EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013. Outcome following active surveillance of men with screen-detected prostate cancer. Results from the Göteborg randomised population-based prostate cancer screening trial. A study of diffusion-weighted magnetic resonance imaging in men with untreated localised prostate cancer on active surveillance. Outcomes of men with screen-detected prostate cancer eligible for active surveillance who were managed expectantly. Novel biparametric MRI and targeted biopsy improves risk stratification in men with a clinical suspicion of prostate cancer (IMPROD Trial) Prostate Imaging-Reporting and Data System Steering Committee: PI-RADS v2 Status Update and Future Directions. Prostate cancer antigen 3 score accurately predicts tumour volume and might help in selecting prostate cancer patients for active surveillance. Focal High Intensity Focused Ultrasound of Unilateral Localized Prostate Cancer: A Prospective Multicentric Hemiablation Study of 111 Patients. Prediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators. Magnetic resonance imaging for the detection, localisation, and characterisation of prostate cancer: recommendations from a European consensus meeting. Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for Advanced Risk Modeling of Prostate Cancer-Patient-tailored Risk Stratification Can Reduce Unnecessary Biopsies. Prebiopsy Biparametric Magnetic Resonance Imaging Combined with Prostate-specific Antigen Density in Detecting and Ruling out Gleason 7-10 Prostate Cancer in Biopsy-naïve Men. Prostate cancer detection in the "grey area" of prostate-specific antigen below 10 ng/ml: head-to-head comparison of the updated PCPT calculator and Chun's nomogram, two risk estimators incorporating prostate cancer antigen 3. Prediction of Prostate Cancer Risk Among Men Undergoing Combined MRI-targeted and Systematic Biopsy Using Novel Pre-biopsy Nomograms That Incorporate MRI Findings. Prostate cancer gene 3 and multiparametric magnetic resonance can reduce unnecessary biopsies: decision curve analysis to evaluate predictive models. Usefulness of pre-biopsy multiparametric magnetic resonance imaging and clinical variables to reduce initial prostate biopsy in men with suspected clinically localized prostate cancer.
OBJECTIVE Our aim was to present a summary of the 2010 version of the European Association of Urology ( EAU ) guidelines on the screening , diagnosis , and treatment of clinical ly localised cancer of the prostate ( PCa ) . METHODS The working panel performed a literature review of the new data emerging from 2007 to 2010 . The guidelines were up date d , and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature , which included a search of online data bases and bibliographic review s. RESULTS A full version is available at the EAU office or Web site ( www.uroweb.org ) . Current evidence is insufficient to warrant widespread population -based screening by prostate-specific antigen ( PSA ) for PCa . A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method . Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy .  PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention . In men with locally advanced PCa in whom local therapy is not m and atory , watchful waiting ( WW ) is a treatment alternative to and rogen-deprivation therapy ( ADT ) with equivalent oncologic efficacy . Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy ( RP ) shown to be superior to WW in a prospect i ve r and omised trial . Nerve-sparing RP represents the approach of choice in organ-confined disease ; neoadjuvant and rogen deprivation demonstrates no improvement of outcome variables . Radiation therapy should be performed with at least 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa , respectively . For locally advanced disease , adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice . Follow-up after local therapy is largely based on PSA , and a disease-specific history with imaging is indicated only when symptoms occur . CONCLUSIONS The knowledge in the field of PCa is rapidly changing . These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice CONTEXT The most recent summary of the European Association of Urology ( EAU ) guidelines on prostate cancer ( PCa ) was published in 2011 . OBJECTIVE To present a summary of the 2013 version of the EAU guidelines on screening , diagnosis , and local treatment with curative intent of clinical ly organ-confined PCa . EVIDENCE ACQUISITION A literature review of the new data emerging from 2011 to 2013 has been performed by the EAU PCa guideline group . The guidelines have been up date d , and levels of evidence and grade s of recommendation have been added to the text based on a systematic review of the literature , which included a search of online data bases and bibliographic review s. EVIDENCE SYNTHESIS A full version of the guidelines is available at the EAU office or online ( www.uroweb.org ) . Current evidence is insufficient to warrant widespread population -based screening by prostate-specific antigen ( PSA ) for PCa . Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method . Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy . A biopsy progression indicates the need for active intervention , whereas the role of PSA doubling time is controversial . In men with locally advanced PCa for whom local therapy is not m and atory , watchful waiting ( WW ) is a treatment alternative to and rogen-deprivation therapy ( ADT ) , with equivalent oncologic efficacy . Active treatment is recommended mostly for patients with localized disease and a long life expectancy , with radical prostatectomy ( RP ) shown to be superior to WW in prospect i ve r and omized trials . Nerve-sparing RP is the approach of choice in organ-confined disease , while neoadjuvant ADT provides no improvement in outcome variables . Radiation therapy should be performed with ≥ 74 Gy in low-risk PCa and 78 Gy in intermediate- or high-risk PCa . For locally advanced disease , adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice . Follow-up after local therapy is largely based on PSA and a disease-specific history , with imaging indicated only when symptoms occur . CONCLUSIONS Knowledge in the field of PCa is rapidly changing . These EAU guidelines on PCa summarize the most recent findings and put them into clinical practice . PATIENT SUMMARY A summary is presented of the 2013 EAU guidelines on screening , diagnosis , and local treatment with curative intent of clinical ly organ-confined prostate cancer ( PCa ) . Screening continues to be done on an individual basis , in consultation with a physician . Diagnosis is by prostate biopsy . Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to and rogen-deprivation therapy in locally advanced PCa not requiring immediate local treatment . Radical prostatectomy is the only surgical option . Radiation therapy can be external or delivered by way of prostate implants . Treatment follow-up is based on the PSA level BACKGROUND Active surveillance ( AS ) has emerged as a treatment strategy for reducing overtreatment of screen-detected , low-risk prostate cancer ( PCa ) . OBJECTIVE To assess outcomes following AS of men with screen-detected PCa . DESIGN , SETTING , AND PARTICIPANTS Of the 968 men who were diagnosed with screen-detected PCa between 1995 and 2010 in the Göteborg r and omised , population -based PCa screening trial , 439 were managed with AS and were included in this study . Median age at diagnosis was 65.4 yr of age , and median follow-up was 6.0 yr from diagnosis . INTERVENTION The study participants were followed at intervals of 3 - 12 mo and were recommended to switch to deferred active treatment in case of a progression in prostate-specific antigen , grade , or stage . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The end points-overall survival ( OS ) , treatment-free survival , failure-free ( no relapse after radical treatment ) survival , and cancer-specific survival-were calculated for various risk groups ( very low , low , intermediate , and high ) with Kaplan-Meier estimates . A Cox proportional hazards model as well as a competing risk analysis were used to assess whether risk group or age at diagnosis was associated with failure after AS . RESULTS AND LIMITATIONS Forty-five per cent of all screen-detected PCa were managed with AS , and very low-risk and low-risk PCa constituted 60 % of all screen-detected PCa . Thirty-seven per cent ( 162 of 439 ) switched from surveillance to deferred active treatment , and 39 men failed AS . The 10-yr OS , treatment-free survival , and failure-free survival were 81.1 % , 45.4 % , and 86.4 % , respectively ( Kaplan-Meier estimates ) . Men with low- , intermediate- , and high-risk tumours had a hazard ratio for failure of 2.1 ( p=0.09 ) , 3.6 ( p=0.002 ) , and 4.6 ( p=0.15 ) , respectively , compared to very low-risk tumours ( Cox regression ) . Only one PCa death occurred , and one patient developed metastasis ( both in the intermediate-risk group ) . The main limitation of this study is the relatively short follow-up . CONCLUSIONS A large proportion of men with screen-detected PCa can be managed with AS . AS appears safe for men with low-risk PCa BACKGROUND Markers that predict the behaviour of localised prostate cancer are needed to identify patients that require treatment . OBJECTIVE We have analysed the apparent diffusion coefficient ( ADC ) generated from diffusion-weighted magnetic resonance imaging ( DW-MRI ) with respect to repeat biopsy findings and time to radical treatment in patients in a prospect i ve study of active surveillance . DESIGN , SETTING , AND PARTICIPANTS Some 86 men recruited between 2002 and 2006 were followed for a median of 29 mo . Patients had clinical stage T1/T2a N0/Nx M0/Mx adenocarcinoma of the prostate , prostate-specific antigen ( PSA ) level<15 ng/ml , Gleason score≤7 , primary Gleason grade ≤3 , and positive biopsy cores (pbc)≤50 % . MEASUREMENTS All patients had DW-MRI in addition to st and ard MRI sequences . Tumour regions of interest ( ROIs ) were identified using T2-weighted fast-spin echo images as focal areas of restricted diffusion . Univariate analyses including all clinical variables and tumour ADC data were performed with respect to repeat biopsy findings and time to radical treatment . Receiver operating curves ( ROC ) compared predictive variables . RESULTS AND LIMITATIONS Patients in the study had a