protocol for AS in LR-CLPC.
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http://dx.doi.org/10.5173/ceju.2020.0167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407781PMC
June 2020

Update on Multiparametric Prostate MRI During Active Surveillance: Current and Future Trends and Role of the PRECISE Recommendations.

AJR Am J Roentgenol 2021 04 3;216(4):943-951. Epub 2021 Feb 3.

Division of Surgery & Interventional Science, University College London, 3rd Fl, Charles Bell House, 43-45 Foley St, London, UK, W1W 7TS.

Active surveillance for low-to-intermediate risk prostate cancer is a conservative management approach that aims to avoid or delay active treatment until there is evidence of disease progression. In recent years, multiparametric MRI (mpMRI) has been increasingly used in active surveillance and has shown great promise in patient selection and monitoring. This has been corroborated by publication of the Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation (PRECISE) recommendations, which define the ideal reporting standards for mpMRI during active surveillance. The PRECISE recommendations include a system that assigns a score from 1 to 5 (the PRECISE score) for the assessment of radiologic change on serial mpMRI scans. PRECISE scores are defined as follows: a score of 3 indicates radiologic stability, a score of 1 or 2 denotes radiologic regression, and a score of 4 or 5 indicates radiologic progression. In the present study, we discuss current and future trends in the use of mpMRI during active surveillance and illustrate the natural history of prostate cancer on serial scans according to the PRECISE recommendations. We highlight how the ability to classify radiologic change on mpMRI with use of the PRECISE recommendations helps clinical decision making.
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http://dx.doi.org/10.2214/AJR.20.23985DOI Listing
April 2021

Detection of Significant Prostate Cancer Using Target Saturation in Transperineal Magnetic Resonance Imaging/Transrectal Ultrasonography-fusion Biopsy.

Eur Urol Focus 2020 Jul 10. Epub 2020 Jul 10.

Department of Urology, University Hospital Essen, Essen, Germany; Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany. Electronic address:

Background: Multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies (TBs) facilitate accurate detection of significant prostate cancer (sPC). However, it remains unclear how many cores should be applied per target.

Objective: To assess sPC detection rates of two different target-dependent magnetic resonance imaging (MRI)/transrectal ultrasonography (TRUS)-fusion biopsy approaches (TB and target saturation [TS]) compared with extended systematic biopsies (SBs).

Design, Setting, And Participants: Retrospective single-centre outcome of transperineal MRI/TRUS-fusion biopsies of 213 men was evaluated. All men underwent TB with a median of four cores per MRI lesion, followed by a median of 24 SBs, performed by experienced urologists. Cancer and sPC (International Society of Urological Pathology grade group ≥2) detection rates were analysed. TB was compared with SB and TS, with nine cores per target, calculated by the Ginsburg scheme and using individual cores of the lesion and its "penumbra".

Outcome Measurements And Statistical Analysis: Cancer detection rates were calculated for TS, TB, and SB at both lesion and patient level. Combination of SB + TB served as a reference. Statistical differences in prostate cancer (PC) detection between groups were calculated using McNemar's tests with confidence intervals.

Results And Limitations: TS detected 99% of 134 sPC lesions, which was significantly higher than the detection by TB (87%, p = 0.001) and SB (82%, p < 0.001). SB detected significantly more of the 72 low-risk PC lesions than TB (99% vs 68%, p < 0.001) and 10% (p = 0.15) more than that detected by TS. At a per-patient level, 99% of men harbouring sPC were detected by TS. This was significantly higher than that by TB and SB (89%, p = 0.03 and 81%, p = 0.001, respectively). Limitations include limited generalisability, as a transperineal biopsy route was used.

Conclusions: TS detected significantly more cases of sPC than TB and extended SB. Given that both 99% of sPC lesions and men harbouring sPC were identified by TS, the results suggest that this approach allows to omit SB cores without compromising sPC detection.

Patient Summary: Target saturation of magnetic resonance imaging-suspicious prostate lesions provides excellent cancer detection and finds fewer low-risk tumours than the current gold standard combination of targeted and systematic biopsies.
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http://dx.doi.org/10.1016/j.euf.2020.06.020DOI Listing
July 2020

Reply to Carissa E. Chu, Peter E. Lonergan, and Peter R. Carroll's Letter to the Editor re: Vasilis Stavrinides, Francesco Giganti, Bruce Trock, et al. Five-year Outcomes of Magnetic Resonance Imaging-based Active Surveillance for Prostate Cancer: A Large Cohort Study. Eur Urol 2020;78:443-51.

