Abstract
The Prostate Imaging Reporting and Data System (PI-RADS) has good ability to identify the nature of lesions on prostate magnetic resonance imaging (MRI). However, some lesions are still reported as PI-RADS 4 and 5 but are biopsy-proven benign. Herein, we aimed to summarize the reasons for the negative prostate biopsy of patients who were assessed as PI-RADS 4 and 5 by biparameter MRI. We retrospectively sorted out the prostate MRI, treatment, and follow-up results of patients who underwent a biparameter MRI examination of the prostate in The First Affiliated Hospital of Nanjing Medical University (Nanjing, China) from August 2019 to June 2021 with PI-RADS 4 and 5 but a negative biopsy. We focused on reviewing the MRI characteristics. A total of 467 patients underwent transperineal prostate biopsy. Among them, biopsy pathology of 93 cases were negative. After follow-up, 90 patients were ruled out of prostate cancer. Among the 90 cases, 40 were considered to be overestimated PI-RADS after review. A total of 22 cases were transition zone (TZ) lesions with regular appearance and clear boundaries, and 3 cases were symmetrical lesions. Among 15 cases, the TZ nodules penetrated the peripheral zone (PZ) and were mistaken for the origin of PZ. A total of 17 cases of lesions were difficult to distinguish from prostate cancer. Among them, 5 cases were granulomatous inflammation (1 case of prostate tuberculosis). A total of 33 cases were ambiguous lesions, whose performance was between PI-RADS 3 and 4. In summary, the reasons for “false-positive MRI diagnosis” included PI-RADS overestimation, ambiguous images giving higher PI-RADS, diseases that were really difficult to distinguish, and missed lesion in the initial biopsy; and the first two accounted for the most.
Keywords: biopsy, negative, PI-RADS 4 and 5, prostate cancer
INTRODUCTION
The incidence of prostate cancer in 2020 has ranked first among men in the world.1 If it could be detected early, the prognosis of prostate cancer after radical surgery or radiotherapy would be good. Notably, the early diagnosis of prostate cancer depends on biopsy and pathological examination.2 Prostate magnetic resonance imaging (MRI) is extensively used clinically to help identify clinically significant prostate cancer and reduce unnecessary prostate cancer biopsy. The Prostate Imaging Reporting and Data System (PI-RADS) scoring system was drafted by the European Society of Urogenital Radiology in 2012 to standardize the interpretation and reporting of prostate MRI images and thus improve the consistency of results reported by different institutions. An improved version of PI-RADS v2.1 was released in 2019.3 According to PI-RADS v2.1, being rated as PI-RADS 4 and 5 means that the lesion has a high and a very high probability of being prostate cancer, respectively. As reported in a multicenter randomized controlled study, the positive rates of transperineal targeted biopsy for patients with PI-RADS 4 and 5 were 69% and 94%, respectively.4
PI-RADS achieves good results in prostate MRI diagnosis, but false positives remain, i.e., the biopsy of a PI-RADS 4 or 5 lesion turns out to be negative. This result may cause the urologist to suspect that the biopsy has failed to reach the lesion and may also cause anxiety in the patient. Prostate biopsy has some complications such as bleeding and infection.5-7 Prostate cancer is also a relatively mild cancer, so biopsy should be performed cautiously. Thus, a precise PI-RADS classification for MRI is needed to reduce the occurrence of false positives.
To summarize the causes of false positives in prostate MRI and reduce that phenomenon, the radiologists and urologists in The First Affiliated Hospital of Nanjing Medical University (Nanjing, China) reviewed the false-positive MRI image and the patient’s treatment and follow-up in the past. We found that the reasons for “false-positive MRI diagnosis” primarily included the following: PI-RADS was overestimated; ambiguous images were given high PI-RADS; diseases were really hard to be distinguished; and the initial biopsy did not hit the lesion. Although our overall PI-RADS 4 and 5 biopsy-positive rate reached 80%, representing the advanced level of MRI diagnosis and biopsy technology, the misjudgment of prostate MRI was still worth noting.
