EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Prostate Imaging-Reporting and Data System Steering Committee: PI-RADS v2 Status Update and Future Directions. Prospective study of diagnostic accuracy comparing prostate cancer detection by transrectal ultrasound-guided biopsy versus magnetic resonance (MR) imaging with subsequent MR-guided biopsy in men without previous prostate biopsies. Prediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators. Prostate Cancer Diagnostics Using a Combination of the Stockholm3 Blood Test and Multiparametric Magnetic Resonance Imaging. Validation of the European Society of Urogenital Radiology scoring system for prostate cancer diagnosis on multiparametric magnetic resonance imaging in a cohort of repeat biopsy patients. Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer. Outcomes of men with screen-detected prostate cancer eligible for active surveillance who were managed expectantly. Multiparametric magnetic resonance imaging vs. standard care in men being evaluated for prostate cancer: a randomized study. One-step TNM staging of high-risk prostate cancer using magnetic resonance imaging (MRI): toward an upfront simplified "all-in-one" imaging approach? Prebiopsy Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis in Biopsy-naive Men with Suspected Prostate Cancer Based on Elevated Prostate-specific Antigen Values: Results from a Randomized Prospective Blinded Controlled Trial. Prediction of Prostate Cancer Risk Among Men Undergoing Combined MRI-targeted and Systematic Biopsy Using Novel Pre-biopsy Nomograms That Incorporate MRI Findings. Prognostic factors for tumor recurrence in patients with clinical stage I seminoma undergoing surveillance—protocol for a systematic review Evaluating localized prostate cancer and identifying candidates for focal therapy. Evaluation of the Prostate Imaging Reporting and Data System for Magnetic Resonance Imaging Diagnosis of Prostate Cancer in Patients with Prostate-specific Antigen <20 ng/ml Multiparametric Magnetic Resonance Imaging/Transrectal Ultrasound Fusion Targeted Biopsy of the Prostate: Preliminary Results of a Prospective Single-Centre Study Outcome following active surveillance of men with screen-detected prostate cancer. Results from the Göteborg randomised population-based prostate cancer screening trial. 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. Multicentric oncologic outcomes of high-intensity focused ultrasound for localized prostate cancer in 803 patients. Screening for prostate cancer with prostate-specific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy-naïve Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. Clinical utility of the PCA3 urine assay in European men scheduled for repeat biopsy.
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 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 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 current diagnosis of prostate cancer ( PCa ) uses transrectal ultrasound-guided biopsy ( TRUSGB ) . TRUSGB leads to sampling errors causing delayed diagnosis , overdetection of indolent PCa , and misclassification . Advances in multiparametric magnetic resonance imaging ( mpMRI ) suggest that imaging and selective magnetic resonance (MR)-guided biopsy ( MRGB ) may be superior to TRUSGB . OBJECTIVE To compare the diagnostic efficacy of the magnetic resonance imaging ( MRI ) pathway with TRUSGB . DESIGN , SETTING , AND PARTICIPANTS A total of 223 consecutive biopsy-naive men referred to a urologist with elevated prostate-specific antigen participated in a single-institution , prospect i ve , investigator-blinded , diagnostic study from July 2012 through January 2013 . INTERVENTION All participants had mpMRI and TRUSGB . Men with equivocal or suspicious lesions on mpMRI also underwent MRGB . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was PCa detection . Secondary outcomes were histopathologic details of biopsy and radical prostatectomy specimens , adverse events , and MRI reader performance . Sensitivity , specificity , negative predictive values ( NPVs ) , and positive predictive values were estimated and basic statistics presented by number ( percentage ) or median ( interquartile range ) . RESULTS AND LIMITATIONS Of 223 men , 142 ( 63.7 % ) had PCa . TRUSGB detected 126 cases of PCa in 223 men ( 56.5 % ) including 47 ( 37.3 % ) classed as low risk . MRGB detected 99 cases of PCa in 142 men ( 69.7 % ) with equivocal or suspicious mpMRI , of which 6 ( 6.1 % ) were low risk . The MRGB pathway reduced the need for biopsy by 51 % , decreased the diagnosis of low-risk PCa by 89.4 % , and increased the detection of intermediate/high-risk