Multiparametric MRI imaging and risk for clinically significant prostate cancer

A new paper in Urology suggests that combination of data from multiparametric magnetic resonance imaging (mpMRI) with traditional risk factors (Gleason score, clinical stage, PSA level, etc.) may be able to improve identification of men at risk for clinically significant prostate cancer at time of diagnosis.

Chamie et al. looked retrospectively at data from 115 patients who all underwent a multiparametric MRI at their institution and then went on to have a radical prostatectomy. They compared the patients on the basis of the historical Johns Hopkins criteria for active surveillance (the so-called “Epstein criteria”) with and without the additional information available from the mpMRI.

Specifically, Chamie et al. were able to show that:

  • 77/115 (67 percent) of their patients had a PSA level between 4.1 and 10.0 ng/ml.
  • 104/115 (90 percent of their patient had a normal rectal examination.
  • 78/115 (68 percent) of their patients had a biopsy Gleason score ≤ 6.
  • 63/115 (55 percent) of their patients had ≤ 2 cores positive for cancer.
  • 58/115 (50 percent) of their patients were pathologically staged with Gleason 7 or pT3 disease at prostatectomy.
  • Of these 58 patients, the historical Epstein criteria failed to identify 12 patients (sensitivity, 79 percent; negative predictive value [NPV], 68 percent).
  • Addition of apparent diffusion coefficient from mpMRI data improved the ability to accurately predict clinically significant disease at prostatectomy (sensitivity, 93 percent; NPV, 84 percent).
  • MRI improved detection of large Gleason 6 lesions (≥ 1.3 ml, P = 0.006) or lesions of any size inclusive of Gleason ≥ 7 (P < 0.001).

The evidence of potential value of mpMRI scans in the early evaluation of men with localized prostate cancer (specifically in terms of the ability to identify those men who are and are not the best candidates for active monitoring as opposed to immediate treatment) is growing. However, the practical application of mpMRI is still a work in progress. There are cost factors and standardization factors that still need to be addressed in the use of mpMRI, as well as appropriate training of uroradiologists in the assessment of these mpMRI scans.

It should also be noted that Johns Hopkins personnel have indicated that they intending to revise and slightly broaden the Epstein criteria for eligibility for active surveillance, and this revision may well be relevant to the accuracy of the criteria alone as compared to the combination of the criteria with additional mpMRI data.

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