Nguyenhuy Minhtuan, Chan Xiang Qian, Homewood David, Ogluszko Cindy, Dundee Philip, Corcoran Niall
Department of Radiology, Austin Health, Melbourne, AUS.
Department of Urology, Western Health, Melbourne, AUS.
Cureus. 2024 Nov 13;16(11):e73607. doi: 10.7759/cureus.73607. eCollection 2024 Nov.
Multiparametric magnetic resonance imaging (mpMRI) is now the standard of care to guide prostate biopsies during workups and assessment of men with suspected prostate cancer (PCa). In addition to intraprostatic lesion detection, MRI usually covers the bony pelvis and pelvic lymph nodes, two of the commonest sites for metastatic disease. Subsequent staging has traditionally been based on further scanning using a combination of computed tomography (CT) and bone scintigraphy (BS), and more recently, positron emission tomography (PET) scanning with prostate-specific membrane antigen (PSMA) ligand. However, the value of additional staging investigations for men who are negative for metastatic disease on pelvic MRI is unclear. This study aims to evaluate the concordance of MRI findings with other imaging performed during staging.
Patients with a Gleason score (GS) of ≥ 7 who had received both a pre-biopsy mpMRI and subsequent staging investigations from a single institution between 2019 to 2022 were identified. Imaging reports for PET, CT, and BS were used as the reference standard to evaluate MRI accuracy. PSMA-PET was considered the definitive outcome if multiple scans were performed. MRI findings were then classified as positive, negative, or equivocal. The accuracy was calculated using interpretations where equivocal cases were considered positive or negative for spread, representing a 'pessimistic' or 'optimistic' reading, respectively. A subgroup assessment of results considering only the use of CT + BS and PET was also done.
This study identified 214 patients for inclusion. The median age was 70 (IQR: 65-75) years, prostate-specific antigen (PSA) was 9.65 (IQR: 6.9-14.3) (ng/ml), and PSA density was 0.26 (ng/ml/cc) (IQR: 0.15-0.46). Complete conventional staging was performed for 130 patients, and PSMA-PET was performed for 102 patients. The results for the optimistic against pessimistic interpretations were the following: overall accuracy (90% vs 89%), sensitivity (0.48 vs 0.52), specificity (0.97 vs 0.95), negative predictive value (NPV) (0.84 vs 0.93), and positive predictive value (PPV) (0.71 vs 0.63). When comparing subgroup results considering only conventional imaging against only PSMA-PET, there were markedly more discordant findings in the PET group.
The impression of nodal and metastatic status through mpMRI poorly correlates with results from conventional staging and PSMA-PET. PSMA-PET more often produces discordant results to mpMRI, signifying an additive diagnostic value. MRI should not be used alone in the workup of prostate cancer in patients with a GS ≥ 7, where metastasis is a concern.
多参数磁共振成像（mpMRI）现在是在对疑似前列腺癌（PCa）男性进行检查和评估期间指导前列腺活检的标准治疗方法。除了检测前列腺内病变外，MRI通常还覆盖骨盆骨骼和盆腔淋巴结，这是转移疾病最常见的两个部位。传统上，后续分期是基于使用计算机断层扫描（CT）和骨闪烁显像（BS）组合的进一步扫描，以及最近使用前列腺特异性膜抗原（PSMA）配体的正电子发射断层扫描（PET）。然而，对于盆腔MRI上转移疾病呈阴性的男性，额外分期检查的价值尚不清楚。本研究旨在评估MRI结果与分期期间进行的其他成像检查结果的一致性。
确定2019年至2022年间在单一机构接受活检前mpMRI和后续分期检查的Gleason评分（GS）≥7的患者。将PET、CT和BS的影像报告用作评估MRI准确性的参考标准。如果进行了多次扫描，则将PSMA-PET视为最终结果。然后将MRI结果分为阳性（positive）、阴性（negative）或不确定（equivocal）。准确性是通过将不确定病例分别视为转移扩散阳性或阴性的解读来计算的，分别代表“悲观”或“乐观”解读。还对仅考虑使用CT + BS和PET的结果进行了亚组评估。
本研究确定了214例纳入患者。中位年龄为70岁（四分位间距：65 - 75岁），前列腺特异性抗原（PSA）为9.65（四分位间距：6.9 - 14.3）（ng/ml），PSA密度为0.26（ng/ml/cc）（四分位间距：0.15 - 0.46）。对130例患者进行了完整的传统分期，对102例患者进行了PSMA-PET检查。乐观解读与悲观解读的结果如下：总体准确性（90%对89%）、敏感性（0.48对0.52）、特异性（0.97对0.95）、阴性预测值（NPV）（0.84对0.93）和阳性预测值（PPV）（0.71对0.63）。当仅比较考虑传统成像与仅考虑PSMA-PET的亚组结果时，PET组中不一致的结果明显更多。
通过mpMRI对淋巴结和转移状态的判断与传统分期和PSMA-PET的结果相关性较差。PSMA-PET与mpMRI相比更常产生不一致的结果，这表明其具有附加的诊断价值。对于GS≥7且存在转移担忧的前列腺癌患者，在检查过程中不应单独使用MRI。