PCa by 17.7 % . The estimated NPVs of TRUSGB and MRGB for intermediate/high-risk disease were 71.9 % and 96.9 % , respectively . The main limitation is the lack of long follow-up . CONCLUSIONS We found that mpMRI/MRGB reduces the detection of low-risk PCa and reduces the number of men requiring biopsy while improving the overall rate of detection of intermediate/high-risk PCa . PATIENT SUMMARY We compared the results of st and ard prostate biopsies with a magnetic resonance ( MR ) image-based targeted biopsy diagnostic pathway in men with elevated prostate-specific antigen . Our results suggest patient benefits of the MR pathway . Follow-up of negative investigations is required 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 More specific diagnostic for prostate cancer is needed to decrease overdetection and number of diagnostic procedures . OBJECTIVE To assess the performance of combining a blood-based biomarker panel and magnetic resonance imaging (MRI)-targeted biopsies for prostate cancer detection . DESIGN , SETTING , AND PARTICIPANTS We used a prospect i ve , multicenter , paired diagnostic study design . A total of 532 men aged 45 - 74 yr referred for prostate cancer workup were included during 2016 - 2017 . INTERVENTION Participants underwent blood sampling for analysis of the Stockholm3 test including protein biomarkers , genetic polymorphisms , and clinical variables ; 1.5 T MRI ; systematic prostate biopsies ; and MRI-targeted biopsies to lesions with Prostate Imaging Reporting and Data System version 2 ≥3 . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The main outcome was numbers of detected prostate cancer characterized by grade group ( GG ) and the number of performed biopsies using relative sensitivity ( RS ) . RESULTS AND LIMITATIONS Median prostate-specific antigen was 6.3 ng/ml , and mean age was 63.9 yr . Targeted and systematic biopsies detected 170 and 162 GG ≥2 tumors , respectively ( RS 1.05 ; 95 % confidence interval [ CI ] 0.96 - 1.14 ) . Compared with performing systematic biopsies on all men , performing targeted and systematic biopsies only on men with > 10 % risk of GG ≥2 cancer , as predicted by the Stockholm3 test , required 62 % ( 95 % CI 58 - 66 ) of the biopsy procedures and detected 58 % ( 95 % CI 48 - 70 ) of GG 1 disease , with increased sensitivity for GG ≥2 detection ( RS 1.10 ; 95 % CI 1.02 - 1.17 ) . Performing only targeted biopsies in men with elevated Stockholm3 test altered these results only slightly . Compared with performing systematic and targeted biopsies on all men , performing this only for men with an elevated Stockholm3 test decreased detection of GG ≥2 cancer slightly ( RS 0.92 ; 95 % CI 0.88 - 0.95 ) . Limitations include lacking knowledge of true disease prevalence . CONCLUSIONS These findings provide evidence that strategies combining the blood-based Stockholm3 test and MRI-targeted biopsies can be used to inform biopsy decision making . PATIENT SUMMARY In this study , 532 men coming for prostate cancer workup underwent blood sampling , and both traditional and magnetic resonance imaging/fusion-guided prostate biopsies . We report that performing targeted biopsies only in men with an elevated risk as assessed by the Stockholm3 test saved biopsies , decreased overdetection , and maintained the number of detected high- grade cancers BACKGROUND Wide variations in acquisition protocol s and the lack of robust diagnostic criteria make magnetic resonance imaging ( MRI ) detection of prostate cancer ( PCa ) one of the most challenging fields in radiology and urology . OBJECTIVE To vali date the recently proposed European Society of Urogenital Radiology ( ESUR ) scoring system for multiparametric MRI ( mpMRI ) of the prostate . DESIGN , SETTING , AND PARTICIPANTS An institutional review board-approved multicentric prospect i ve study ; 129 consecutive patients ( 1514 cores ) referred for mpMRI after at least one set of negative biopsies . INTERVENTION Transfer of mpMRI-suspicious areas on three-dimensional ( 3D ) transrectal ultrasound images by 3D elastic surface registration ; r and om systematic and targeted cores followed by core-by-core analysis of pathology and mpMRI characteristics of the core locations . The ESUR scores were assigned after the procedure on annotated Digital Imaging and Communications in Medicine archives . