James Buchanan Brady Urological Institute, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Section of Abdominal Imaging, Imaging Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
J Urol. 2017 Dec;198(6):1301-1308. doi: 10.1016/j.juro.2017.07.011. Epub 2017 Jul 11.
PI-RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion-weighted imaging score 3 peripheral zone lesions as PI-RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer.
We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging-transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with a diffusion-weighted imaging score of 3 or 4. Each lesion was grouped into 1 of 3 classifications, including group 1-diffusion-weighted imaging score 3/nonenhancing/PI-RADS score 3, group 2-diffusion-weighted imaging score 3/enhancing/PI-RADS score 4 or group 3-diffusion-weighted imaging score 4/PI-RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy.
We identified a total of 389 peripheral zone diffusion-weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer on biopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p <0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy (28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p = 0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9).
Diffusion-weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1-weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.
PI-RADS™第 2 版规定，动态对比增强成像应用于将弥散加权成像评分 3 的外周区病变分类为 PI-RADS 评分 3（动态对比增强成像阴性或无增强）或 4（动态对比增强成像阳性或增强）。然而，据我们所知，尚不清楚动态对比增强成像是否能将病变分为具有临床意义的病理组。我们研究了动态对比增强成像是否能提高对临床显著癌症的检测能力。
我们确定了未诊断过前列腺癌的患者，这些患者接受了多参数磁共振成像-经直肠超声融合靶向活检，活检的外周区病变弥散加权成像评分为 3 或 4。每个病变分为 3 个组之一，包括组 1-弥散加权成像评分 3/无增强/PI-RADS 评分 3、组 2-弥散加权成像评分 3/增强/PI-RADS 评分 4 或组 3-弥散加权成像评分 4/PI-RADS 评分 4。我们测量了每个病变组中分级组 2 或更高级别病理的检出率，并在有和没有先前阴性系统活检的患者中进行了亚组分析。
我们共确定了 290 名患者的 389 个外周区弥散加权成像评分 3 或 4 的病变。组 1、2 和 3 病变的活检分级组 2 或更高级别癌症的发生率分别为 8.9%、21%和 36.5%（p<0.03）。在有先前阴性系统前列腺活检的患者中，组 2 病变的分级组 2 或更高级别病理的发生率高于组 1 病变（28%比 5.0%，p<0.001），但在没有此类活检的患者中则没有差异（16%比 12%，p=0.5）。在无系统活检的亚组中，组 3 病变的分级组 2 或更高级别癌症的发生率高于组 2 病变（46%比 16%，p=0.001）。然而，在有先前阴性系统前列腺活检的患者中，两组的发生率相似（27%比 28%，p=0.9）。
如果外周区弥散加权成像评分 3 的病变是动态对比增强 T1 加权成像阳性，则更有可能是临床显著的癌症（分级组 2 或更高级别）。在有先前阴性系统前列腺活检的患者中，这种情况最为明显。在这些患者中，包括动态对比增强序列在内的多参数磁共振成像可实现最佳病变风险分层。
