Evaluating the Role of PIRADS V2  and TRUSgBX for Improving Detection of Clinically Significant Prostate Cancer at Radical Prostatectomy
Alireza Ziaei1, Francesco Alessandrino1,2, Mark Vangel3, Tina Kapur1, Clare Mary Tempany1, and Fiona Mary Fennessy1,2

1Dept. of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States, 2Dept. of Imaging, Dana–Farber Cancer Institute, Boston, MA, United States, 3Dept. of Radiology, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, United States


The aim of this retrospective study was to determine a role for PIRADS V2 in conjunction with TRUSgBX to predict the presence of clinically significant prostate cancer (csPCa) in treatment naïve men with pathology-proven prostate cancer who underwent TRUSgBX, followed by 3T mp-MRI prostate, and subsequently underwent RP. Our findings suggest that adding PIRADS V2 assessment to TRUSgBX improves the prediction of final pathology for presence of indolent disease and csPCa, and may help alleviate the rate of upgrading at RP.


Transrectal ultrasound guided prostate biopsy (TRUSgBX) is a common diagnostic test for prostate cancer (PCa), which is known to have significant limitations [1-4]. Multiparametric MRI (mp-MRI) guided target biopsy methods have been shown to out-perform TRUSgBX for detection and diagnosis of clinically significant PCa (csPCa) [5-7], defined as presence of Gleason pattern > 4 and/or tumor volume> 0.5 ccs, and to reduce detection of indolent cancers [8]. We sought to determine the role of PIRADS V2 in conjunction with TRUSgBX to predict presence of csPCa.


This study was an IRB approved, HIPAA compliant, retrospective study of treatment naïve men with pathology-proven PCa who underwent TRUSgBX, followed by 3T mp-MRI prostate, and subsequently underwent radical prostatectomy (RP) within 6 months of mp-MRI. A PIRADS V2 assessment category was assigned by a radiologist blinded to all pathology. For this study we defined a positive score of 4 or 5 as indicating csPCa. PIRADS V2 assessment for csPCa and TRUSgBX pathology were compared to reference RP pathology. The statistical tests were performed using the SPSS 15.0 (SPSS Inc., Chicago, Illinois, USA) software, with p < 0.05 signifying statistical significance.


Our cohort consisted of 208 men, with a mean age of 59±7 years, and mean PSA level of 6.7±4.6 ng/ml. The majority (94%) of patients underwent mp-MRI after TRUSgBX (1.3 months median time interval), and went to RP within 1.7 months (median time) of the mp-MRI. Final pathology documented GS ≥ 7 in 155/208 cases (74.5%). On average, there were 12 samples/patient for TRUSgBX, with mean positive core involvement of 4.3/12, range of positive core was1 to 14. Pre-operative TRUSgBX revealed 127/208 (61%) of subjects to have csPCA. Pre-operative PIRADS V2 assessment category 4/5 was reported in 156/208 (75%) cases. TRUS failed to detect csPCa in 34/208 (16.34%) cases, with subsequent upstaging to csPCa at final pathology (Table 1). There were 8/208 cases considered csPCa at TRUSgBX, who ultimately had indolent disease at final pathology. Of the 34 TRUSgBX underdiagnosed cases, 28 (82%) were correctly diagnosed as csPCa with PIRADS V2, and 6 were not identified either. Of the 8 TRUSgBX-overdiagnosed cases, 6 (75%) were correctly diagnosed as indolent with PIRADS V2. PIRADS V2 was more sensitive than TRUSgBX (86.5% vs. 77% respectively, p = 0.04) for csPCa detection. TRUSgBX was more specific than PIRADS V2 (86.7% vs. 53.3%, p < 0.001) (Table 2 and 3). TRUSgBX had a higher Positive Predictive Value (PPV) compare to PIRADS V2 (93% vs. 82% respectively). Negative Predictive Value (NPV)s for TRUSgBX and PIRADS V2 were 60% and 61% respectively.


Our study demonstrates a potential role for PIRADS V2 assessment in conjunction with TRUSgBX, for increased sensitivity in detection of both indolent and csPCa, with a potential for reduction in TRUSgBX-underdiagnosis and and overdiagnosis of csPCa. PIRADS V2 failed to detect a small number (6/34) of csPCa cases that were also not diagnosed by TRUSgBX. These findings suggest that adding PIRADS V2 assessment to TRUSgBX increases the sensitivity for csPCa detection prior to RP, and may alleviate the rate of upgrading at RP. However, this should be evaluated in a prospective clinical trial. It is important to note that our study has some inherent biases, as it focused on a surgical population of men with known PCa. As such, this selection bias increased the probability of having csPCa, which affected both the PPV and NPV.


A combination of TRUSgBX and PIRADS V2 assessment improves the prediction of final pathology for presence of indolent disease and csPCa, compared to TRUSgBX alone.


Research reported in this abstract is supported by NIH Grants No. R25CA089017 and P41EB015898.


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Table 1: Comparing Gleason score distribution based on TRUSgBX and RPP

Table 2: Sensitivity and specificity of PIRADS V2

Table 3: Sensitivity and specificity of TRUSgBX

Proc. Intl. Soc. Mag. Reson. Med. 26 (2018)