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relationships between ESUR scores and biopsy results were assessed by the Mann-Whitney U test . The Yates correction and Pearson χ(2 ) tests evaluated the association between categorical variables . A teaching set was r and omly drawn to construct the receiver operating characteristic curve of the ESUR score sum ( ESUR-S ) . The threshold to recommend biopsy was obtained from the Youden J statistics and tested in the remaining validation set in terms of sensitivity , specificity , positive predictive value , negative predictive value , and accuracy . RESULTS AND LIMITATIONS Higher T2-weighted , dynamic weighted imaging and dynamic contrast-enhanced ESUR scores were observed in areas yielding cancer-positive cores . The proportion of positive cores increased with the ESUR-S aggregated in five increments ( ESUR-S 3 - 5 : 2.9 % ; ESUR-S 6 - 8 : 11.1 % ; ESUR-S 9 - 10 : 38.2 % ; ESUR-S 11 - 12 : 63.4 % ; and ESUR-S 13 - 15 : 83.3 % ; p<0.0001 ) . A threshold of ESUR-S ≥ 9 exhibited the following characteristics : sensitivity : 73.5 % ; specificity : 81.5 % ; positive predictive value : 38.2 % ; negative predictive value : 95.2 % ; and accuracy : 80.4 % . Although the study was not design ed to compare repeat biopsy strategies , more targeted cores than r and om systematic cores were found to be positive for cancer ( 36.3 % compared with 4.9 % , p<0.00001 ) . CONCLUSIONS In the challenging situation of repeat biopsies , the ESUR scoring system was shown to provide clinical ly relevant stratification of the risk of showing PCa in a given location BACKGROUND An approach based on multiparametric magnetic resonance imaging ( mpMRI ) might increase the detection rate ( DR ) of clinical ly significant prostate cancer ( csPCa ) . OBJECTIVE To compare an mpMRI-based pathway with the st and ard approach for the detection of prostate cancer ( PCa ) and csPCa . DESIGN , SETTING , AND PARTICIPANTS Between November 2014 and April 2016 , 212 biopsy-naïve patients with suspected PCa ( prostate specific antigen level ≤15 ng/ml and negative digital rectal examination results ) were included in this r and omized clinical trial . Patients were r and omized into a prebiopsy mpMRI group ( arm A , n=107 ) or a st and ard biopsy ( SB ) group ( arm B , n=105 ) . INTERVENTION In arm A , patients with mpMRI evidence of lesions suspected for PCa  underwent mpMRI/transrectal ultrasound fusion software-guided targeted biopsy ( TB ) ( n=81 ) . The remaining patients in arm A ( n=26 ) with negative mpMRI results and patients in arm B underwent 12-core SB . OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was comparison of the DR of PCa and csPCa between the two arms of the study ; the secondary end point was comparison of the DR between TB and SB . RESULTS AND LIMITATIONS The overall DRs were higher in arm A versus arm B for PCa ( 50.5 % vs 29.5 % , respectively ; p=0.002 ) and csPCa ( 43.9 % vs 18.1 % , respectively ; p<0.001 ) . Concerning the biopsy approach , that is , TB in arm A , SB in arm A , and SB in arm B , the overall DRs were significantly different for PCa ( 60.5 % vs 19.2 % vs 29.5 % , respectively ; p<0.001 ) and for csPCa ( 56.8 % vs 3.8 % vs 18.1 % , respectively ; p<0.001 ) . The reproducibility of the study could have been affected by the single-center nature . CONCLUSIONS A diagnostic pathway based on mpMRI had a higher DR than the st and ard pathway in both PCa and csPCa . PATIENT SUMMARY In this r and omized trial , a pathway for the diagnosis of prostate cancer based on multiparametric magnetic resonance imaging ( mpMRI ) was compared with the st and ard pathway based on r and om biopsy . The mpMRI-based pathway had better performance than the st and ard pathway 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 OBJECTIVES To assess whether the proportion of men with clinical ly significant prostate cancer ( PCa ) is higher among men r and omized to multiparametric magnetic resonance imaging (mp-MRI)/biopsy vs. those r and omized to transrectal ultrasound (TRUS)-guided biopsy . METHODS In total , 1,140 patients with symptoms highly suggestive of PCa were enrolled and divided in 2 groups of 570 patients to follow 2 different diagnostic algorithms . Group A underwent a TRUS-guided r and om biopsy . Group B underwent an mp-MRI and a TRUS-guided targeted+r and om biopsy . The accuracy of mp-MRI in the diagnosis of PCa was calculated using prostatectomy as the st and ard of reference . RESULTS In group A , PCa was detected in 215 patients . The remaining 355 patients underwent an mp-MRI : the findings were positive in 208 and unremarkable in 147 patients . After the second r and om+targeted biopsy , PCa was detected in 186 of the 208 patients . In group B , 440 patients had positive findings on mp-MRI , and PCa was detected in 417 at first biopsy ; 130 group B patients had unremarkable findings on both mp-MRI and biopsy . In the 130 group B patients with unremarkable findings