median age of 66 yr and a median initial PSA level of 6.7 ng/ml . Some 39 patients ( 45 % ) received deferred radical treatment , and 34 patients ( 40 % ) had adverse histology on repeat biopsy . According to univariate analysis , tumour ADC was a significant predictor of both adverse repeat biopsy findings ( p<0.0001 ; hazard ratio [ HR ] : 1.3 ; 95 % confidence interval [ CI ] : 1.1 - 1.6 ) , and time to radical treatment ( p<0.0001 ; HR : 1.5 ; 95 % CI : 1.2 - 1.8 ) . ROC curves for ADC showed an area under the curve ( AUC ) of 0.7 for prediction of adverse repeat biopsy findings and an AUC of 0.83 for prediction of radical treatment . CONCLUSIONS In patients with low-risk , localised disease  , tumour ADC on DW-MRI may be a useful marker of prostate cancer progression and may help to identify patients who st and to benefit from radical treatment . This possibility warrants further study BACKGROUND The incidence of small , localised , well-differentiated prostate cancer ( PCa ) is increasing , mainly as a result of screening . Many of these cancers will not progress , and radical therapy may lead to substantial overtreatment . Active surveillance ( AS ) has emerged as an alternative . OBJECTIVE To retrospectively vali date the currently used criteria for eligibility for AS . DESIGN , SETTING , AND PARTICIPANTS For this cohort study , data from 616 men who were diagnosed with PCa between 1994 and 2007 at a mean age of 66.3 yr in four centres of the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) were combined . All patients fit the criteria for AS ( prostate-specific antigen [ PSA ] < or = 10.0 ng/ml , PSA-density < 0.2 ng/ml per ml , stage T1C/T2 , Gleason score < or = 3 + 3 = 6 , and < or = 2 positive biopsy cores ) , and initially they were managed expectantly . Median follow-up was 3.91 yr . MEASUREMENTS Disease specific- , overall- , and treatment-free survival were studied . Present PSA characteristics were assessed and also compared between men who were switching to deferred active therapy during follow-up and men remaining untreated . RESULTS AND LIMITATIONS The calculated ( Kaplan-Meier ) 10-yr PCa-specific survival ( 21 patients at risk ) was 100 % , which sharply contrasted with 77 % overall survival . Men still alive showed favourable PSA characteristics . Although the calculated 10-yr treatment-free survival was only 43 % , objective signs of progression often did not indicate the shift to radical treatment . The cohort consisted of men on AS and those on watchful waiting ( WW ) ; information on comorbidity or psychological distress was not available . CONCLUSIONS AS seems justified in selected men with screen-detected PCa . Prospect i ve protocol -based AS programs are necessary to optimise selection criteria and to find the appropriate trigger points for switching to active therapy . Possible negative psychological reactions with AS against improved quality of life by withholding side-effects from radical treatment should be considered PURPOSE To evaluate the role of a 3 T biparametric magnetic resonance imaging ( bpMRI ) , T2 -weighted imaging , and three separate diffusion-weighted imaging acquisitions combined with targeted biopsy ( TB ) for improving risk stratification of men with elevated prostate-specific antigen ( PSA ) . MATERIAL S AND METHODS Between March 2013 and February 2015 , 175 men with a clinical suspicion of prostate cancer ( PCa ) were offered bpMRI  ( NCT01864135 ) based on a suspicion of PCa ( two repeated PSA measurements in the range 2.5 - 20.0 ng/ml and /or abnormal digital rectal examination ) . Men with an equivocal to high suspicion of PCa had two TBs of the dominant lesion using cognitive ultrasound guidance , followed by systematic biopsy ( SB ) . Men with a low to very low suspicion had only SB . In total , 161 ( 161/175 , 92 % ) prospect ively enrolled men completed the trial and were included in the final analyses . The primary endpoint of the trial was the cancer detection rate ( CDR ) of TB and SB . Clinical ly significant cancer ( SPCa ) was defined as Gleason score ≥3 + 4 . RESULTS TB compared with SB had higher CDR for SPCa ( 45 % , 72/161 vs. 39 % , 63/161 , respectively ; P > 0.05 ) and a lower CDR for Gleason score 3 + 3 ( 8 % , 15/161 vs. 16 % , 30/161 ; P < 0.05 ) . Restricting biopsy to men with equivocal to highly suspicious bpMRI findings would have result ed in a 24 % ( 38/161 ) reduction in the number of men undergoing biopsy , while missing 4 ( 2 % ) with SPCa . All anonymized data sets , including bpMRI reports and follow up information , are freely available on the trial server . CONCLUSION Prebiopsy bpMRI and TB in men with a clinical suspicion of PCa improved risk stratification . LEVEL OF EVIDENCE 1 Technical Efficacy : Stage 5 J. Magn . Reson . Imaging 2017;46:1089 - 1095 CONTEXT The Prostate Imaging-Reporting and Data System ( PI-RADS ) v2 analysis system for multiparametric magnetic resonance imaging ( mpMRI ) detection of prostate cancer ( PCa ) is based on PI-RADS v1 , accumulated scientific evidence , and expert consensus opinion . OBJECTIVE To summarize the accuracy , strengths and weaknesses of PI-RADS v2 , discuss pathway implication s of its use and outline opportunities for