BACKGROUND
Local staging of prostate cancer (PCa) is important for treatment planning. Radiologist interpretation using qualitative criteria is variable with high specificity but low sensitivity. Quantitative methods may be useful in the diagnosis of extracapsular extension (ECE).


PURPOSE
To assess the performance of quantitative MRI markers for detecting ECE.


STUDY TYPE
Systematic review and meta-analysis.


SUBJECTS
4800 patients from 28 studies with histopathologically confirmed PCa on radical prostatectomy were pooled for meta-analysis. Patients from 46 studies were included for systematic review.


FIELD STRENGTH/SEQUENCE
Diffusion-weighted, T2-weighted, and dynamic contrast-enhanced MRI at 1.5 T or 3 T.


ASSESSMENT
PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched to identify studies on diagnostic test accuracy or association of any quantitative MRI markers with ECE. Results extracted by two independent reviewers for tumor contact length (TCL) and mean apparent diffusion coefficient (ADC-mean) were pooled for meta-analysis, but not for other quantitative markers including radiomics due to low number of studies available.


STATISTICAL TESTS
Hierarchical summary receiver operating characteristic (HSROC) curves were computed for both TCL and ADC-mean, but summary operating points were computed for TCL only. Heterogeneity was investigated by meta-regression. Results were significant if P ≤ 0.05.


RESULTS
At the 10 mm threshold for TCL, summary sensitivity and specificity were 0.76 [95% confidence interval (CI) 0.71-0.81] and 0.68 [95% CI 0.63-0.73], respectively. At the 15 mm threshold, summary sensitivity and specificity were 0.70 [95% CI 0.53-0.83] and 0.74 [95% CI 0.60-0.84] respectively. The area under the HSROC curves for TCL and ADC-mean were 0.79 and 0.78, respectively. Significant sources of heterogeneity for TCL included timing of MRI relative to biopsy.


DATA CONCLUSION
Both 10 mm and 15 mm thresholds for TCL may be reasonable for clinical use. From comparison of the HSROC curves, ADC-mean may be superior to TCL at higher sensitivities.


LEVEL OF EVIDENCE
3 TECHNICAL EFFICACY STAGE: 2.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/jmri.28742

Quantitative MRI in the Local Staging of Prostate Cancer: A Systematic Review and Meta-Analysis.

To identify the predictive factors of prostate cancer extracapsular extension (ECE) in an institutional cohort of patients who underwent multiparametric MRI of the prostate prior to radical prostatectomy (RP).Overall, 126 patients met the selection criteria, and their medical records were retrospectively collected and analysed; 2 experienced radiologists reviewed the imaging studies. Logistic regression analysis was conducted to identify the variables associated to ECE at whole-mount histology of RP specimens; according to the statistically significant variables associated, a predictive model was developed and calibrated with the Hosmer-Lomeshow test.The predictive ability to detect ECE with the generated model was 81.4% by including the length of capsular involvement (LCI) and intraprostatic perineural invasion (IPNI). The predictive accuracy of the model at the ROC curve analysis showed an area under the curve (AUC) of 0.83 [95% CI (0.76-0.90)], p < 0.001. Concordance between radiologists was substantial in all parameters examined (p < 0.001). Limitations include the retrospective design, limited number of cases, and MRI images reassessment according to PI-RADS v2.0.The LCI is the most robust MRI factor associated to ECE; in our series, we found a strong predictive accuracy when combined in a model with the IPNI presence. This outcome may prompt a change in the definition of PI-RADS score 5. 

Defining the role of multiparametric MRI in predicting prostate cancer extracapsular extension

Abstract Background Extraprostatic extension (EPE) of prostate cancer (PCa) on transrectal (TR) needle core biopsy (Bx) is a rare histopathological finding that can help in clinical decision-making. The detection efficiency of the transperineal (TP) approach is yet to be explored. Methods We retrospectively reviewed 2848 PCa cases using concomitant systemic template biopsy (SBx) and multiparametric magnetic resonance imaging (MRI)-ultrasound fusion-targeted biopsy (TBx) using the TR (n = 1917) or TP (n = 931) approach at our institution between January 2015 and July 2022. We assessed and compared clinical, MRI, and biopsy characteristics using different approaches (TP and TR) and methods (SBx and TBx). Results In total, 40 EPE cases were identified (40/2848, 1.4%). TP showed a significantly higher EPE detection rate compared to TR in SBx (TR:0.7% vs. TP:1.6%; p = 0.028) and TBx (TR:0.5% vs. TP:1.2%; p = 0.033), as well as the combined methods (2.1% vs. 1.1%, p = 0.019). A significantly higher incidence of EPEs was found at non-base sites in TP than in TR (76.7% vs. 50%, p = 0.038). SBx showed a higher EPE detection rate than TBx; however, the difference was not statistically significant. TP showed higher prostate-specific antigen density (0.35 vs. 0.17, p = 0.005), higher frequency of GG4-5 in the cores with EPE (65.0% vs. 50.0%, p = 0.020), and more PCa-positive SBx cores (10 vs. 8, p = 0.023) compared to the TR. Conclusions TP may improve EPE detection compared with TR and should be applied to patients with adverse pre-biopsy features. 