on mp-MRI and biopsy , a PCa Gleason score of 6 or precancerous lesions were detected after saturation biopsy . mp-MRI showed an accuracy of 97 % for the diagnosis of PCa . CONCLUSIONS The proportion of men with clinical ly significant PCa is higher among those r and omized to mp-MRI/biopsy vs. those r and omized to TRUS-guided biopsy ; moreover , mp-MRI is a very reliable tool to identify patients to schedule in active surveillance BACKGROUND Multiparametric magnetic resonance imaging ( mpMRI ) is the st and ard for local prostate cancer ( PCa ) staging . Whole-body MRI ( wbMRI ) has shown capabilities for metastatic screening . This study assesses the feasibility and value of an all-in-one AJCC TNM staging of PCa during a unique MRI session combining mpMRI and wbMRI . METHODS Thirty consecutive patients with " high-risk " PCa prospect ively underwent  mpMRI of the prostate and wbMRI , in addition to ( 99 m ) Tc bone scan ( BS ) , completed with st and ard X-rays ( ±TXR ) and contrast enhanced CT for distant staging . For the statistical analysis , a " best valuable comparator " ( BVC ) combining a panel review of all available baseline and follow-up imaging , biological , and clinical data was used to adjudicate lymph node and bone metastatic status . RESULTS Prostate mpMRI was analyzed using ESUR guidelines . Sensitivity of BS ± TXR combined with CT and of wbMRI for detecting metastases ( bones or nodes ) was 85 % and 100 % , respectively , and specificity was 88 % and 100 % , respectively . For the overall staging of the patients as being either N0M0 or having disease extension beyond the prostate , wbMRI was superior to the combination of BS and CT ( improvement in all ROC characteristics and of AUC by 13.6 % ( 95 % CI : + 0.7 % to + 26.5 % , P = 0.039 ) ) . The main limitation is the limited number of patients . CONCLUSIONS AJCC M and N staging using wbMRI is feasible during the same imaging session as mpMRI performed for T staging , in less then one hour . wbMRI  outperforms BS ± TXR and abdomino-pelvic CT work up for discriminating subsets of patients with or without distant spread of the cancer BACKGROUND Multiparametric magnetic resonance imaging ( MP-MRI ) may improve the detection of clinical ly significant prostate cancer ( PCa ) . OBJECTIVE To compare MP-MRI transrectal ultrasound (TRUS)-fusion targeted biopsy with routine TRUS-guided r and om biopsy for overall and clinical ly significant PCa detection among patients with suspected PCa based on prostate-specific antigen ( PSA ) values . DESIGN , SETTING , AND PARTICIPANTS This institutional review board-approved , single-center , prospect i ve , r and omized controlled trial ( April 2011 to December 2014 ) included 130 biopsy-naive patients referred for prostate biopsy based on PSA values ( PSA < 20 ng/ml or free-to-total PSA ratio ≤0.15 and PSA < 10 ng/ml ) . Patients were r and omized 1:1 to the MP-MRI or control group . Patients in the MP-MRI group  underwent prebiopsy MP-MRI followed by 10- to 12-core TRUS-guided r and om biopsy and cognitive MRI/TRUS fusion targeted biopsy . The control group underwent TRUS-guided r and om biopsy alone . INTERVENTION MP-MRI 3-T phased-array surface coil . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the number of patients with biopsy-proven PCa  in the MP-MRI and control groups . Secondary outcome measures included the number of positive prostate biopsies and the proportion of clinical ly significant PCa in the MP-MRI and control groups . Between-group analyses were performed . RESULTS AND LIMITATIONS Overall , 53 and 60 patients were evaluable in the MP-MRI and control groups , respectively . The overall PCa detection rate and the clinical ly significant cancer detection rate were similar between the MP-MRI and control groups , respectively ( 64 % [ 34 of 53 ] vs 57 % [ 34 of 60 ] ; 7.5 % difference [ 95 % confidence interval ( CI ) , -10 to 25 ] , p=0.5 , and 55 % [ 29 of 53 ] vs 45 % [ 27 of 60 ] ; 9.7 % difference [ 95 % CI , -8.5 to 27 ] , p=0.8 ) . The PCa detection rate was higher than assumed during the planning of this single-center trial . CONCLUSIONS MP-MRI/TRUS-fusion targeted biopsy did not improve PCa detection rate compared with TRUS-guided biopsy alone in patients with suspected PCa based on PSA values . PATIENT SUMMARY In this r and omized clinical trial , additional prostate magnetic resonance imaging ( MRI ) before prostate biopsy appeared to offer similar diagnostic accuracy compared with routine transrectal ultrasound-guided r and om biopsy in the diagnosis of prostate cancer . Similar numbers of cancers were detected with and without MRI . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT01357512 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 Background Testicular cancer is primarily treated with the surgical removal of the affected testis . About 50 % of testicular cancer patients present with a stage I seminoma . If no chemo- or radiotherapy as adjuvant treatment is initiated after orchiectomy , 15–20 % of these patients will develop metastases . Although adjuvant treatment is effective in reducing the relapse risk , there is rising concern about overtreatment of these patients . Prognostic factors at primary diagnosis might have the potential to identify patients at higher risk of tumor relapse , allowing to guide individual therapy and to avoid overtreatment . Therefore , we aim to synthesize the available evidence on tumor or patient characteristics as possible prognostic factors for cancer recurrence in patients with clinical stage I seminoma . Methods / design We will conduct a broad systematic review to analyze what prognostic factors predict cancer recurrence in patients with a first time diagnosis of clinical stage I seminoma , who received no adjuvant chemo- or radiotherapy after orchiectomy .  The literature search will comprise MEDLINE , Web of Science , the Cochrane Central Register of Controlled Trials ( CENTRAL ) , and the conference proceedings of the American Society of Clinical Oncology ( ASCO ) , American Urologic Association ( AUA ) , and European Urologic Association ( EAU ) Annual Meetings . Prospect i ve and retrospective longitudinal studies reporting on prognostic factors for cancer recurrence will be considered . We will consider the wealth of any c and i date clinical or pathological prognostic factor reported in the literature . Our outcome of interest will be tumor recurrence at a minimum of 2 years follow-up . Study screening , data extraction , and quality assessment will be done by two review ers independently . Hazard ratios will be used to measure the relationship between the potential prognostic factor and tumor recurrence . Meta-analyses will be conducted with sufficiently homogeneous studies and separately with respect to study design , by using the r and om-effects generic inverse variance model . Discussion Limitations and strengths will be discussed in our review , and the results will be put into context with other studies in this field . Our results will help to guide evidence -based decision-making on patients with clinical stage I seminoma , allowing a better adjustment of therapies with regard to the individual patient ’s risk . Our findings will furthermore help to formulate recommendations for future research . Systematic review registration PROSPERO Can focal therapy successfully control  prostate cancer  ? Also , if so , which patients should be considered eligible ? With limited data available from relatively few patients , these questions are difficult to answer . At this writing , the most likely c and i date s for focal therapy are patients with low-risk , small-volume tumors , located in 1 region or sector of the prostate , who would benefit from early intervention . The difficulty lies in reliably identifying these men . The larger number of cores obtained in each needle biopsy session has increased both the detection of prostate cancer and the potential risk of overtreating many patients whose cancers pose very little risk to life or health . Urologists typically perform at least a 12-core template biopsy . Although the debate continues about the optimal template , laterally and peripherally directed biopsies have been shown to improve the diagnostic yield . However , as many as 25 % of tumors arise anteriorly and can be missed with peripherally directed techniques . Prostate cancer tends to be multifocal , even in its earliest stages . However , the secondary cancers are usually smaller and less aggressive than the index cancer . They appear similar to the incidental cancers found in cystoprostatectomy specimens and appear to have little effect on prognosis in surgical series . When a single focus of cancer is found in 1 core , physicians rightly suspect that more foci of cancer are present in the prostate . Assessing the risk in these patients is challenging when determined by the biopsy data alone . To predict the presence of a very low-risk or " indolent " cancer , nomograms have been developed to incorporate clinical stage , Gleason grade , prostate-specific antigen levels , and prostate volume , along with the quantitative analysis of the biopsy results . Transperineal " mapping " or " saturation " biopsies have been advocated to detect cancers missed or underestimated by previous transrectal biopsies . This approach