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Published on: March 21, 2025
Preoperative Multiparametric Prostate Magnetic Resonance Imaging Structured Report Informs Risk for Positive Apical
Daniel N Costa1, Xiaosong Meng2, Aaron Tverye2
1From the Departments of Radiology.
Background:
The prostatic apex is the most frequent location of positive surgical margin (PSM) after surgery. Data regarding the ability of multiparametric magnetic resonance imaging (mpMRI) to prospectively identify men at risk for apical PSMs (aPSMs) using a structured report are lacking.
Objectives:
The aims of the study are to determine and to compare the rate of aPSM in men with versus without prospectively flagged at-risk prostate lesions during clinical mpMRI interpretation using whole-mount histopathology as the reference standard.
Methods:
This single-center, retrospective study of prospectively collected data included treatment-naive men with abnormal 3T mpMRI (PI-RADS v2 score ≥3) between January 2016 and December 2018 followed by surgery. During routine clinical interpretation, radiologists flagged prostate lesions abutting the apical most gland and/or encircling the distal most prostatic urethra using standardized language available as a "pick list" option in the structured report. Logistic regression was used to compare the rate of PSM in 2 groups (flagged vs nonflagged men). Propensity score covariate adjustment corrected for potential selection bias according to age, prostate-specific antigen (PSA), PSA density, grade group, and pT stage. The estimate was further adjusted by including surgeon as a covariate.
Results:
A total of 428 men were included. A statistically significant higher proportion of aPSMs was noted in flagged (56% [51/91]) compared with nonflagged apical lesions (31% [105/337]; adjusted odds ratio, 2.5; 95% confidence interval, 1.6-4.1; P < 0.01). The difference in aPSM between both groups also varied according to the surgeon performing the RP. Prostate-specific antigen, PSA density, lesion size, apical location, Prostate Imaging Reporting & Data System score, grade group, pT stage, and surgeon's experience were associated with higher PSM rate. Biochemical recurrence, defined as PSA greater than 0.2 ng/mL on 2 measurements after RP, was significantly associated with PSM status (propensity score adjusted odds ratio, 3.1; 95% confidence interval, 1.8-5.3; P < 0.0001); however, patients flagged by radiologists did not have a significant difference in biochemical recurrence rates as compared with nonflagged patients ( P = 0.11).
Conclusions:
Standard language built into structured reports for mpMRI of the prostate helps identify preoperatively patients at risk for aPSM.
Clinical Impact:
Multiparametric MRI is able to identify patients at increased risk for aPSM, and this information can be conveyed in a structured report to urologists, facilitating patient counseling and treatment decisions.
Insights
Multiparametric MRI (mpMRI) can identify men at risk for apical positive surgical margins (aPSMs). Structured reports flagging at-risk lesions improve preoperative risk assessment for prostate cancer surgery.
Area of Science:
- Urologic oncology and radiology
- Prostate cancer diagnostics
- Surgical pathology
Background:
- The prostatic apex is a common site for positive surgical margins (PSMs) after prostatectomy.
- Prospective data on multiparametric magnetic resonance imaging (mpMRI) for identifying men at risk for apical PSMs (aPSMs) using structured reports are limited.
Purpose of the Study:
- To determine and compare the rate of aPSMs in men with and without prospectively flagged at-risk prostate lesions on mpMRI.
- To utilize whole-mount histopathology as the reference standard for evaluating aPSM rates.
Main Methods:
- Retrospective analysis of prospectively collected data from 428 treatment-naive men with abnormal 3T mpMRI (PI-RADS v2 score ≥3) undergoing surgery.
- Radiologists prospectively flagged lesions near the apical gland or distal urethra using standardized language in structured reports.
- Logistic regression and propensity score adjustment were used to compare aPSM rates between flagged and non-flagged groups, controlling for clinical factors and surgeon experience.
Main Results:
- Men with flagged lesions had a significantly higher rate of aPSMs (56%) compared to non-flagged men (31%) (adjusted odds ratio, 2.5; P < 0.01).
- Factors associated with higher PSM rates included PSA, PSA density, lesion size, apical location, PI-RADS score, grade group, pT stage, and surgeon experience.
- While PSM status was associated with biochemical recurrence, flagged patients did not show a significant difference in recurrence rates compared to non-flagged patients.
Conclusions:
- Standardized language in structured mpMRI reports effectively identifies patients at increased risk for aPSMs.
- mpMRI can preoperatively identify patients at higher risk for aPSMs, aiding urologists in patient counseling and treatment decisions.