PATIENTS AND METHODS
Patients
Suspected prostate cancer patients in our center from August 2019 to June 2021 who met the following conditions were included in the study: (1) received prostate MRI examination in our hospital (The First Affiliated Hospital of Nanjing Medical University) with PI-RADS 4 or 5; (2) targeted and systematic biopsy was negative (considering postoperative pathological escalation and that ours was not a whole cross-sectional pathology, the presence of high-grade tumors cannot be ruled out, and tumor of Gleason score 3 + 3 was not included in this study); and (3) after biopsy, the pathology of benign prostatic hyperplasia surgery (holmium laser enucleation of the prostate [HoLEP]) or rebiopsy, or continuous prostate-specific antigen (PSA) monitoring was available to provide more definitive pathological findings. A total of 467 patients with PI-RADS 4 or 5 who underwent targeted + systematic biopsy in our center were identified. They all received biparametric MRI (bp-MRI), and the overall positive rate of biopsy was 80.1%. A total of 93 patients had a negative biopsy. Ninety of them were ruled out to have prostate cancer by surgical (HoLEP) pathology or continued PSA examination. This study was approved by the Ethics Committee of The First Affiliated Hospital of Nanjing Medical University (Approval No. 2021-SR-593), and informed consent was obtained from the included patients.
MRI and biopsy methods
All patients underwent 3.0T bp-MRI. All biopsy procedures were performed by four experienced urologists. Transperineal template prostate biopsy or freehand transperineal prostate biopsy was performed (chosen by each urologist according to his own habit) under the guidance of cognitively fused or software-fused bp-MRI and transrectal real-time biplane ultrasound (chosen by each urologist according to his own habit). Each urologist conducting biopsy had the experience of more than 100 cases. The biopsy method included 2–6 cores of targeted biopsy and 12 cores of systematic biopsy.
Review of the false-positive MRI image
Daily radiological diagnosis was performed by radiologists according to work arrangements. These radiologists did not all focus on prostate MRI but undertook the diagnosis of computed tomography (CT) and MRI of the entire abdominal and pelvic organs. The review was conducted by one experienced radiologist (FPZ) who focused on prostate MRI diagnosis and four urologists (YHW, CL, BJL, and ZJW) who focused on prostate cancer diagnosis, biopsy, treatment, and follow-up. They carefully reassessed the prostate MRI of the patients included in this study according to PI-RADS without knowing the specific pathological results. The interpretations of MRI in the initial scoring and review process were based on PI-RADS v2.1.
RESULTS
Summary of review of false-positive MRI image
The mean (standard deviation [s.d.]) age of the 93 patients with negative biopsy was 66.78 (7.27) years. After reviewing MRI images by the experienced prostate MRI special radiologist and urologists focusing on prostate cancer diagnosis and treatment, results showed the existence of granulomatous inflammation, prostate tuberculosis, and other diseases that were difficult to distinguish from prostate cancer on MRI. We also noticed a phenomenon worthy of attention. Among these patients with positive MRI but negative biopsy, 40 patients had overestimated PI-RADS. The classification of negative biopsy is shown in Table 1.
Table 1.
The classification of negative biopsy
| Classification of false-positive MRI | Patients, n (%) |
|---|---|
| TZ lesions with clear boundary | 22 (23.7) |
| Symmetrical lesions | 3 (3.2) |
| TZ lesions entering PZ and mistaken for PZ lesions | 15 (16.1) |
| Indistinguishable images (specific disease, such as prostate tuberculosis and granulomatous inflammation) | 5 (5.4) |
| Indistinguishable images (nonspecific chronic inflammation of the prostate) | 12 (12.9) |
| Ambiguous images | 33 (35.5) |
| Prostate cancer not detected by biopsy | 3 (3.2) |
MRI: magnetic resonance imaging; TZ: transition zone; PZ: peripheral zone
Overestimated PI-RADS: focusing on signal intensity and ignoring shape feature
After reviewing, a total of 22 patients were overestimated as PI-RADS 4 or 5 due to a regular-shaped nodule with a typical signal intensity and a clear boundary or envelope. Three patients were overestimated as PI-RADS 4 or 5 because of symmetrical nodules with typical signal intensity. One of the major advantages of MRI was that it provides a wealth of sequences, which can be used to determine the nature of the lesion based on the signal intensity of a specific sequence (such as diffusion-weighted imaging [DWI]). However, in practical applications, radiologists and urologists tend to pay more attention to the signal intensity of the lesion and ignore the shape feature of the lesion, thereby misjudging the nature of the disease. Image examples are shown in Figure 1.
Figure 1.