could provide the accurate staging , grading , and tumor localization needed for a focal therapy program . Nevertheless , for men with minimal cancer who are amenable to active surveillance or focal therapy , consensus about the most accurate biopsy strategy has not yet been reached . Imaging , particularly magnetic resonance imaging and magnetic resonance spectroscopic imaging , has been used to assess men with early-stage prostate cancer . Large-volume cancers can be seen reasonably well , but small lesions have been difficult to detect reliably or measure accurately . Factors such as voxel resolution , organ movement , biopsy artifact , and benign changes have limited the consistent estimation of the quantitative tumor volume . Nevertheless , magnetic resonance imaging and magnetic resonance spectroscopic imaging can aid in evaluating patients with prostate cancer being considered for focal therapy by providing additional evidence that the patient does not harbor an otherwise undetected high-risk , aggressive cancer . In some cases , imaging can usefully identify the location of even a limited-sized index cancer . When imaging findings are substantiated by mapping biopsy results , confidence in the accurate characterization of the cancer is enhanced . Correlating the imaging results with tissue changes during and after treatment can be of use in monitoring the ablative effects in the prostate and in assessing for tumor recurrence . More work is necessary before staging studies can uniformly characterize a prostate cancer before therapy , much less reliably identify and locate small-volume cancer within the prostate . However , exploring the role of focal ablation as a therapeutic option for selected men with low-risk , clinical ly localized , prostate cancer need not await the emergence of perfectly accurate staging studies , any more than the application of radical surgery or radiotherapy have . Modern biopsy strategies , combined with optimal imaging and nomograms to estimate the pathologic stage and risk , taken together , provide a sound basis for the selection of appropriate patients for entry into prospect i ve clinical trials of focal therapy Background : The European Society of Urogenital Radiology has built the Prostate Imaging Reporting and Data System ( PI-RADS ) for st and ardizing the diagnosis of prostate cancer ( PCa ) . This study evaluated the PI-RADS diagnosis method in patients with prostate-specific antigen ( PSA ) < 20 ng/ml . Methods : A total of 133 patients with PSA < 20 ng/ml were prospect ively recruited .  T2-weighted ( T2WI ) and diffusion-weighted ( DWI ) magnetic resonance images of the prostate were acquired before a 12-core transrectal prostate biopsy . Each patient 's peripheral zone was divided into six regions on the images ; each region corresponded to two of the 12 biopsy cores . T2WI , DWI , and T2WI + DWI scores were computed according to PI-RADS . The diagnostic accuracy of the PI-RADS score was evaluated using histopathology of prostate biopsies as the reference st and ard . Results : PCa was histologically diagnosed in 169 ( 21.2 % ) regions . Increased PI-RADS score correlated positively with increased cancer detection rate . The cancer detection rate for scores 1 to 5 was 2.8 % , 15.0 % , 34.6 % , 52.6 % , and 88.9 % , respectively , using T2WI and 12.0 % , 20.2 % , 48.0 % , 85.7 % , and 93.3 % , respectively , using DWI . For T2WI + DWI , the cancer detection rate was 1.5 % ( score 2 ) , 13.5 % ( scores 3–4 ) , 41.3 % ( scores 5–6 ) , 75.9 % ( scores 7–8 ) , and 92.3 % ( scores 9–10 ) . The area under the curve for cancer detection was 0.700 ( T2WI ) , 0.735 ( DWI ) and 0.749 ( T2WI + DWI ) . The sensitivity and specificity were 53.8 % and 89.2 % , respectively , when using scores 5–6 as the cutoff value for T2WI + DWI . Conclusions : The PI-RADS score correlates with the PCa detection rate in patients with PSA < 20 ng/ml . The summed score of T2WI + DWI has the highest accuracy in detection of PCa . However , the sensitivity should be further improved Purpose : To evaluate multiparametric magnetic resonance imaging/transrectal ultrasound ( mpMRI/TRUS ) fusion targeted biopsy ( TB ) of the prostate for prostate cancer ( PCa ) diagnosis . Patients and Methods : From April 2013 to January 2014 , 53 men were included in this prospect i ve single-centre study . The degree of PCa suspicion from mpMRI findings was classified according to the PI-RADS scoring system . Of these , 50 patients underwent both an mpMRI/TRUS fusion TB and a  10-core systematic biopsy ( SB ) of  the prostate and were eligible for analysis . Results : 225 targeted and 500 systematic cores