Detection of extraprostatic extension by transperineal multiparametric magnetic resonance imaging-ultrasound fusion targeted combined with systemic template prostate biopsy

https://www.nature.com/articles/s41598-023-38878-0.pdf

MR imaging features to predict the type of bone metastasis in prostate cancer

This study aims to confirm the diagnostic accuracy of extra-prostatic extension (EPE) grading system and to explore the predictive capabilities of the prostate MRI while considering various MRI features such as lesion location, ADC values and capsular enhancement sign (CES).Our monocentric study is based on a retrospective analysis of 99 patients who underwent radical prostatectomy from January 2021 to January 2023. The observers reviewed for each lesion, including location (transitional or peripheral zone, anterior or posterior location), capsular contact length, irregular bulging of the capsule, asymmetry of the neuro-vascular bundle, obliteration of the recto-prostatic angle, macroscopic EPE, ADC value, and CES.Among 99 patients, 31 patients had EPE. Lesions with EPE have broadercapsule contact (24 mm vs 12 mm) with contact ≥14mm being the optimal cut-off for EPE discrimination.Among the morphological MRI criteria used to determine the EPE, the one with major sensitivity was shown to be bulging (sen 81%), while macroscopic extension had highest specificity (100%).Univariate analysis showed as significative risk factors for EPE: capsular contact ≥14 mm (p < 0.001), ISUP ≥3 (p 0.005), CES (p < 0.001), bulging (p 0.001), neuro-vascular bundle asymmetry (p < 0.001) and EPE score ≥2 (p < 0.001), and in multivariate analysis CES (p 0.001) and EPE score ≥2 (p 0.004) were significant.The AUC of the EPE score was 0.76, raised to 0.83 when combining it with CES (P = 0.11).CES in the setting of multiparametric MRI can increase diagnostic accuracy for the prediction of extra-capsular disease.This study highlights the potential of contrast media in prostate cancer local staging. 

Extra-prostatic extension (EPE) grading system: Correlation with MRI features and integration of capsular enhancement sign (CES) for “enhanced” detection of T3a lesions

Purpose: To investigate the diagnostic performance of using quantitative assessment with multiparametric MRI (mpMRI) for prediction of extraprostatic extension (EPE) in patients with prostate cancer (PCa). Methods: We performed a computerized search of MEDLINE, Embase, Cochrane Library, Web of Science, and Google Scholar from inception until July 31, 2021. Summary estimates of sensitivity and specificity were pooled with the bivariate model, and quality assessment of included studies was performed with the Quality Assessment of Diagnostic Accuracy Studies-2. We plotted forest plots to graphically present the results. Multiple subgroup analyses and meta-regression were performed to explore the variate clinical settings and heterogeneity. Results: a total of 23 studies with 3931 participants were included. The pooled sensitivity and specificity for length of capsular contact (LCC) were 0.79 (95% CI 0.75-0.83) and 0.77 (95% CI 0.73-0.80), for apparent diffusion coefficient (ADC) were 0.71 (95% CI 0.50-0.86) and 0.71 (95% CI 059-0.81), for tumor size were 0.62 (95% CI 0.57-0.67) and 0.75 (95% CI 0.67-0.82), and for tumor volume were 0.77 (95% CI 0.68-0.84) and 0.72 (95% CI 0.56-0.83), respectively. Substantial heterogeneity was presented among included studies, and meta-regression showed that publication year (≤2017 vs. >2017) was the significant factor in studies using LCC as the quantitative assessment (P=0.02). Conclusion: Four quantitative assessments of LCC, ADC, tumor size, and tumor volume showed moderate to high diagnostic performance for prediction of EPE. However, the optimal cutoff threshold varied widely among studies and should be established to apply them in clinical practice.

The Quantitative Assessment of Using Multiparametric MRI for Prediction of Extraprostatic Extension in Patients Undergoing Radical Prostatectomy: A Systematic Review and Meta-Analysis

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The Quantitative Assessment of Using Multiparametric MRI for Prediction of Extraprostatic Extension in Patients Undergoing Radical Prostatectomy: A Systematic Review and Meta-Analysis