Overestimation of PI-RADS lesions due to ignorance of shape features. (a) A regular-shaped nodule with a typical signal intensity and a clear boundary or envelope (from left to right: T2WI, DWI, and ADC). (b) Symmetrical nodules with typical signal intensity (from left to right: T2, DWI, and ADC). PI-RADS: Prostate Imaging Reporting and Data System; T2WI: T2 weighted imaging; DWI: diffusion-weighted imaging; ADC: apparent diffusion coefficient.
Overestimated PI-RADS: transition zone (TZ) lesions entering peripheral zone (PZ) and mistaken for PZ origin
For PZ and central zone (CZ)/TZ lesions, PI-RADS has different focuses and criteria. To date, the judgment of MRI and PI-RADS for PZ lesions has higher accuracy and stability among different doctors than CZ/TZ ones.8,9 However, after reviewing, we found 15 patients whose lesions originated from the CZ/TZ and protruded into the PZ. The TZ standard should be applied, but they were misjudged as PZ nodules, which led to the overestimation of the PI-RADS score. Image examples are shown in Figure 2.
Figure 2.
TZ lesions entering PZ and mistaken for PZ-origin. (a) T2WI-sagittal; (b) DWI; and (c) ADC. TZ: transition zone; T2WI: T2 weighted imaging; DWI: diffusion-weighted imaging; ADC: apparent diffusion coefficient; PZ: peripheral zone.
Indistinguishable diseases: specific disease
Through review, the pathological results of five patients were granulomatous inflammation, and one of them was confirmed to be tuberculosis of the male reproductive system after further examination. The MRI of tuberculosis or nontuberculous granulomatosis of the prostate was difficult to be distinguished from prostate cancer, and the lesions were usually large. These five patients were rated as PI-RADS 5. Image examples are shown in Figure 3a and 3b.
Figure 3.
Specific diseases that are difficult to distinguish from prostate cancer. (a) Nontuberculous granulomatous inflammation (from left to right: T2WI, DWI, and ADC). (b) Tuberculosis granulomatous inflammation (from left to right: T2WI, DWI, and ADC). (c) Nonspecific chronic prostatitis difficult to distinguish from prostate cancer (from left to right: T2WI, DWI, and ADC). T2WI: T2 weighted imaging; DWI: diffusion-weighted imaging; ADC: apparent diffusion coefficient.
Indistinguishable diseases: nonspecific chronic inflammation of the prostate
In addition to granulomatous inflammation, MRI images of 12 patients with nonspecific chronic prostatitis were also difficult to be distinguished from those of patients with prostate cancer and were still classified as PI-RADS 4 or 5 after being reviewed. An image example is shown in Figure 3c.
Ambiguous images
After reviewing, we found that 33 patients had MRI features between PI-RADS 3 and 4. Although they were rated as PI-RADS 4 in the report, we also found it somewhat reasonable if they had been rated as PI-RADS 3 after being reviewed by different radiologists and urologists (without considering dynamic contrast enhanced [DCE]).
Follow-up results of the patients
All 90 MRI false-positive patients were followed up after biopsy. Some patients were treated with enucleation of the prostate due to urination obstruction, but no prostate cancer was found in postoperative pathological examination. In other patients, PSA was monitored multiple times after biopsy, and the PSA level was stable (primarily in patients with original PSA <10 ng ml−1) or significantly decreased (primarily in patients with original PSA >10 ng ml−1). Three patients whose PSA remained above 10 ng ml−1 underwent repeat biopsies, and no prostate cancer was found.
DISCUSSION
Our study summarized the reasons why patients with PI-RADS score of 4 or 5 showed a negative biopsy. The most common situation was the misjudgment of MRI, which led to the overestimation of the PI-RADS score. Although PI-RADS v2.1 has separately mentioned several special cases where the PI-RADS standard may be easy to be misused,3 only a few studies summarize this phenomenon in the real world. Through our summary, we found that the misuse of PI-RADS scores was primarily found in two situations: TZ lesions with clear boundaries or envelopes, and misjudgment of the zone where the lesion originated. As MRI contains shape and signal-intensity features, the PI-RADS v2.1 scoring standard describes the characteristics of shape and signal intensity at the same time. However, in practical applications, the effect of signal intensity and the impression on doctors is greater, so one of the advantages of MRI is to judge the nature of the lesion through the different signal intensities of different sequences. The contrast of light and dark also leaves a deeper impression on humans. These factors may explain why a typical hyperplastic nodule was misjudged as a high score of PI-RADS in actual work.