improvements and future developments . EVIDENCE ACQUISITION For this consensus expert opinion from the PI-RADS steering committee , clinical studies , systematic review s , and professional guidelines for mpMRI PCa detection were evaluated . We focused on the performance characteristics of PI-RADS v2 , comparing data to systems based on clinicoradiologic Likert scales and non-PI-RADS v2 imaging only . Evidence selection s were based on high- quality , prospect i ve , histologically verified data , with minimal patient selection and verifications biases . EVIDENCE SYNTHESIS It has been shown that the test performance of PI-RADS v2 in research and clinical practice retains higher accuracy over systematic transrectal ultrasound ( TRUS ) biopsies for PCa diagnosis . PI-RADS v2 fails to detect all cancers but does detect the majority of tumors capable of causing patient harm , which should not be missed . Test performance depends on the definition and prevalence of clinical ly significant disease . Good performance can be attained in practice when the quality of the diagnostic process can be assured , together with joint working of robustly trained radiologists and urologists , conducting biopsy procedures within multidisciplinary teams . CONCLUSIONS It has been shown that the test performance of PI-RADS v2 in research and clinical practice is improved , retaining higher accuracy over systematic TRUS biopsies for PCa diagnosis . PATIENT SUMMARY Multiparametric magnetic resonance imaging ( MRI ) and MRI-directed biopsies using the Prostate Imaging-Reporting and Data System improves the detection of prostate cancers likely to cause harm , and at the same time decreases the detection of disease that does not lead to harms if left untreated . The keys to success are high- quality imaging , reporting , and biopsies by radiologists and urologists working together in multidisciplinary teams BACKGROUND The optimal selection of prostate cancer ( PCa ) patients for active surveillance ( AS ) is currently being debated . OBJECTIVE To assess the impact of urinary prostate cancer antigen 3 ( PCA3 ) score as an AS criterion instead of and in addition to the current criteria . DESIGN , SETTING , AND PARTICIPANTS We prospect ively studied 106 consecutive low-risk PCa patients ( prostate-specific antigen [ PSA ] ≤10 ng/ml , clinical stage T1c-T2a , and biopsy Gleason score 6 ) who underwent a PCA3 urine test before radical prostatectomy ( RP ) .  MEASUREMENTS Performance of AS criteria ( biopsy criteria , PCA3 score , PSA density , and magnetic resonance imaging [ MRI ] findings ) was tested in predicting four prognostic pathologic findings in RP specimens : ( 1 ) pT3 - 4 disease ; ( 2 ) overall unfavourable disease ( OUD ) defined by pT3 - 4 disease and /or pathologic primary Gleason pattern 4 ; ( 3 ) tumour volume < 0.5 cm(3 ) ; and ( 4 ) insignificant PCa . RESULTS AND LIMITATIONS The PCA3 score was strongly correlated with the tumour volume in a linear regression analysis ( p<0.001 , r=0.409 ) . The risk of having a cancer ≥0.5 cm(3 ) and a significant PCa was increased three-fold in men with a PCA3 score of ≥25 compared with men with a PCA3 score of < 25 with most AS biopsy criteria used . There was a trend towards higher PCA3 scores in patients with unfavourable and non-organ-confined disease and Gleason > 6 cancers . In a multivariate analysis taking into account each AS criterion , a high PCA3 score ( ≥25 ) was an important predictive factor for tumour volume ≥0.5 cm(3 ) ( odds ratio [ OR ] : 5.4 ; p=0.010 ) and significant PCa ( OR : 12.7 ; p=0.003 ) . Biopsy criteria and MRI findings were significantly associated with OUD ( OR : 3.9 and 5.0 , respectively ; p=0.030 and p=0.025 , respectively ) . CONCLUSIONS PCA3 score may be a useful marker to improve the selection for AS in addition to the current AS criteria . With a predictive cut-off of 25 , PCA3 score is strongly indicative for tumour volume and insignificant PCa BACKGROUND Up to a third of patients with localized prostate cancer have unilateral disease that may be suitable for partial treatment with hemiablation . OBJECTIVE To evaluate the ability of high intensity focused ultrasound ( HIFU ) to achieve local control of the tumor in patients with unilateral localized prostate cancer . DESIGN , SETTING , AND PARTICIPANTS The French Urological Association initiated a prospect i ve IDEAL multi-institutional study ( 2009 - 2015 ) , to evaluate HIFU-hemiablation as a primary treatment . INTERVENTION Multiparametric magnetic resonance imaging and biopsy were used for unilateral cancer diagnosis and control , and HIFU-hemiablation . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary : absence of clinical ly significant cancer ( CSC ) on control biopsy at 1 yr ( CSC : Gleason score ≥ 7 or cancer core length>3 mm regardless of grade or > 2 positive cores ) . Secondary : presence of any cancer on biopsy , biochemical response , radical treatment free survival , adverse events , continence ( no pad ) , erectile function ( International Index of Erectile Function-5 ≥ 16 ) , and quality of life ( European Organization for Research and Treatment of Cancer QLQ-C28 ) question naires . RESULTS AND LIMITATIONS One hundred and eleven patients were treated ( mean age : 64.8 yr [ st and ard deviation 6.2 ] ; mean prostate-specific antigen : 6.2 ng/ml [ st and ard deviation 2.6 ] ; 68 % low risk , 32 % intermediate risk ) . Of the 101 patients with control biopsy , 96 ( 95 % ) and 94 ( 93 % ) had no CSC in the treated and contralateral lobes , respectively . Mean prostate-specific antigen at 2 yr was 2.3 ng/ml ( st and ard deviation 1.7 ) . The radical treatment-free survival rate at 2 years was 89 % ( radical treatments : six radical prostatectomies , three radiotherapies , and two HIFU ) . Adverse events were Grade 3 in 13 % . At 12 mo continence and erectile functions were preserved in 97 % and 78 % . No significant decrease in quality of life score was observed at 12 mo . One limitation is the number of low-risk patients included in this study . CONCLUSIONS At 1 yr , HIFU-hemiablation was efficient with 95 % absence of clinical ly significant cancer associated with low morbidity and preservation of quality of life . Radical treatment-free survival rate was 89 % at 2 yr . PATIENT SUMMARY This report shows that high intensity focused ultrasound half-gl and treatment of unilateral prostate cancer provides promising results with high cancer control and low morbidity BACKGROUND The Rotterdam European R and omized Study of Screening for Prostate Cancer risk calculators ( ERSPC-RCs ) help to avoid unnecessary transrectal ultrasound-guided systematic biopsies ( TRUS-Bx ) . Multivariable risk stratification could also avoid unnecessary biopsies following multiparametric magnetic resonance imaging ( mpMRI ) . OBJECTIVE To construct MRI-ERSPC-RCs for the prediction of any- and high- grade ( Gleason score ≥3 + 4 ) prostate cancer ( PCa ) in 12-core TRUS-Bx±MRI-targeted biopsy ( MRI-TBx ) by adding Prostate Imaging Reporting and Data System ( PI-RADS ) and age as parameters to the ERSPC-RC3 ( biopsy-naïve men ) and ERSPC-RC4 ( previously biopsied men ) . DESIGN , SETTING , AND PARTICIPANTS A total of 961 men received mpMRI and 12-core TRUS-Bx±MRI-TBx ( in case of PI-RADS ≥3 ) in five institutions . Data of 504 biopsy-naïve and 457 previously biopsied men were used to adjust the ERSPC-RC3 and ERSPC-RC4 . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Logistic regression models were constructed . The areas under the curve ( AUCs ) of the original ERSPC-RCs and MRI-ERSPC-RCs ( including PI-RADS and age ) for any- and high- grade PCa were compared . Decision curve analysis was performed to assess the clinical utility of the MRI-ERSPC-RCs . RESULTS AND LIMITATIONS MRI-ERSPC-RC3 had a significantly higher AUC for high- grade PCa compared with the ERSPC-RC3 : 0.84 ( 95 % confidence interval [ CI ] 0.81 - 0.88 ) versus 0.76 ( 95 % CI 0.71 - 0.80 , p<0.01 ) . Similarly , MRI-ERSPC-RC4 had a higher AUC for high- grade PCa compared with the ERSPC-RC4 : 0.85 ( 95 % CI 0.81 - 0.89 ) versus 0.74 ( 95 % CI 0.69 - 0.79 , p<0.01 ) . Unlike for the MRI-ERSPC-RC3 , decision curve analysis showed clear net benefit of the MRI-ERSPC-RC4 at a high- grade PCa risk threshold of ≥5 % . Using a ≥10 % high- grade PCa risk threshold to biopsy for the MRI-ERSPC-RC4 , 36 % biopsies are saved , missing low- and high- grade PCa , respectively , in 15 % and 4 % of men who are not biopsied . CONCLUSIONS We adjusted the ERSPC-RCs for the prediction of any- and high- grade PCa in 12-core TRUS-Bx±MRI-TBx . Although the ability of the MRI-ERSPC-RC3 for biopsy-naïve men to avoid biopsies remains question able , application of the MRI-ERSPC-RC4 in previously biopsied men in our cohort would have avoided 36 % of biopsies , missing high- grade PCa in 4 % of men who would not have received a biopsy . PATIENT SUMMARY We have constructed magnetic resonance imaging-based Rotterdam European R and omized study of Screening for Prostate Cancer ( MRI-ERSPC ) risk calculators for prostate cancer prediction in transrectal ultrasound-guided biopsy and MRI-targeted biopsy by incorporating age and Prostate Imaging Reporting and Data System score into the original ERSPC risk calculators . The MRI-ERSPC risk calculator for previously biopsied men could be used to avoid one-third of biopsies following MRI BACKGROUND Multiparametric magnetic resonance imaging ( mpMRI ) may have a role in detecting clinical ly significant prostate cancer in men with raised serum prostate-specific antigen levels . Variations in technique and the interpretation of images have contributed to inconsistency in its reported performance characteristics . OBJECTIVE Our aim was to make recommendations on a st and ardised method for the conduct , interpretation , and reporting of prostate mpMRI for prostate cancer detection and localisation . DESIGN , SETTING , AND PARTICIPANTS A consensus meeting of 16 European prostate cancer experts was held that followed the UCLA-R AND Appropriateness Method and facilitated by an independent chair . MEASUREMENT Before the meeting , 520 items were scored for " appropriateness " by panel members , discussed face to face , and rescored . RESULTS AND LIMITATIONS Agreement was reached in 67 % of 260 items related to imaging sequence parameters . T2-weighted , dynamic contrast-enhanced , and diffusion-weighted MRI were the key sequences incorporated into the