UCL Division of Surgery & Interventional Science, University College London, London, UK; London Deanery of Urology, London, UK; Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.
UCL Division of Surgery & Interventional Science, University College London, London, UK.
Eur Urol. 2020 Aug;78(2):163-170. doi: 10.1016/j.eururo.2020.04.029. Epub 2020 May 1.
All risk stratification strategies in cancer overlook a spectrum of disease. The Prostate MR Imaging Study (PROMIS) provides a unique opportunity to explore cancers that are overlooked by multiparametric magnetic resonance imaging (mpMRI).
To summarise attributes of cancers that are systematically overlooked by mpMRI.
DESIGN, SETTING, AND PARTICIPANTS: PROMIS tested performance of mpMRI and transrectal ultrasonography (TRUS)-guided biopsy, using 5 mm template mapping (TPM) biopsy as the reference standard.
Outcomes were overall and maximum Gleason scores, maximum cancer core length (MCCL), and prostate-specific antigen density (PSAD). Cancer attributes were compared between cancers that were overlooked and those that were detected.
Of men with cancer, 7% (17/230; 95% confidence interval [CI] 4.4-12%) had significant disease overlooked by mpMRI according to definition 1 (Gleason ≥ 4 + 3 of any length or MCCL ≥ 6 mm of any grade) and 13% (44/331; 95% CI 9.8-17%) according to definition 2 (Gleason ≥ 3 + 4 of any length or MCCL ≥ 4 mm). In comparison, TRUS-guided biopsy overlooked 52% (119/230; 95% CI 45-58%) of significant disease by definition 1 and 40% (132/331; 95% CI 35-45%) by definition 2. Prostate cancers undetected by mpMRI had significantly lower overall and maximum Gleason scores (p = 0.0007; p < 0.0001) and shorter MCCL (median difference: 3 mm [5 vs 8 mm], p < 0.0001; 95% CI 1-3) than cancers that were detected. No tumours with overall Gleason score > 3 + 4 (Gleason Grade Groups 3-5; 95% CI 0-6.4%) or maximum Gleason score > 4 + 3 (Gleason Grade Groups 4-5; 95% CI 0-8.0%) on TPM biopsy were undetected by mpMRI. Application of a PSAD threshold of 0.15 reduced the proportion of men with undetected cancer to 5% (12/230; 95% CI 2.7-8.9%) for definition 1 and 9% (30/331; 95% CI 6.2-13%) for definition 2. Application of a PSAD threshold of 0.10 reduced the proportion of men with undetected disease to 3% (6/230; 95% CI 1.0-5.6%) for definition 1 cancer and to 3% (11/331; 95% CI 1.7-5.9%) for definition 2 cancer. Limitations were post hoc analysis and uncertain significance of undetected lesions.
Overall, a small proportion of cancers are overlooked by mpMRI, with estimates ranging from 4.4% (lower boundary of 95% CI for definition 1) to 17% (upper boundary of 95% CI for definition 2). Prostate cancers undetected by mpMRI are of lower grade and shorter length than cancers that are detected.
Prostate cancers that are undetected by magnetic resonance imaging (MRI) are smaller and less aggressive than those that are detected, and none of the most aggressive cancers are overlooked by MRI.
所有的风险分层策略都忽略了癌症的一个谱。前列腺磁共振成像研究（PROMIS）为探索多参数磁共振成像（mpMRI）忽略的癌症提供了一个独特的机会。
总结系统地被 mpMRI 忽略的癌症的特征。
设计、设置和参与者：PROMIS 测试了 mpMRI 和经直肠超声（TRUS）引导活检的性能，使用 5mm 模板映射（TPM）活检作为参考标准。
结果是总和最大 Gleason 评分、最大癌核长度（MCCL）和前列腺特异性抗原密度（PSAD）。将被忽略的癌症与被检测到的癌症的癌症属性进行比较。
在患有癌症的男性中，根据定义 1（任何长度的 Gleason 等级≥4+3 或任何等级的 MCCL≥6mm），有 7%（17/230；95%置信区间[CI]4.4-12%）的癌症被 mpMRI 系统地忽略，根据定义 2（任何长度的 Gleason 等级≥3+4 或任何长度的 MCCL≥4mm），有 13%（44/331；95%CI9.8-17%）的癌症被忽略。相比之下，TRUS 引导活检根据定义 1 忽略了 52%（119/230；95%CI45-58%）的显著疾病，根据定义 2 忽略了 40%（132/331；95%CI35-45%）的显著疾病。mpMRI 未检测到的前列腺癌的总和最大 Gleason 评分明显较低（p=0.0007;p<0.0001），MCCL 较短（中位数差异：3mm[5 与 8mm]，p<0.0001；95%CI1-3），比检测到的癌症。在 TPM 活检中，没有总 Gleason 评分>3+4（Gleason 分级组 3-5；95%CI0-6.4%）或最大 Gleason 评分>4+3（Gleason 分级组 4-5；95%CI0-8.0%）的肿瘤被 mpMRI 漏诊。应用 PSAD 阈值 0.15 将未检测到的癌症的男性比例降低到 5%（12/230；95%CI2.7-8.9%），定义 1；9%（30/331；95%CI6.2-13%），定义 2。应用 PSAD 阈值 0.10 将未检测到疾病的男性比例降低到定义 1 癌症的 3%（6/230；95%CI1.0-5.6%）和定义 2 癌症的 3%（11/331；95%CI1.7-5.9%）。局限性在于事后分析和未检测到病变的意义不确定。
总的来说，mpMRI 忽略了一小部分癌症，估计范围从 4.4%（定义 1 的 95%CI 下限）到 17%（定义 2 的 95%CI 上限）。mpMRI 未检测到的前列腺癌比检测到的癌症分级和长度都要低。
磁共振成像（MRI）未检测到的前列腺癌比检测到的癌症体积更小、侵袭性更小，而且没有一种最具侵袭性的癌症被 MRI 忽略。