When reading MRI before biopsy, urologists are accustomed to scrolling different sequences of axial images simultaneously to locate the lesion, which was advised in PI-RADS v2.1, as DWI and apparent diffusion coefficient (ADC) images are both in the axial direction and so is the ultrasound image during the transperineal biopsy.3 Some radiologists also have this habit. The sagittal image can help judge the zoning of the lesion; the radiologists and urologists may put more focus on axial images and ignore sagittal images in actual work. Through our review, the misjudgment of TZ nodules as PZ nodules was almost entirely due to the lack of detailed observation of the sagittal images. As their workload increases,10 doctors also form an unbalanced subjective pattern of thinking set in their daily work. This problem inevitably occurs in the practical application of theoretical objective standards.
In addition to the misuse of PI-RADS, some diseases are indeed difficult to distinguish from prostate cancer. The most common one is granulomatous inflammation. Bour et al.11 reported the clinical features of granulomatous inflammation and prostate tuberculosis. It has an MRI similar to that of prostate cancer and is usually accompanied by increased PSA. In their study, among the 5 cases, 2 were nonspecific granulomatous inflammation, and 3 had been treated with Bacillus Calmette-Guerin (BCG). Three of the five cases resembled T3b tumors on MRI. In our study, four cases were nonspecific, and one was proven to be male reproductive tuberculosis. Consistently, the lesions of granulomatous inflammation were very large, and all of our five patients were assessed as PI-RADS 5. Tafuri et al.12 proposed that systematic biopsy can be omitted for patients with PI-RADS 5 and PSA density >0.15 ng ml−2. We believe that this idea is very insightful, and that the logical basis for this conclusion is that PI-RADS 5 and high PSA density ensure that the lesion is highly likely to be prostate cancer. For the purpose of diagnosis, only target biopsy can be used to diagnose prostate cancer. When the result turns out to be granulomatosis of the prostate, the doctors can also confidently explain the result to the patient that the disease can also lead to elevated PSA and is difficult to distinguish from prostate cancer on MRI.
In addition to granulomatous inflammation, some nonspecific chronic inflammations are similar to prostate cancer on MRI and assessed as high PI-RADS. Gordetsky et al.13 studied their pathological characteristics. In our study, a large number of lymphocyte infiltration was a common pathological feature of these patients. The performance on MRI was not very large and thus often misjudged as PI-RADS 4.
PI-RADS has a good guiding role in detecting prostate cancer, especially the detection of clinically significant cancer. Park et al.14 proved that with increased PI-RADS score, the detection rate of clinically significant cancer monotonously increases. However, meta-analysis also revealed that for PI-RADS 4, the heterogeneity of the research is very large. Our review has found that in PI-RADS 4 biopsy-negative cases, partially ambiguous images exist, and they can be reasonably evaluated as PI-RADS 4 or 3. The PI-RADS scoring standards have some vague expressions such as “heterogeneous”, “homogeneous”, “mildly”, “moderately”, or “markedly”. Different radiologists and urologists may have different classifications for the same image. The same radiologist and urologist may have different impressions when facing the same image at different times, and interobserver variation is somehow inevitable. bp-MRI has reportedly the same diagnostic performance as multiparametric-MRI (mp-MRI).15,16 Enhanced scanning only plays a decisive role in the PI-RADS 3 results. For lesions directly judged as PI-RADS 4 and 5, the lack of enhanced scanning does not affect the results. Therefore, performing bp-MRI was reasonable for us. However, if we could perform enhanced scanning, perhaps a more accurate classification would be available for this type of ambiguous cases, which is also one of the shortcomings of our study. Optimizing bp-MRI parameters may also provide more information to compensate for the lack of enhanced scanning.17 In addition to retrospective analyses, several prospective clinical trials (such as NCT04571840) are comparing mp-MRI and bp-MRI for prostate cancer diagnosis. We expect the results of these trials to help us make better clinical decisions. Anyhow, more accurate identification of PI-RADS 3 and 4 should be the focus of future research.