minimum requirements . Consensus was also reached on 54 % of 260 items related to image interpretation and reporting , including features of malignancy on individual sequences . A 5-point scale was agreed on for communicating the probability of malignancy , with a minimum of 16 prostatic regions of interest , to include a pictorial representation of suspicious foci . Limitations relate to consensus methodology . Dominant personalities are known to affect the opinions of the group and were countered by a neutral chairperson . CONCLUSIONS Consensus was reached on a number of areas related to the conduct , interpretation , and reporting of mpMRI for the detection , localisation , and characterisation of prostate cancer . Before optimal dissemination of this technology , these outcomes will require formal validation in prospect i ve trials BACKGROUND Multiparametric magnetic resonance imaging ( mpMRI ) is gaining widespread acceptance in prostate cancer ( PC ) diagnosis and improves significant PC ( sPC ; Gleason score≥3 + 4 ) detection . Decision making based on European R and omised Study of Screening for PC ( ERSPC ) risk-calculator ( RC ) parameters may overcome prostate-specific antigen ( PSA ) limitations . OBJECTIVE We added pre-biopsy mpMRI to ERSPC-RC parameters and developed risk models ( RMs ) to predict individual sPC risk for biopsy-naïve men and men after previous biopsy . DESIGN , SETTING , AND PARTICIPANTS We retrospectively analyzed clinical parameters of 1159 men who underwent mpMRI prior to MRI/transrectal ultrasound fusion biopsy between 2012 and 2015 . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariate regression analyses were used to determine significant sPC predictors for RM development . The prediction performance was compared with ERSPC-RCs , RCs refitted on our cohort , Prostate Imaging Reporting and Data System ( PI-RADS ) v1.0 , and ERSPC-RC plus PI-RADSv1.0 using receiver-operating characteristics ( ROCs ) . Discrimination and calibration of the RM , as well as net decision and reduction curve analyses were evaluated based on resampling methods . RESULTS AND LIMITATIONS PSA , prostate volume , digital-rectal examination , and PI-RADS were significant sPC predictors and included in the RMs together with age . The ROC area under the curve of the RM for biopsy-naïve men was comparable with ERSPC-RC3 plus PI-RADSv1.0 ( 0.83 vs 0.84 ) but larger compared with ERSPC-RC3 ( 0.81 ) , refitted RC3 ( 0.80 ) , and PI-RADS ( 0.76 ) . For postbiopsy men , the novel RM 's discrimination ( 0.81 ) was higher , compared with PI-RADS ( 0.78 ) , ERSPC-RC4 ( 0.66 ) , refitted RC4 ( 0.76 ) , and ERSPC-RC4 plus PI-RADSv1.0 ( 0.78 ) . Both RM benefits exceeded those of ERSPC-RCs and PI-RADS in the decision regarding which patient to receive biopsy and enabled the highest reduction rate of unnecessary biopsies . Limitations include a monocentric design and a lack of PI-RADSv2.0 . CONCLUSIONS The novel RMs , incorporating clinical parameters and PI-RADS , performed significantly better compared with RMs without PI-RADS and provided measurable benefit in making the decision to biopsy men at a suspicion of PC . For biopsy-naïve patients , both our RM and ERSPC-RC3 plus PI-RADSv1.0 exceeded the prediction performance compared with clinical parameters alone . PATIENT SUMMARY Combined risk models including clinical and imaging parameters  predict clinical ly relevant prostate cancer significantly better than clinical risk calculators and multiparametric magnetic resonance imaging alone . The risk models demonstrate a benefit in making a decision about which patient needs a biopsy and concurrently help avoid unnecessary biopsies BACKGROUND Multiparametric magnetic resonance imaging ( MRI ) combined with prostate-specific-antigen density ( PSAd ) enhances the detection of significant prostate cancer ( sPCa ) . However , it is unclear whether simple biparametric ( bp ) MRI , which reduces scan sequences , time , and cost , may be an equally effective noninvasive tool for detecting and ruling out sPCa and avoiding biopsies in biopsy-naïve men . OBJECTIVE To assess the diagnostic accuracy , predictive values , and best biopsy strategy combining bpMRI and PSAd in detecting and ruling out sPCa ( Gleason score ≥7 ) . DESIGN , SETTING , AND PARTICIPANTS Assessment of 808 biopsy-naïve men with clinical suspicion of localised PCa ( prostate-specific antigen < 20ng/ml , rectal examination < cT3 ) , prospect ively enrolled between November 2015 and June 2017 . INTERVENTION All men underwent upfront bpMRI ( T2- and diffusion-weighted imaging ) followed by st and ard and targeted biopsies of any suspicious bpMRI findings . