MRI can identify suspicious lesions, providing the semi-quantitative risk of csPCa through the Prostate Imaging-Report and Data System (PI-RADS). Predictive models of clinical variables that individualise the risk of csPCa have been developed by adding PI-RADS score (MRI-PMs). Our objective is to analyse the current developed MRI-PMs and define their clinical usefulness. A systematic review was performed after a literature search performed by two independent investigators in PubMed, Cochrane, and Web of Science databases, with the Medical Subjects Headings (MESH): predictive model, nomogram, risk model, magnetic resonance imaging, PI-RADS, prostate cancer, and prostate biopsy. This review was made following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and studied eligibility based on the Participants, Intervention, Comparator, and Outcomes (PICO) strategy. Among 723 initial identified registers, 18 studies were finally selected. Warp analysis of selected studies was performed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Clinical predictors in addition to the PI-RADS score in developed MRI-PMs were age, PCa family history, digital rectal examination, biopsy status (initial vs. repeat), ethnicity, serum PSA, prostate volume measured by MRI, or calculated PSA density. All MRI-PMs improved the prediction of csPCa made by clinical predictors or imaging alone and achieved most areas under the curve between 0.78 and 0.92. Among 18 developed MRI-PMs, 7 had any external validation, and two RCs were available. The updated PI-RADS version 2 was exclusively used in 11 MRI-PMs. The performance of MRI-PMs according to PI-RADS was only analysed in a single study. We conclude that MRI-PMs improve the selection of candidates for prostate biopsy beyond the PI-RADS category. However, few developed MRI-PMs meet the appropriate requirements in routine clinical practice.

The correct identification of extracapsular extension (ECE) of prostate cancer (PCa) on multiparametric magnetic resonance imaging (mpMRI) is crucial for surgeons in order to plan the nerve-sparing approach in radical prostatectomy. Nerve-sparing strategies allow for better outcomes in preserving erectile function and urinary continence, notwithstanding this can be penalized with worse oncologic results. The aim of this study was to assess the ability of preoperative mpMRI to predict ECE in the final prostatic specimen (PS) and identify other possible preoperative predictive factors of ECE as a secondary end-point. We investigated a database of two high-volume hospitals to identify men who underwent a prostate biopsy with a pre-biopsy mpMRI and a subsequent RP. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of mpMRI in predicting ECE were calculated. A univariate analysis was performed to find the association between image staging and pathological staging. A multivariate logistic regression was performed to investigate other preoperative predictive factors. A total of 1147 patients were selected, and 203 out of the 1147 (17.7%) patients were classified as ECE according to the mpMRI. ECE was reported by pathologists in 279 out of the 1147 PS (24.3%). The PPV was 0.58, the NPV was 0.72, the sensitivity was 0.32, and the specificity was 0.88. The multivariate analysis found that PSA (OR 1.057, C.I. 95%, 1.016–1.100, p = 0.006), digital rectal examination (OR 0.567, C.I. 95%, 0.417–0.770, p = 0.0001), ratio of positive cores (OR 9.687, C.I. 95%, 3.744–25.006, p = 0.0001), and biopsy grade in prostate biopsy (OR 1.394, C.I. 95%, 1.025–1.612, p = 0.0001) were independent factors of ECE. The mpMRI has a great ability to exclude ECE, notwithstanding that low sensitivity is still an important limitation of the technique.

Pelvic lymph node dissection (PLND) is the most accurate procedure for lymph node (LN) staging in prostate cancer (PCa) patients. LN sectioning and hematoxylin and eosin (H&E) staining of at least one slice remains the gold standard for LN evaluation, potentially leading to misdetection of small metastatic focus. Entire LN analysis is possible with One-Step Nucleic Acid Amplification (OSNA) by detecting cytokeratin 19 (CK19) mRNA as a surrogate for LN invasion. This study aimed to compare postoperative performance of OSNA pooling with conventional H&E staining for pathological LN detection in PCa patients. POPCORN was an observational, prospective, and multicenter study of patients with PCa who underwent PLND. Dissected LNs were analyzed by both methods. This study included 2503 LNs from 131 patients, showing no statistically significant differences in pathological LN detection. Concordance between methods was high (93.9%), as were specificity (96.6%) and negative predictive value (96.6%) of OSNA pooling. The measure of agreement (Cohen’s Kappa [κ]) was 0.70. Only eight (6.1%) discordances were observed, including four misdetections from each method. Results showed a high concordance between OSNA pooling and H&E staining, suggesting that OSNA pooling may be a good alternative to H&E staining to detect LN metastases in PCa patients.

