Division of Urologic Surgery and Duke Prostate Center, Department of Surgery, Duke University Medical Center, DUMC Box 2804, Durham, NC, 27710, USA.
Department of Radiology, Duke University Medical Center, DUMC Box 3808, Durham, NC, 27710, USA.
Abdom Radiol (NY). 2022 Aug;47(8):2917-2927. doi: 10.1007/s00261-022-03562-w. Epub 2022 Jun 8.
Prostate multiparametric magnetic resonance imaging (mpMRI) can identify lesions within the prostate with characteristics identified in Prostate Imaging Reporting and Data System (PI-RADS) v2.1 associated with clinically significant prostate cancer (csPCa) or Gleason grade group (GGG) ≥ 2 at biopsy.
To assess concordance (PI-RADS 5 lesions with csPCa) of PI-RADS v2/2.1 with targeted, fusion biopsy results and to examine causes of discordance (PI-RADS 5 lesions without csPCa) with aim to provide a structured approach to resolving discordances and develop quality improvement (QI) protocols.
A retrospective study of 392 patients who underwent mpMRI at 3 Tesla followed by fusion biopsy. PI-RADS v2/2.1 scores were assigned to lesions identified on mpMRI and compared to biopsy results expressed as GGG. Positive predictive value (PPV) of PI-RADS v2/2.1 was calculated for all prostate cancer and csPCa. Discordant cases were re-reviewed by a radiologist with expertise in prostate mpMRI to determine reason for discordance.
A total of 521 lesions were identified on mpMRI. 121/521 (23.2%), 310/524 (59.5%), and 90/521 (17.3%) were PI-RADS 5, 4, and 3, respectively. PPV of PI-RADS 5, 4, and 3 for all PCa and csPCa was 0.80, 0.55, 0.24 and 0.63, 0.33, and 0.09, respectively. 45 cases of discordant biopsy results for PI-RADS 5 lesions were found with 27 deemed "true" discordances or "unresolved" discordances where imaging re-review confirmed PI-RADS appropriateness, while 18 were deemed "false" or resolved discordances due to downgrading of PI-RADS scores based on imaging re-review. Adjusting for resolved discordances on re-review, the PPV of PI-RADS 5 lesions for csPCa was deemed to be 0.74 and upon adjusting for presence of csPCa found in cases of unresolved discordance, PPV rose to 0.83 for PI-RADS 5 lesions.
Although PIRADS 5 lesions are considered high risk for csPCa, the PPV is not 100% and a diagnostic dilemma occurs when targeted biopsy returns discordant. While PI-RADS score is downgraded in some cases upon imaging re-review, a number of "false" or "unresolved" discordances were identified in which MRI re-review confirmed initial PI-RADS score and subsequent pathology confirmed presence of csPCa in these lesions.
We propose a structured approach to resolving discordant biopsy results using multi-disciplinary re-review of imaging and archived biopsy strikes as a quality improvement pathway. Further work is needed to determine the value of re-biopsy in cases of unresolved discordance and to develop robust QI systems for prostate MRI.
前列腺多参数磁共振成像（mpMRI）可以识别前列腺内的病变，这些病变的特征在前列腺成像报告和数据系统（PI-RADS）v2.1 中得到识别，与临床上显著的前列腺癌（csPCa）或活检时 Gleason 分级组（GGG）≥2 相关。
评估 PI-RADS v2/2.1 与靶向、融合活检结果的一致性（PI-RADS 5 病变与 csPCa），并检查不一致性（PI-RADS 5 病变无 csPCa）的原因，旨在提供一种解决不一致性的结构化方法，并制定质量改进（QI）方案。
对 392 例在 3 Tesla 磁共振上进行 mpMRI 后行融合活检的患者进行回顾性研究。对 mpMRI 上识别出的病变分配 PI-RADS v2/2.1 评分，并与活检结果表示的 GGG 进行比较。计算 PI-RADS v2/2.1 对所有前列腺癌和 csPCa 的阳性预测值（PPV）。由具有前列腺 mpMRI 专业知识的放射科医生对不一致的病例进行重新评估，以确定不一致的原因。
mpMRI 共发现 521 个病变。PI-RADS 5、4 和 3 的病变分别为 121/521（23.2%）、310/524（59.5%）和 90/521（17.3%）。PI-RADS 5、4 和 3 对所有 PCa 和 csPCa 的 PPV 分别为 0.80、0.55、0.24 和 0.63、0.33 和 0.09。PI-RADS 5 病变的活检结果发现 45 例不一致，其中 27 例被认为是“真正”不一致或“未解决”不一致，即影像学重新评估证实 PI-RADS 合适，而 18 例被认为是“假”或“已解决”不一致，因为根据影像学重新评估降低了 PI-RADS 评分。在重新评估解决不一致的病例后，PI-RADS 5 病变的 csPCa 的 PPV 被认为是 0.74，而在考虑未解决不一致病例中存在 csPCa 后，PI-RADS 5 病变的 PPV 上升至 0.83。
尽管 PI-RADS 5 病变被认为是 csPCa 的高危病变，但阳性预测值并非 100%，当靶向活检结果不一致时，就会出现诊断难题。虽然在影像学重新评估时，一些病例的 PI-RADS 评分有所降低，但在一些“假”或“未解决”的不一致病例中，MRI 重新评估证实了最初的 PI-RADS 评分，随后的病理学证实了这些病变中存在 csPCa。
我们提出了一种使用多学科重新评估影像学和存档活检穿刺作为质量改进途径来解决不一致的活检结果的结构化方法。需要进一步研究来确定在未解决的不一致病例中重新活检的价值，并为前列腺 MRI 制定稳健的 QI 系统。
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