Meng et al.18 followed up patients whose initial MRI is PI-RADS 4 and 5 but have a negative biopsy. They found that some of these patients experience PI-RADS downgrading. It may be less likely to detect prostate cancer in these patients in the future, and 62.5% of patients with persistent PI-RADS 4 and 5 develop tumors on subsequent biopsy.18 We also observed PI-RADS downgrading during follow-up. According to our experience, part of the downgrade was due to the improvement in the original benign disease that caused the PI-RADS abnormality. The reason can also be due to more experienced radiologists’ downgrading PI-RADS, which was originally overestimated. As to PSA, in patients with a high initial PSA (primarily seen in some granulomatous inflammations), the PSA often significantly decreases several months after biopsy. In the case of misdiagnosed hyperplastic nodules as high PI-RADS lesions, such patients tend to have larger prostate volume and mildly elevated PSA. Their PSA does not drop significantly in the months following the biopsy but does not rise either.
Our research focused on the radiological factors in the false-positive MRI of prostate cancer. Some researchers have focused on the technical issues of biopsy. Williams et al.19 found that most MRI-targeted biopsy misses are due to errors in lesion targeting. The puncture method in this study was transrectal. It showed that the imperfection of the puncture operation of the urologists played some role in the false-positive result of the initial MRI. Studies have shown that transperineal puncture can detect more clinically meaningful cancers than transrectal puncture.20,21 Our research showed that the imperfect diagnosis of radiologists also played a role as a supplement in the transperineal era.
In recent years, with the spread of PSA screening, concerns about overdiagnosis and treatment of prostate cancer have emerged. With the application of mp-MRI/bp-MRI, this concern has also spread to the possible overdiagnosis and treatment caused by MRI.22–25 A high PI-RADS result also brought long-term anxiety to the patient. These findings remind us that PI-RADS 4 and 5 should be reported with more caution.
The biopsy of prostate cancer includes two parts: MRI diagnosis and puncture operation. It is not rigorous to compare the positive rate of biopsy of different PI-RADS scores without considering the difference in MRI diagnosis. The great heterogeneity in this type of research illustrates this point.26 In particular, the radiologist’s attitude (conservative or aggressive) often affects the final PI-RADS classification of ambiguous images. We should understand the biopsy-positive rate more dialectically and consider it in a more complete screening, imaging, and puncture process.
MRI, as a powerful tool for tumor detection, has also brought some new perspectives, such as biopsy-free prostatectomy.27,28 Although most studies also include prostate-specific membrane antigen-positron emission tomography (PSMA-PET) in the evaluation of prostate cancer and show that PSMA-PET greatly improves the diagnosis, MRI remains an important part of it. It is undoubtedly important to noninvasively diagnose prostate cancer through more precise examinations. However, at present, we must pay special attention to making more accurate and reasonable interpretations of MRI images when making important decisions based on MRI to avoid overestimating PI-RADS and identifying specific diseases, such as granulomatous inflammation and tuberculosis.
Now, artificial intelligence has been involved in clinical decision-making and exhibits strong performance.29,30 However, at present, biopsy after manual interpretation of MRI remains the cornerstone of prostate cancer diagnosis. Although humans have done well, a room for improvement remains.
CONCLUSION
The reasons for “false-positive MRI diagnosis” primarily include PI-RADS overestimation, ambiguous images given a high PI-RADS score, diseases that are really hard to distinguish, and missed lesion in the initial biopsy. The first two reasons account for the most. We should apply PI-RADS scoring rules more carefully and strictly follow the protocol. We also need to pay attention to the possibility of granulomatous inflammation and tuberculosis of the prostate.
AUTHOR CONTRIBUTIONS
YHW carried out the biopsies and drafted the manuscript. CL carried out the biopsies and the MRI review work and helped draft the manuscript. FPZ carried out the MRI review work and helped draft the manuscript. TRZ helped carry out the biopsies and helped draft the manuscript. JL participated in the design and coordination and helped draft the manuscript. ZJW conceived of the study, participated in its design and coordination, and helped draft the manuscript. BJL conceived of the study, participated in its design and coordination, carried out the MRI review work, and helped draft the manuscript. All authors read and approved the final manuscript.
COMPETING INTERESTS
All authors declared no competing interests.