Eur Urol 2020 09 9;78(3):e112-e113. Epub 2020 Jul 9.

Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK.

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http://dx.doi.org/10.1016/j.eururo.2020.06.038DOI Listing
September 2020

Prostate Imaging Quality (PI-QUAL): A New Quality Control Scoring System for Multiparametric Magnetic Resonance Imaging of the Prostate from the PRECISION trial.

Eur Urol Oncol 2020 10 6;3(5):615-619. Epub 2020 Jul 6.

Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK.

The PRECISION trial was a multicentre randomised study that demonstrated that multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy is superior to standard transrectal ultrasound-guided biopsy for the detection of prostate cancer. The outcomes of studies reporting mpMRI-targeted biopsies are dependent on the quality of the mpMRI but there are currently no scoring systems available for evaluating this. We introduced a novel scoring system, the Prostate Imaging Quality (PI-QUAL) score, to assess the quality of scans in the PRECISION trial. PI-QUAL is a score on a Likert scale from 1 to 5, where 1 means that no mpMRI sequences are of diagnostic quality and 5 implies that each sequence is independently of optimal diagnostic quality. Fifty-eight out of 252 (23%) mpMRI scans chosen at random from each of the 22 centres in this trial were evaluated by two experienced radiologists from the coordinating trial centre, in consensus, blinded to pathology results. Overall, the mpMRI quality in the centres participating in PRECISION was good. MpMRI quality was of sufficient diagnostic quality (PI-QUAL ≥3) for 55 scans (95%) and of good or optimal diagnostic quality (PI-QUAL ≥4) for 35 scans (60%). Fifty-five out of 58 (95%) scans were of diagnostic quality for T2WI, followed by DWI (46/58 scans; 79%), and DCE (38/58 scans; 66%). Further validation of this scoring system is warranted. PATIENT SUMMARY: In this study we developed a scoring system (PI-QUAL) to assess the quality of multiparametric magnetic resonance imaging (mpMRI) in prostate cancer detection. We used scans from 22 centres that participated in the PRECISION trial. Although there was room for improvement in images that used intravenous contrast, we found that mpMRI in the PRECISION trial was of sufficient diagnostic quality (PI-QUAL score ≥3) for 95% of the scans.
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http://dx.doi.org/10.1016/j.euo.2020.06.007DOI Listing
October 2020

The role of additional standard biopsy in the MRI-targeted biopsy era.

Minerva Urol Nefrol 2020 10 2;72(5):637-639. Epub 2020 Jun 2.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

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http://dx.doi.org/10.23736/S0393-2249.20.03958-2DOI Listing
October 2020

The Role of Percentage of Prostate-specific Antigen Reduction After Focal Therapy Using High-intensity Focused Ultrasound for Primary Localised Prostate Cancer. Results from a Large Multi-institutional Series.

Eur Urol 2020 08 19;78(2):155-160. Epub 2020 May 19.

Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK.

Focal therapy (FT) for prostate cancer (PCa) is emerging as a novel therapeutic approach for patients with low- to intermediate-risk disease, in order to provide acceptable oncological control, whilst avoiding the side effects of radical treatment. Evidence regarding the ideal follow-up strategy and the significance of prostate-specific antigen (PSA) kinetics after treatment is needed. In this study, we aimed to assess the value of the percentage of PSA reduction (%PSA reduction) after FT in predicting the likelihood of any additional treatment or any radical treatment. We retrospectively analysed a multicentre cohort of 703 men receiving FT for low- and intermediate-risk PCa. Overall, the rates of any additional treatment and any radical treatment were 30% and 13%, respectively. The median follow-up period was 41 mo. The median %PSA reduction after FT was 73%. At Cox multivariable analysis, %PSA reduction was an independent predictor of any additional treatment (hazard ratio [HR]: 0.96; p < 0.001) and radical treatment (HR: 0.97; p < 0.001) after FT. For %PSA reduction of>90%, the probability of any additional treatment within 5 yr was 20%. Conversely, for %PSA reduction of <10%, the probability of receiving any additional treatment within 5 yr was roughly 70%. This study is the first to assess the role of %PSA reduction in the largest multicentre cohort of men receiving FT for PCa. Given the lack of standardised follow-up strategies in the FT field, the use of the %PSA reduction should be considered. PATIENT SUMMARY: The percentage of prostate-specific antigen reduction is a useful tool to assess men following focal therapy (FT). It can assist the urologist in setting up an appropriate follow-up and during post-FT patient counselling.
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http://dx.doi.org/10.1016/j.eururo.2020.04.068DOI Listing
August 2020