Background: Active surveillance (AS) is increasingly considered for selected patients with International Society of Urological Pathology (ISUP) Grade Group (GG) 2 prostate cancer. However, candidate selection remains controversial due to histological heterogeneity and the risk of harboring adverse pathology (AP). We aimed to identify preoperative clinical, multiparametric magnetic resonance imaging (mpMRI), and histological predictors of AP, biochemical recurrence (BCR), and postoperative PSMA PET/CT positivity in men with biopsy-confirmed ISUP GG 2 disease undergoing robotic-assisted radical prostatectomy (RARP). Methods: We retrospectively analyzed 127 consecutive patients with biopsy-proven ISUP GG 2 prostate adenocarcinoma from a prospective single-center RARP database (2012–2024). All patients underwent pre-biopsy 3T mpMRI and systematic plus software-fusion targeted biopsies, with diagnostic specimens strictly lacking cribriform architecture or intraductal carcinoma. AP was defined as pathological stage ≥ pT3 and/or ISUP GG upgrading to ≥3 in the final surgical specimen. BCR was defined as two consecutive postoperative PSA measurements ≥ 0.2 ng/mL. Patients with BCR underwent PSMA PET/CT restaging. Univariable and multivariable logistic regression analyses evaluated independent preoperative predictors of AP, incorporating separate models for ≥10% and ≥15 biopsy Gleason pattern 4 thresholds to prevent collinearity. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and Hosmer–Lemeshow calibration tests. Results: Median patient age was 63.2 years, median PSA was 7.6 ng/mL, and median PSA density (PSAD) was 0.18 ng/mL. PI-RADS ≥ 4 lesions were identified in 71.6% of patients, and median biopsy pattern 4 proportion was 21.1%. Overall, AP occurred in 39 of 127 patients (30.7%), driven by ISUP upgrading to GG ≥ 3 in 21.3% (n = 27) and upstaging to ≥pT3 in 17.3% (n = 22). No undergrading was observed. On univariable analysis, PSA (p = 0.028), PSAD (p = 0.011), and biopsy pattern 4 proportion ≥ 10% (p = 0.042) and ≥15% (p = 0.027) were significantly associated with AP. On multivariable analysis, PSAD (OR 6.75, 95% CI 3.51–12.87, p = 0.005) and biopsy pattern 4 proportion ≥ 10% (OR 2.54, 95% CI 1.15–6.54, p = 0.036) or ≥15% (OR 2.74, 95% CI 1.06–6.06, p = 0.023) remained independent predictors of AP. The final multivariable model demonstrated solid discrimination (AUC = 0.78, 95% CI 0.71–0.85) and satisfactory calibration (p = 0.42). At a mean follow-up of 32.3 months, BCR occurred in 23 patients (18.1%; 3-year recurrence-free survival: 81.3%). Restaging PSMA PET/CT was positive in 8 of 23 recurrences (34.8%; three local, four regional nodal, one solitary bone). Neither clinical nor radiological parameters independently predicted BCR or PSMA PET/CT positivity. Conclusions: Biopsy Gleason pattern 4 extent (<10% and <15%) and PSAD are the strongest independent preoperative predictors of organ-confined, non-upgraded pathology in ISUP GG 2 prostate cancer. Combining a low pattern 4 burden (<10%, or up to 15% in highly selected cases) with a low PSAD provides objective parameters to refine “favorable intermediate-risk” stratification by identifying patients with a lower probability of adverse pathological features.