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Various bpMRI scores and PSAd thresholds were assessed using sPCa detection rates , predictive values , and proportion of biopsies avoided . Net benefits and decision curve analyses were compared . Combined biopsies from all men were used for reference . RESULTS AND LIMITATIONS Significant prostate cancers were detected in 283/808 ( 35 % ) men with median age and PSA ( interquartile range ) of 65 yr ( 60 - 70 ) and 6.9ng/ml ( 5.4 - 9.5 ) , respectively . PSAd significantly influenced the predictive values of bpMRI in detecting and ruling out sPCa . The best strategy was restricting biopsies to men with highly suspicious bpMRI findings ( score ≥4 ) or PSAd ≥0.15ng/ml/cc . This reduced the number of men requiring biopsies by 41 % ( 329/808 ) and overdiagnosis of insignificant cancers by 45 % ( 79/177 ) , while missing only 5 % ( 17/329 ) of men with sPCa . Study limitations included single-centre analysis and combined biopsies as the reference st and ard . CONCLUSIONS Combination of bpMRI with PSAd improves diagnostic accuracy and predictive values for sPCa detection in biopsy-naïve men . Restricting biopsies to men with highly suspicious bpMRI findings ( score ≥4 ) or PSAd ≥0.15ng/ml/cc was the best biopsy strategy in our patient cohort , effectively balancing risks and benefits . Studies are needed to vali date our findings in other patient population s. PATIENT SUMMARY This report shows that biopsy-naïve men with clinical suspicion of prostate cancer who have low- or equivocal-suspicion biparametric magnetic resonance imaging results and a low prostate-specific antigen density may not require immediate prostate biopsies BACKGROUND Prostate cancer antigen 3 ( PCA3 ) holds promise in diagnosing prostate cancer ( PCa ) , but no consensus has been reached on its clinical use . Multivariable predictive models have shown increased accuracy over individual risk factors . OBJECTIVE To compare the performance of the two available risk estimators incorporating PCA3 in the detection of PCa in the " grey area " of prostate-specific antigen ( PSA ) < 10 ng/ml : the up date d Prostate Cancer Prevention Trial ( PCPT ) calculator and Chun 's nomogram . DESIGN , SETTING , AND PARTICIPANTS Two hundred eighteen patients presenting with an abnormal PSA ( excluding those with PSA > 10 ng/ml ) and /or abnormal digital rectal examination were prospect ively enrolled in a multicentre Italian study between October 2008 and October 2009 . All patients underwent ≥12-core prostate biopsy .  MEASUREMENTS PCA3 scores were assessed using the Progensa assay ( Gen-Probe , San Diego , CA , USA ) . Comparisons between the two models were performed using tests of accuracy ( area under the receiver operating characteristic curve [ AUC-ROC ] ) , calibration plots , and decision curve analysis . Biopsy predictors were identified by univariable and multivariable logistic regression . In addition , performance of PCA3 was analysed through AUC-ROC and predictive values . RESULTS AND LIMITATIONS PCa was detected in 73 patients ( 33.5 % ) . Among predictors included in the models , only PCA3 , PSA , and prostate volume retained significant predictive value . AUC-ROC was higher for the up date d PCPT calculator compared to Chun 's nomogram ( 79.6 % vs 71.5 % ; p=0.043 ) ; however , Chun 's nomogram displayed better overall calibration and a higher net benefit on decision curve analysis . Using a probability threshold of 25 % , no high- grade cancers would be missed ; the PCPT calculator would save 11 % of biopsies , missing no cancer , whereas Chun 's nomogram would save 22 % of avoidable biopsies , although missing 4.1 % non-high- grade cancers . The small number of patients may account for the lack of statistical significance in the predictive value of individual variables or model comparison . CONCLUSIONS Both Chun 's nomogram and the PCPT calculator , by incorporating PCA3 , can assist in the decision to biopsy by assignment of an individual risk of PCa , specifically in the PSA levels < 10 ng/ml OBJECTIVE To develop nomograms that predict the probability of overall prostate cancer ( PCa ) and clinical ly significant PCa ( Gleason ≥7 ) on magnetic resonance imaging (MRI)-targeted , and combined MRI-targeted and systematic , prostate biopsy . MATERIAL S AND METHODS From June 2012 to August 2014 , magnetic resonance imaging to ultrasound fusion-targeted prostate biopsy was performed on 464 men with suspicious regions identified on pre-biopsy 3 T MRI along with systematic 12 core biopsy .  Logistic regression modeling was used to evaluate predictors of overall and clinical ly significant PCa , and corresponding nomograms were generated for men who were not previously biopsied or had 1 or more prior negative biopsies . Models were created with 70 % of a r and omly selected training sample and bias-corrected using bootstrap resampling . The models were then vali date d with the remaining 30 % testing sample pool . RESULTS A total of 459 patients were included for analysis ( median age 66 years , prostate-specific antigen [ PSA ] 5.2 ng/mL , prostate volume 49 cc ) . Independent predictors of PCa on targeted and systematic prostate biopsy were PSA density , age , and MRI suspicion score . PCa probability nomograms were generated for each cohort using the predictors . Bias-corrected areas under the receiver-operating characteristic curves for overall and clinical ly significant PCa detection were 0.82 ( 0.78 ) and 0.91 ( 0.84 ) for men without prior biopsy and 0.76 ( 0.65 ) and 0.86 ( 0.87 ) for men with a prior negative biopsy in the training ( testing ) sample s. CONCLUSION PSA density , age , and MRI suspicion score predict PCa on combined MRI-targeted and systematic biopsy . Our generated nomograms demonstrate