REFERENCES
- 1.Siegel RL, Miller KD, Jemal A. Cancer statistics. CA Cancer J Clin. 2020;2020;70:7–30. doi: 10.3322/caac.21590. [DOI] [PubMed] [Google Scholar]
- 2.Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1:screening, diagnosis, and local treatment with curative intent. Eur Urol. 2017;71:618–29. doi: 10.1016/j.eururo.2016.08.003. [DOI] [PubMed] [Google Scholar]
- 3.Turkbey B, Rosenkrantz AB, Haider MA, Padhani AR, Villeirs G, et al. Prostate imaging reporting and data system version 2.1:2019 update of prostate imaging reporting and data system version 2. Eur Urol. 2019;76:340–51. doi: 10.1016/j.eururo.2019.02.033. [DOI] [PubMed] [Google Scholar]
- 4.Kasivisvanathan V, Rannikko AS, Borghi M, Panebianco V, Mynderse LA, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med. 2018;378:1767–77. doi: 10.1056/NEJMoa1801993. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Borghesi M, Ahmed H, Nam R, Schaeffer E, Schiavina R, et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. 2017;71:353–65. doi: 10.1016/j.eururo.2016.08.004. [DOI] [PubMed] [Google Scholar]
- 6.Bruyère F, Malavaud S, Bertrand P, Decock A, Cariou G, et al. Prosbiotate:a multicenter, prospective analysis of infectious complications after prostate biopsy. J Urol. 2015;193:145–50. doi: 10.1016/j.juro.2014.07.086. [DOI] [PubMed] [Google Scholar]
- 7.Stefanova V, Buckley R, Flax S, Spevack L, Hajek D, et al. Transperineal prostate biopsies using local anesthesia:experience with 1,287 patients. Prostate cancer detection rate, complications and patient tolerability. J Urol. 2019;201:1121–6. doi: 10.1097/JU.0000000000000156. [DOI] [PubMed] [Google Scholar]
- 8.Rosenkrantz AB, Ginocchio LA, Cornfeld D, Froemming AT, Gupta RT, et al. Interobserver reproducibility of the PI-RADS version 2 lexicon:a multicenter study of six experienced prostate radiologists. Radiology. 2016;280:793–804. doi: 10.1148/radiol.2016152542. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Maas MC, Litjens GJ, Wright AJ, Attenberger UI, Haider MA, et al. A single-arm, multicenter validation study of prostate cancer localization and aggressiveness with a quantitative multiparametric magnetic resonance imaging approach. Invest Radiol. 2019;54:437–47. doi: 10.1097/RLI.0000000000000558. [DOI] [PubMed] [Google Scholar]
- 10.Bruls RJ, Kwee RM. Workload for radiologists during on-call hours:dramatic increase in the past 15 years. Insights Imaging. 2020;11:121. doi: 10.1186/s13244-020-00925-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Bour L, Schull A, Delongchamps NB, Beuvon F, Muradyan N, et al. Multiparametric MRI features of granulomatous prostatitis and tubercular prostate abscess. Diagn Interv Imaging. 2013;94:84–90. doi: 10.1016/j.diii.2012.09.001. [DOI] [PubMed] [Google Scholar]
- 12.Tafuri A, Iwata A, Shakir A, Iwata T, Gupta C, et al. Systematic biopsy of the prostate can be omitted in men with PI-RADS™5 and prostate specific antigen density greater than 15. J Urol. 2021;206:289–97. doi: 10.1097/JU.0000000000001766. [DOI] [PubMed] [Google Scholar]
- 13.Gordetsky JB, Ullman D, Schultz L, Porter KK, Del Carmen Rodriguez Pena M, et al. Histologic findings associated with false-positive multiparametric magnetic resonance imaging performed for prostate cancer detection. Hum Pathol. 2019;83:159–65. doi: 10.1016/j.humpath.2018.08.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Park KJ, Choi SH, Lee JS, Kim JK, Kim MH, et al. Risk stratification of prostate cancer according to PI-RADS® Version 2 categories:meta-analysis for prospective studies. J Urol. 2020;204:1141–9. doi: 10.1097/JU.0000000000001306. [DOI] [PubMed] [Google Scholar]