were included in this study . PCa was histologically confirmed in 52.0 % of patients ( 26/50 ) , whereas TB revealed PCa in 46.0 % ( 23/50 ) and SB in 36.0 % ( 18/50 ) . TB identified PCa in 16.0 % of all patients ( 8/50 ) that were missed by SB . All told , the targeted core was 2.8 times more likely to be PCa-positive than the systematic core ( 29.3 vs. 10.4 % ) . Conclusions : mpMRI/TRUS fusion TB of the prostate is safe , practicable and may improve PCa diagnosis using fewer biopsy cores compared to SB 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 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 High-intensity focused ultrasound ( HIFU ) is an emerging treatment for select patients with localized prostate cancer ( PCa ) . OBJECTIVES To report the oncologic outcome of HIFU as a primary care option for localized prostate cancer from a multicenter data base . DESIGN , SETTING , AND PARTICIPANTS Patients with localized PCa treated with curative intent and presenting at least a 2-yr follow-up from February 1993 were considered in this study . Previously irradiated patients were excluded from this analysis . In case of any residual or recurrent PCa , patients were systematic ally offered a second session . Kaplan-Meier analysis was performed to determine disease-free survival rates ( DFSR ) . MEASUREMENTS Prostate-specific antigen ( PSA ) , clinical stage , and pathologic results were measured pre- and post-HIFU . RESULTS AND LIMITATIONS A total of 803 patients from six urologic departments met the inclusion criteria . Stratification according to d'Amico 's risk group was low , intermediate , and high in 40.2 % , 46.3 % , and 13.5 % of patients , respectively . Mean follow-up was 42+/-33 mo . Mean PSA nadir was 1.0+/-2.8 ng/ml with 54.3 % reaching a nadir of < or = 0.3 ng/ml . Control biopsies were negative in 85 % of cases . The overall and cancer-specific survival rates at 8 yr were 89 % and 99 % , respectively . The metastasis-free survival rate at 8 yr was 97 % . Initial PSA value and Gleason score value significantly influence the DFSR . The 5- and 7-yr biochemical-free survival rates ( Phoenix criteria ) were 83 - 75 % , 72 - 63 % , and 68 - 62 % ( p=0.03 ) and the additional treatment-free survival rates were 84 - 79 % , 68 - 61 % , and 52 - 54 % ( p<0.001 ) for low- , intermediate- , and high-risk patients , respectively . PSA nadir was a major predictive factor for HIFU success : negative biopsies , stable PSA , and no additional therapy . CONCLUSIONS Local control and DFSR achieved with HIFU were similar to those expected with conformal external-beam radiation therapy ( EBRT ) . The excellent cancer-specific survival rate is also explained by the possibility to repeat HIFU and use salvage EBRT PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to the ASCO membership after publication or presentation of potentially practice -changing data from major studies . This PCO addresses the role of prostate-specific antigen ( PSA ) testing in the screening of men for prostate cancer . CLINICAL CONTEXT Prostate cancer is the second leading cause of cancer deaths among men in the United States . The rationale for screening men for prostate cancer is the potential to reduce the risk of death through early detection . RECENT DATA Evidence from a 2011 Agency for Healthcare Research and Quality systematic review primarily informs this PCO on the benefits and harms of PSA-based screening . An up date search was conducted to March 16 , 2012 , for additional evidence related to the topic . RESULTS In one r and omized trial ,  PSA testing in men who would not otherwise have been screened result ed in reduced death rates from prostate cancer , but it is uncertain whether the size of the effect was worth the harms associated with screening and subsequent unnecessary treatment . Although there are limitations to the existing data , there is evidence to suggest that men with longer life expectancy may benefit from PSA testing . Adverse events associated with prostate biopsy are low for the majority of men ; however , several population -based studies have shown increasing rates of infectious complications after prostate biopsy , which is a concern BACKGROUND There is growing interest to implement multiparametric magnetic resonance imaging ( mpMRI ) and MR-guided biopsy ( MRGB ) for biopsy-naïve men with suspected prostate cancer . OBJECTIVE Primary objective was to compare and evaluate an MRI pathway and a transrectal ultrasound-guided biopsy ( TRUSGB ) pathway in biopsy-naïve men with prostate-specific antigen levels of ≥3ng/ml . DESIGN , SETTING , AND POPULATION A prospect i ve , multicenter , powered , comparative effectiveness study included 626 biopsy-naïve patients ( from February 2015 to February 2018 ) . INTERVENTION All patients underwent prebiopsy mpMRI followed by systematic TRUSGB .  