high diagnostic accuracy and may further aid in the decision to perform biopsy in men with clinical suspicion of PCa OBJECTIVE To overcome the well-known prostate-specific antigen limits , several new biomarkers have been proposed . Since its introduction in clinical practice , the urinary prostate cancer gene 3 ( PCA3 ) assay has shown promising results for prostate cancer ( PC ) detection . Furthermore , multiparametric magnetic resonance imaging ( mMRI ) has the ability to better describe several aspects of PC . METHODS A prospect i ve study of 171 patients with negative prostate biopsy findings and a persistent high prostate-specific antigen level was conducted to assess the role of mMRI and PCA3 in identifying PC . All patients underwent the PCA3 test and mMRI before a  second transrectal ultrasound-guided prostate biopsy . The accuracy and reliability of PCA3 ( 3 different cutoff points ) and mMRI were evaluated . Four multivariate logistic regression models were analyzed , in terms of discrimination and the cost benefit , to assess the clinical role of PCA3 and mMRI in predicting the biopsy outcome . A decision curve analysis was also plotted . RESULTS Repeated transrectal ultrasound-guided biopsy identified 68 new cases ( 41.7 % ) of PC . The sensitivity and specificity of the PCA3 test and mMRI was 68 % and 49 % and 74 % and 90 % , respectively . Evaluating the regression models , the best discrimination ( area under the curve 0.808 ) was obtained using the full model ( base clinical model plus mMRI and PCA3 ) . The decision curve analysis , to evaluate the cost/benefit ratio , showed good performance in predicting PC with the model that included mMRI and PCA3 . CONCLUSION mMRI increased the accuracy and sensitivity of the PCA3 test , and the use of the full model significantly improved the cost/benefit ratio , avoiding unnecessary biopsies PURPOSE We evaluated the usefulness of pre-biopsy multiparametric magnetic resonance imaging and clinical variables to decrease initial prostate biopsies . MATERIAL S AND METHODS We prospect ively evaluated 351 consecutive men with prostate specific antigen between 2.5 and 20 ng/ml , and /or digital rectal examination suspicious for clinical ly localized disease . All men underwent  pre-biopsy multiparametric magnetic resonance imaging and initial 14 to 29-core biopsy , including anterior sampling . Three definitions of significant cancer were defined based on Gleason score and cancer volume ( percent positive core and /or maximum cancer length ) . The overall cohort was divided into men at low risk-prostate specific antigen less than 10 ng/ml and normal digital rectal examination , and high risk-prostate specific antigen 10 ng/ml or greater and /or abnormal digital rectal examination . We evaluated the frequency of significant cancer according to magnetic resonance imaging and risk categories . Clinical variables as significant cancer predictors were analyzed using logistic regression . The sensitivity , specificity , and positive and negative predictive values of magnetic resonance imaging were calculated with or without clinical variables for significant cancer . RESULTS The frequency of significant cancer in men with negative vs positive magnetic resonance imaging was 9 % to 13 % vs 43 % to 50 % in the low risk group and 47 % to 51 % vs 68 % to 71 % in the high risk group . In men at low risk with negative magnetic resonance imaging prostate volume was the only significant predictor of significant cancer . In the low risk group the negative predictive value for significant cancer of a combination of positive magnetic resonance imaging and lower prostate volume ( less than 33 ml ) was 93.7 % to 97.5 % . CONCLUSIONS Pre-biopsy multiparametric magnetic resonance imaging along with prostate volume decreases the number of initial prostate biopsies by discriminating between significant cancer and other cancer in men with prostate specific antigen less than 10 ng/ml and normal digital rectal examination
Moderate hypofractionation is safe and effective , but longer-term data are still lacking .
Brachytherapy represents an effective way to increase the delivered dose .
OBJECTIVE To present a summary of the 2016 version of the European Association of Urology ( EAU ) - European Society for Radiotherapy & Oncology ( ESTRO ) - International Society of Geriatric Oncology ( SIOG ) Guidelines on screening , diagnosis , and local treatment with curative intent of clinical ly localised prostate cancer ( PCa ) .
EVIDENCE SYNTHESIS BRCA2 mutations have been added as risk factors for early and aggressive disease .
Systematic screening is still not recommended .
An early prostate-specific antigen test , the use of a risk calculator , or one of the promising biomarker tools are being investigated and might be able to limit the overdetection of insignificant PCa .
Breaking the link between diagnosis and treatment may lower the overtreatment risk .
Multiparametric magnetic resonance imaging using st and ardised reporting can not replace systematic biopsy , but robustly nested within the diagnostic work-up , it has a key role in local staging .
In Northern and Western Europe , the number of men diagnosed with PCa has been on the rise .