- 15.Sherrer RL, Glaser ZA, Gordetsky JB, Nix JW, Porter KK, et al. Comparison of biparametric MRI to full multiparametric MRI for detection of clinically significant prostate cancer. Prostate Cancer Prostatic Dis. 2019;22:331–6. doi: 10.1038/s41391-018-0107-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Wallström J, Geterud K, Kohestani K, Maier SE, Månsson M, et al. Bi- or multiparametric MRI in a sequential screening program for prostate cancer with PSA followed by MRI?Results from the Göteborg prostate cancer screening 2 trial. Eur Radiol. 2021;31:8692–702. doi: 10.1007/s00330-021-07907-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Bao J, Zhi R, Hou Y, Zhang J, Wu CJ, et al. Optimized MRI assessment for clinically significant prostate cancer:a stard-compliant two-center study. J Magn Reson Imaging. 2021;53:1210–9. doi: 10.1002/jmri.27394. [DOI] [PubMed] [Google Scholar]
- 18.Meng X, Chao B, Chen F, Huang R, Taneja SS, et al. Followup of men with PI-RADS™4 or 5 abnormality on prostate magnetic resonance imaging and nonmalignant pathological findings on initial targeted prostate biopsy. J Urol. 2021;205:748–54. doi: 10.1097/JU.0000000000001424. [DOI] [PubMed] [Google Scholar]
- 19.Williams C, Ahdoot M, Daneshvar MA, Hague C, Wilbur AR, et al. Why does magnetic resonance imaging-targeted biopsy miss clinically significant cancer?J Urol . 2022;207:95–107. doi: 10.1097/JU.0000000000002182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Rai BP, Mayerhofer C, Somani BK, Kallidonis P, Nagele U, et al. Magnetic resonance imaging/ultrasound fusion-guided transperineal versus magnetic resonance imaging/ultrasound fusion-guided transrectal prostate biopsy-a systematic review. Eur Urol Oncol. 2021;4:904–13. doi: 10.1016/j.euo.2020.12.012. [DOI] [PubMed] [Google Scholar]
- 21.Qu LG, Al-Shawi M, Howard T, Papa N, Poyet C, et al. Gleason grade accuracy of transperineal and transrectal prostate biopsies in MRI-naïve patients. Int Urol Nephrol. 2021;53:2445–52. doi: 10.1007/s11255-021-03007-1. [DOI] [PubMed] [Google Scholar]
- 22.Lee DJ, Mallin K, Graves AJ, Chang SS, Penson DF, et al. Recent changes in prostate cancer screening practices and epidemiology. J Urol. 2017;198:1230–40. doi: 10.1016/j.juro.2017.05.074. [DOI] [PubMed] [Google Scholar]
- 23.Albertsen PC. Prostate cancer screening and treatment:where have we come from and where are we going?BJU Int . 2020;126:218–24. doi: 10.1111/bju.15153. [DOI] [PubMed] [Google Scholar]
- 24.Vickers AJ. Effects of magnetic resonance imaging targeting on overdiagnosis and overtreatment of prostate cancer. Eur Urol. 2021;80:567–72. doi: 10.1016/j.eururo.2021.06.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Van Poppel H, Hogenhout R, Albers P, van den Bergh RC, Barentsz JO, et al. Early detection of prostate cancer in 2020 and beyond:facts and recommendations for the European Union and the European Commission. Eur Urol. 2021;79:327–9. doi: 10.1016/j.eururo.2020.12.010. [DOI] [PubMed] [Google Scholar]
- 26.Mazzone E, Stabile A, Pellegrino F, Basile G, Cignoli D, et al. Positive predictive value of Prostate Imaging Reporting and Data System Version 2 for the detection of clinically significant prostate cancer:a systematic review and meta-analysis. Eur Urol Oncol. 2021;4:697–713. doi: 10.1016/j.euo.2020.12.004. [DOI] [PubMed] [Google Scholar]
- 27.Xing NZ, Wang MS, Fu Q, Yang FY, Li CL, et al. Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques. World J Clin Cases. 2019;7:1403–9. doi: 10.12998/wjcc.v7.i12.1403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Meissner VH, Rauscher I, Schwamborn K, Neumann J, Miller G, et al. Radical prostatectomy without prior biopsy following multiparametric magnetic resonance imaging and prostate-specific membrane antigen positron emission tomography. Eur Urol. 2021;82:156–60. doi: 10.1016/j.eururo.2021.11.019. [DOI] [PubMed] [Google Scholar]
- 29.Schelb P, Kohl S, Radtke JP, Wiesenfarth M, Kickingereder P, et al. Classification of cancer at prostate MRI:deep learning versus clinical PI-RADS assessment. Radiology. 2019;293:607–17. doi: 10.1148/radiol.2019190938. [DOI] [PubMed] [Google Scholar]
- 30.Bardis MD, Houshyar R, Chang PD, Ushinsky A, Glavis-Bloom J, et al. Applications of artificial intelligence to prostate multiparametric MRI (mpMRI):current and emerging trends. Cancers (Basel) 2020;12:1204. doi: 10.3390/cancers12051204. [DOI] [PMC free article] [PubMed] [Google Scholar]