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Article of the week: Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant PCa

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a video prepared by the authors; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one. 

Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer

Christopher C. Khoo*, David Eldred-Evans*, Max Peters, Mariana Bertoncelli Tanaka*, Mohamed Noureldin*, Saiful Miah*, Taimur Shah*, Martin J. Connor*, Deepika Reddy*, Martin Clark§, Amish Lakhani§, Andrea Rockall§, Feargus Hosking-Jervis*, Emma Cullen*, Manit Arya*, David Hrouda, Hasan Qazi, Mathias Winkler*, Henry Tam§ and Hashim U. Ahmed*

*Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK, Department of Radiotherapy, University Medical Centre, Utrecht, The Netherlands, §Department of Radiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust and Department of Urology, St. George’s Hospital, St. George’s Healthcare NHS Trust, London, UK

Abstract

Objective

To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI‐RADS) v2 in the detection of clinically significant and insignificant prostate cancer.

Patients and Methods

A total of 489 pre‐biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI‐RADS v2 by expert uro‐radiologists. Patients were offered biopsy for any Likert or PI‐RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a ‘per score’ basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver‐operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used.

Table 1: Comparison of Likert and Prostate Imaging Reporting and Data System scoring.

Results

The median (interquartile range [IQR]) age was 66 (60–72) years and the median (IQR) prostate‐specific antigen level was 7 (5–10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI‐RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI‐RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI‐RADS v2, exhibiting higher total and partial areas under the ROC curve.

Conclusions

Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

Editorial: Does prostate MRI reporting system affect performance of MRI in men with a clinical suspicion of PCa?

Magnetic Resonance Imaging (MRI) of prostate continues to transform the way prostate cancer is being diagnosed and risk stratified. Multiple prospective single (e.g. the Biparametric MRI for Detection of Prostate Cancer [BIDOC] [1] and Improved Prostate Cancer Diagnosis ‐ Combination of Magnetic Resonance Imaging and Biomarkers [IMPROD] [2]) and multi‐institution trials (e.g. PROstate MRI Imaging Study [PROMIS] [3], PRostate Evaluation for Clinically Important Disease: Sampling Using Image‐guidance Or Not? [PRECISION] [4], multi‐institutional IMPROD (Multi‐IMPROD) [5], Assessment of Prostate MRI Before Prostate Biopsies [MRI‐FIRST] [6]) have demonstrated the potential of prostate MRI to limit the number of unnecessary biopsies in men with suspected prostate cancer.

In this issue of the BJUI, Khoo et al. [7] retrospectively analysed reports from a multicentre prostate cancer pathway registry, Rapid Assessment and Prostate Imaging for Diagnosis (RAPID). Men with a clinical suspicion of prostate cancer were enrolled based on various clinical criteria such as: age, performance status, and PSA level. All men had a pre‐biopsy MRI, including dynamic contrast‐enhanced MRI, reported using a 5‐point Likert scale and Prostate Imaging Reporting and Data System version 2.0 (PI‐RADSv2.0) systems by one of four uro‐radiologists (5–9 years of experience of prostate multi‐parametric MRI). Subsequently, all Likert and PI‐RADSv2.0 scores were reviewed by a dedicated reader in a multidisciplinary team setting. Likert scores were reported with knowledge of clinical variables such as: PSA, patient age, and past medical history. Men with Likert or PI‐RADSv2.0 score ≥4 or a score of 3 with a PSA density ≥0.12 ng/mL/mL underwent transperineal targeted prostate biopsies. Additionally, some men below these thresholds deemed to be at particularly high risk of prostate cancer (usually based on presence of other risk factors such as family history, high PSA kinetics or ethnic risk) were also offered biopsy on a case‐by‐case basis. At least three targeted cores were taken from each MRI‐suspicious lesion and no systematic biopsy cores were included in this analysis.

In total, 489 men were included in the analyses, with 377 and 408 men meeting the Likert and PI‐RADSv2.0 biopsy thresholds, respectively, of whom 316 (83.8%) and 346 (84.8%) proceeded to biopsy (P = 0.704), respectively. The Likert system predicted more clinically significant prostate cancer than PI‐RADSv2.0, e.g., 58.2% (184/316) vs 53.2% (184/346) of prostate cancer (P = 0.190) with Gleason score ≥3+4. Detection rates of clinically insignificant prostate cancer were comparable. The authors concluded that the Likert system was superior to PI‐RADSv2.0.

The authors should be congratulated on their effort to improve prostate MRI as a risk‐stratification and biopsy targeting tool. However, caution should be applied when translating these results to other centres. In order to access inter‐centre variability and to allow independent external validation, research groups should provide access to their imaging and patient level data. The authors do not provide such access and do not present inter‐reader variability of Likert vs PI‐RADv2.0 for all enrolled men. Similar to other trials evaluating prostate MRI in men with a clinical suspicion of prostate cancer, true prostate cancer and significant prostate cancer prevalence in this cohort is unknown, as men did not undergo saturation biopsy or prostatectomy with whole‐mount prostatectomy sections.

Overall, this retrospective analysis by Khoo et al. [7], comparing Likert scores reported using clinical variables vs PIRADSv2.0, provides further evidence that good quality prostate MRI can be used as a risk‐stratification and biopsy targeting tool in men with a clinical suspicion of prostate cancer. Each centre needs to develop its own quality control process and continually review its own performance measures of prostate MRI and MRI‐targeted biopsy. Furthermore, in order to access inter‐centre variability in performance of prostate MRI and MRI‐targeted biopsy, free public access to imaging and patient level data should be provided.

by Ivan Jambor and Ugo Falagorio

References

  1. Boesen LNørgaard NLogager V et al. Assessment of the diagnostic accuracy of biparametric magnetic resonance imaging for prostate cancer in biopsy‐naive men: the Biparametric MRI for Detection of Prostate Cancer (BIDOC) study. JAMA Netw Open 201811– 28
  2. Jambor IBoström PJTaimen P et al. Novel biparametric MRI and targeted biopsy improves risk stratification in men with a clinical suspicion of prostate cancer (IMPROD Trial). J Magn Reson Imaging 2017461089– 95
  3. Ahmed HUEl‐Shater Bosaily ABrown LC et al. Diagnostic accuracy of multi‐parametric MRI and TRUS Biopsy in prostate cancer (PROMIS): a paired validating confirmatory  study. Lancet 2017389815– 22
  4. Kasivisvanathan VRannikko ASBorghi M et al. MRI‐targeted or standard biopsy for prostate‐cancer diagnosis. N Engl J Med 20183781767– 77
  5. Jambor IVerho JEttala O et al. Validation of IMPROD biparametric MRI in men with clinically suspected prostate cancer: A prospective multi‐institutional trial. PLoS Med 201916: e1002813.
  6. Rouvière OPuech PRenard‐Penna R et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy‐naive patients (MRI‐FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol 201920100– 9
  7. Khoo CCEldred‐Evans DPeters M et al. Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer. BJU Int 2019; 125:49-55.

 

Video: Likert vs PI-RADS v2

Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer

Abstract

Objective

To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI‐RADS) v2 in the detection of clinically significant and insignificant prostate cancer.

Patients and Methods

A total of 489 pre‐biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI‐RADS v2 by expert uro‐radiologists. Patients were offered biopsy for any Likert or PI‐RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a ‘per score’ basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver‐operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used.

Results

The median (interquartile range [IQR]) age was 66 (60–72) years and the median (IQR) prostate‐specific antigen level was 7 (5–10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI‐RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI‐RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI‐RADS v2, exhibiting higher total and partial areas under the ROC curve.

Conclusions

Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

 

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