ESUR/ESUI consensus statements on multi-parametric MRI for the detection of clinically significant prostate cancer: quality requirements for image acquisition, interpretation and radiologists' training.

Eur Radiol 2020 Oct 19;30(10):5404-5416. Epub 2020 May 19.

Department of Radiology & Nuclear Medicine and Anatomy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.

Objectives: This study aims to define consensus-based criteria for acquiring and reporting prostate MRI and establishing prerequisites for image quality.

Methods: A total of 44 leading urologists and urogenital radiologists who are experts in prostate cancer imaging from the European Society of Urogenital Radiology (ESUR) and EAU Section of Urologic Imaging (ESUI) participated in a Delphi consensus process. Panellists completed two rounds of questionnaires with 55 items under three headings: image quality assessment, interpretation and reporting, and radiologists' experience plus training centres. Of 55 questions, 31 were rated for agreement on a 9-point scale, and 24 were multiple-choice or open. For agreement items, there was consensus agreement with an agreement ≥ 70% (score 7-9) and disagreement of ≤ 15% of the panellists. For the other questions, a consensus was considered with ≥ 50% of votes.

Results: Twenty-four out of 31 of agreement items and 11/16 of other questions reached consensus. Agreement statements were (1) reporting of image quality should be performed and implemented into clinical practice; (2) for interpretation performance, radiologists should use self-performance tests with histopathology feedback, compare their interpretation with expert-reading and use external performance assessments; and (3) radiologists must attend theoretical and hands-on courses before interpreting prostate MRI. Limitations are that the results are expert opinions and not based on systematic reviews or meta-analyses. There was no consensus on outcomes statements of prostate MRI assessment as quality marker.

Conclusions: An ESUR and ESUI expert panel showed high agreement (74%) on issues improving prostate MRI quality. Checking and reporting of image quality are mandatory. Prostate radiologists should attend theoretical and hands-on courses, followed by supervised education, and must perform regular performance assessments.

Key Points: • Multi-parametric MRI in the diagnostic pathway of prostate cancer has a well-established upfront role in the recently updated European Association of Urology guideline and American Urological Association recommendations. • Suboptimal image acquisition and reporting at an individual level will result in clinicians losing confidence in the technique and returning to the (non-MRI) systematic biopsy pathway. Therefore, it is crucial to establish quality criteria for the acquisition and reporting of mpMRI. • To ensure high-quality prostate MRI, experts consider checking and reporting of image quality mandatory. Prostate radiologists must attend theoretical and hands-on courses, followed by supervised education, and must perform regular self- and external performance assessments.
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http://dx.doi.org/10.1007/s00330-020-06929-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476997PMC
October 2020

Five-year Outcomes of Magnetic Resonance Imaging-based Active Surveillance for Prostate Cancer: A Large Cohort Study.

Eur Urol 2020 09 30;78(3):443-451. Epub 2020 Apr 30.

Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, UCLH NHS Foundation Trust, London, UK.

Background: Although the use of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) for prostate cancer is of increasing interest, existing data are derived from small cohorts.

Objective: We describe clinical, histological, and radiological outcomes from an established AS programme, where protocol-based biopsies were omitted in favour of MRI-led monitoring.

Design, Setting, And Participants: Data on 672 men enrolled in AS between August 2004 and November 2017 (inclusion criteria: Gleason 3 + 3 or 3 + 4 localised prostate cancer, presenting prostate-specific antigen <20 ng/ml, and baseline mpMRI) were collected from the University College London Hospital (UCLH) database.

Outcome Measurements And Statistical Analysis: Primary outcomes were event-free survival (EFS; event defined as prostate cancer treatment, transition to watchful waiting, or death) and treatment-free survival (TFS). Secondary outcomes included rates of all-cause or prostate cancer-related mortality, metastasis, and upgrading to Gleason ≥4 + 3. Data on radiological and histological progression were also collected.

