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Updated: Jan 6, 2026
A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound
Published on: March 21, 2025
Histopathological Features of MRI-Invisible Regions of Prostate Cancer Lesions
Petra J van Houdt1, Ghazaleh Ghobadi1, Ivo G Schoots2,3
1Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands.
Background:
Previous studies have reported tumor volume underestimation with multiparametric (mp)MRI in prostate cancer diagnosis.
Purpose:
To investigate why some parts of lesions are not visible on mpMRI by comparing their histopathology features to those of visible regions.
Study Type:
Retrospective.
Population:
Thirty-four patients with biopsy-proven prostate cancer scheduled for prostatectomy (median 68.7 years).
Field Strength/Sequence:
T2 -weighted, diffusion-weighted imaging, T2 mapping, and dynamic contrast-enhanced MRI on two 3T systems and one 1.5T system.
Assessment:
Two readers delineated suspicious lesions on mpMRI. A pathologist delineated the lesions on histopathology. A patient-customized mold enabled the registration of histopathology and MRI. On histopathology we identified mpMRI visible and invisible lesions. Subsequently, within the visible lesions we identified regions that were visible and regions that were invisible on mpMRI. For each lesion and region the following characteristics were determined: size, location, International Society of Urological Pathology (ISUP) grade, and Gleason subpatterns (density [dense/intermediate], tumor morphology [homogeneous/heterogeneous], cribriform growth [yes/no]).
Statistical Tests:
With generalized linear mixed-effect modeling we investigated which features explain why a lesion or a region was invisible on MRI. We compared imaging values (T2 , ADC, and Ktrans ) for these features with one-way analysis of variance (ANOVA).
Results:
Small, anterior, and ISUP grade 1-2 lesions (n = 34) were missed more frequent than large, posterior, ISUP grade ≥ 3 lesions (n = 35). Invisible regions on mpMRI had lower tumor density, heterogeneous tumor morphology, and were located in the transition zone. Both T2 and ADC values were higher in "intermediate" compared with "dense" regions (P = 0.002 and < 0.001) and in regions with heterogeneous compared with homogeneous morphology (P < 0.001 and 0.03). Ktrans was not significantly different (P = 0.24 and 0.99).
Data Conclusion:
Regions of prostate cancer lesions that are invisible on mpMRI have different histopathology features than visible regions. This may have implications for monitoring during active surveillance and focal treatment strategies.
Level Of Evidence:
3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2020;51:1235-1246.
Insights
Multiparametric MRI (mpMRI) can underestimate prostate cancer tumor volume. Invisible lesions on mpMRI exhibit distinct histopathology, impacting active surveillance and focal therapy strategies.
Area of Science:
- Radiology
- Oncology
- Pathology
Background:
- Multiparametric MRI (mpMRI) is crucial for prostate cancer diagnosis.
- Previous studies indicate mpMRI may underestimate tumor volume.
- Understanding MRI-invisible regions is key to improving diagnostic accuracy.
Purpose of the Study:
- To identify histopathological features differentiating visible from invisible prostate cancer lesions on mpMRI.
- To compare the characteristics of visible and invisible regions within lesions on mpMRI.
Main Methods:
- Retrospective analysis of 34 prostatectomy patients with biopsy-proven cancer.
- mpMRI performed on 3T and 1.5T systems using T2-weighted, DWI, T2 mapping, and DCE sequences.
- Correlation of MRI findings with detailed histopathology, including ISUP grade and Gleason subpatterns, using a patient-customized mold for registration.
Main Results:
- Smaller, anterior, and lower-grade (ISUP 1-2) lesions were more frequently missed.
- mpMRI-invisible regions showed lower tumor density, heterogeneous morphology, and were located in the transition zone.
- Higher T2 and ADC values were associated with intermediate density and heterogeneous morphology (P < 0.05).
Conclusions:
- Histopathological differences exist between visible and invisible prostate cancer regions on mpMRI.
- These findings have implications for refining active surveillance protocols.
- Improved understanding can enhance the efficacy of focal treatment strategies for prostate cancer.
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