Men with suspicious lesions on mpMRI also underwent  MRGB  prior to TRUSGB . MRGB was performed using the in-bore approach . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinical ly significant prostate cancer ( csPCa ) was defined as grade group ≥2 ( Gleason score ≥3 + 4 ) in any core . The main secondary objectives were the number of men who could avoid biopsy after nonsuspicious mpMRI , the number of biopsy cores taken , and oncologic follow-up . Differences in proportions were tested using McNemar 's test with adjusted Wald confidence intervals for differences of proportions with matched pairs . RESULTS AND LIMITATIONS The MRI pathway detected csPCa in 159/626 ( 25 % ) patients and insignificant prostate cancer ( insignPCa ) in 88/626 patients ( 14 % ) . TRUSGB detected csPCa in 146/626 patients ( 23 % ) and insignPCa in 155/626 patients ( 25 % ) . Relative sensitivity of the MRI pathway versus the TRUSGB pathway was 1.09 for csPCa ( p=0.17 ) and 0.57 for insignPCa ( p<0.0001 ) . The total number of biopsy cores reduced from 7512 to 849 ( -89 % ) . The MRI pathway enabled biopsy avoidance in 309/626 ( 49 % ) patients due to nonsuspicious mpMRI . Immediate TRUSGB detected csPCa in only 3 % ( 10/309 ) of these patients , increasing to 4 % ( 13/309 ) with 1-yr follow-up . At the same time , TRUSGB would overdetect insignPCa in 20 % ( 63/309 ) . " Focal saturation " by four additional perilesional cores to MRGB improved the detection of csPCa in 21/317 ( 7 % ) patients . Compared with the literature , our proportion of nonsuspicious mpMRI cases is significantly higher ( 27 - 36 % vs 49 % ) and that of equivocal cases is lower ( 15 - 28 % vs 6 % ) . This is probably due to the high- quality st and ard in this study . Therefore , a limitation is the duplication of these results in less experienced centers . CONCLUSIONS In biopsy-naïve men , the MRI pathway compared with the TRUSGB pathway results in an identical detection rate of csPCa , with significantly fewer insignPCa cases . In this high- quality st and ard study , almost half of men have nonsuspicious MRI , which is higher compared with other studies . Not performing TRUS biopsy is at the cost of missing csPCa only in 4 % . PATIENT SUMMARY We compared magnetic resonance imaging ( MRI ) with MRI-guided biopsy against st and ard transrectal ultrasound biopsy for the diagnosis of prostate cancer in biopsy-naïve men . Our results show that patients can benefit from MRI because biopsy may be omitted in half of men , and fewer indolent cancers are detected , without compromising the detection of harmful disease . Men also need fewer needles to make a diagnosis BACKGROUND The Prostate CAncer gene 3 ( PCA3 ) assay has shown promise as an aid in prostate cancer ( pCA ) diagnosis in identifying men with a high probability of a positive ( repeat ) biopsy . OBJECTIVE This study evaluated the clinical utility of the PROGENSA PCA3 assay . DESIGN , SETTING , AND PARTICIPANTS This European prospect i ve , multicentre study enrolled men with one or two negative biopsies scheduled for repeat biopsy . MEASUREMENTS After digital rectal examination ( DRE ) , first-catch urine was collected to measure PCA3 mRNA concentration and to calculate the PCA3 score . The PCA3 score was compared to biopsy outcome . The diagnostic accuracy of the PCA3 assay was compared to percent of free prostate-specific antigen ( % fPSA ) . RESULTS AND LIMITATIONS In 463 men , the positive repeat biopsy rate was 28 % . The higher the PCA3 score , the greater the probability of a positive repeat biopsy . The PCA3 score ( cut-off of 35 ) had a greater diagnostic accuracy than % fPSA ( cut-off of 25 % ) . The PCA3 score was independent of the number of previous biopsies , age , prostate volume , and total prostate-specific antigen ( PSA ) level . Moreover , the PCA3 score was significantly higher in men with high- grade prostate intraepithelial neoplasia ( HGPIN ) versus those without HGPIN , clinical stage T2 versus T1 , Gleason score > or=7 versus < 7 , and " significant " versus " indolent " ( clinical stage T1c , PSA density [ PSAD ] < 0.15ng/ml , Gleason score in biopsy < or=6 , and percent positive cores < or=33 % ) pCA . CONCLUSIONS The probability of a positive repeat biopsy increases with rising PCA3 scores . The PCA3 score was superior to % fPSA for predicting repeat prostate biopsy outcome and may be indicative of clinical stage and significance of pCa
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 .