Results And Limitations: More than 3800 person-years (py) of follow-up were accrued (median: 58 mo; interquartile range 37-82 mo). Approximately 84.7% (95% confidence interval [CI]: 82.0-87.6) and 71.8% (95% CI: 68.2-75.6) of patients remained on AS at 3 and 5 yr, respectively. EFS and TFS were lower in those with MRI-visible (Likert 4-5) disease or secondary Gleason pattern 4 at baseline (log-rank test; p <  0.001). In total, 216 men were treated. There were 24 deaths, none of which was prostate cancer related (6.3/1000 py; 95% CI: 4.1-9.5). Metastases developed in eight men (2.1 events/1000 py; 95% CI: 1.0-4.3), whereas 27 men upgraded to Gleason ≥4 + 3 on follow-up biopsy (7.7 events/1000 py; 95% CI: 5.2-11.3).

Conclusions: The rates of discontinuation, mortality, and metastasis in MRI-led surveillance are comparable with those of standard AS. MRI-visible disease and/or secondary Gleason grade 4 at baseline are associated with a greater likelihood of moving to active treatment at 5 yr. Further research will concentrate on optimising imaging intervals according to baseline risk.

Patient Summary: In this report, we looked at the outcomes of magnetic resonance imaging (MRI)-based surveillance for prostate cancer in a UK cohort. We found that this strategy could allow routine biopsies to be avoided. Secondary Gleason pattern 4 and MRI visibility are associated with increased rates of treatment. We conclude that MRI-based surveillance should be considered for the monitoring of small prostate tumours.
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http://dx.doi.org/10.1016/j.eururo.2020.03.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443696PMC
September 2020

Factors Influencing Variability in the Performance of Multiparametric Magnetic Resonance Imaging in Detecting Clinically Significant Prostate Cancer: A Systematic Literature Review.

Eur Urol Oncol 2020 04 17;3(2):145-167. Epub 2020 Mar 17.

Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.

Context: There is a lack of comprehensive data regarding the factors that influence the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI) to detect and localize clinically significant prostate cancer (csPCa).

Objective: To systematically review the current literature assessing the factors influencing the variability of mpMRI performance in csPCa diagnosis.

Evidence Acquisition: A computerized bibliographic search of Medline/PubMed database was performed for all studies assessing magnetic field strength, use of an endorectal coil, assessment system used by radiologists and inter-reader variability, experience of radiologists and urologists, use of a contrast agent, and use of computer-aided diagnosis (CAD) tools in relation to mpMRI diagnostic accuracy.

Evidence Synthesis: A total of 77 articles were included. Both radiologists' reading experience and urologists'/radiologists' biopsy experience were the main factors that influenced diagnostic accuracy. Therefore, it is mandatory to indicate the experience of the interpreting radiologists and biopsy-performing urologists to support the reliability of the findings. The most recent Prostate Imaging Reporting and Data System (PI-RADS) guidelines are recommended for use as the main assessment system for csPCa, given the simplified and standardized approach as well as its particular added value for less experienced radiologists. Biparametric MRI had similar accuracy to mpMRI; however, biparametric MRI performed better with experienced readers. The limited data available suggest that the combination of CAD and radiologist readings may influence diagnostic accuracy positively.

Conclusions: Multiple factors affect the accuracy of mpMRI and MRI-targeted biopsy to detect and localize csPCa. The high heterogeneity across the studies underlines the need to define the experience of radiologists and urologists, implement quality control, and adhere to the most recent PI-RADS assessment guidelines. Further research is needed to clarify which factors impact the accuracy of the MRI pathway and how.

Patient Summary: We systematically reported the factors influencing the accuracy of multiparametric magnetic resonance imaging (mpMRI) in detecting clinically significant prostate cancer (csPCa). These factors are significantly related to each other, with the experience of the radiologists being the dominating factor. In order to deliver the benefits of mpMRI to diagnose csPCa, it is necessary to develop expertise for both radiologists and urologists, implement quality control, and adhere to the most recent Prostate Imaging Reporting and Data System assessment guidelines.
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http://dx.doi.org/10.1016/j.euo.2020.02.005DOI Listing
April 2020