The use of risk assessment with MRI before biopsy and MRI-targeted biopsy was superior to standard transrectal ultrasonography-guided biopsy in men at clinical risk for prostate cancer who had not undergone biopsy previously. (Funded by the National Institute for Health Research and the European Association of Urology Research Foundation; PRECISION ClinicalTrials.gov number, NCT02380027 .).

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SummaryBackgroundRadical whole-gland therapy can lead to significant genitourinary and rectal side-effects for men with localised prostate cancer. We report on whether selective focal ablation of unifocal and multifocal cancer lesions can reduce this treatment burden.MethodsMen aged 45–80 years were eligible for this prospective development study if they had low-risk to high-risk localised prostate cancer (prostate specific antigen [PSA] ≤15 ng/mL, Gleason score ≤4 + 3, stage ≤T2), with no previous androgen deprivation or treatment for prostate cancer, and who could safely undergo multiparametric MRI and have a general anaesthetic. Patients received focal therapy using high-intensity focused ultrasound, delivered to all known cancer lesions, with a margin of normal tissue, identified on multiparametric MRI, template prostate-mapping biopsies, or both. Primary endpoints were adverse events (serious and otherwise) and urinary symptoms and erectile function assessed using patient questionnaires. Analyses were done on a per-protocol basis. This study is registered with ClinicalTrials.gov, number NCT00561314.Findings42 men were recruited between June 27, 2007, and June 30, 2010; one man died from an unrelated cause (pneumonia) 3 months after treatment and was excluded from analyses. After treatment, one man was admitted to hospital for acute urinary retention, and another had stricture interventions requiring hospital admission. Nine men (22%, 95% CI 11–38) had self-resolving, mild to moderate, intermittent dysuria (median duration 5·0 days [IQR 2·5–18·5]). Urinary debris occurred in 14 men (34%, 95% CI 20–51), with a median duration of 14·5 days (IQR 6·0–16·5). Urinary tract infection was noted in seven men (17%, 95% CI 7–32). Median overall International Index of Erectile Function-15 (IIEF-15) scores were similar at baseline and at 12 months (p=0·060), as were median IIEF-15 scores for intercourse satisfaction (p=0·454), sexual desire (p=0·644), and overall satisfaction (p=0·257). Significant deteriorations between baseline and 12 months were noted for IIEF-15 erectile (p=0·042) and orgasmic function (p=0·003). Of 35 men with good baseline function, 31 (89%, 95% CI 73–97) had erections sufficient for penetration 12 months after focal therapy. Median UCLA Expanded Prostate Cancer Index Composite (EPIC) urinary incontinence scores were similar at baseline as and 12 months (p=0·045). There was an improvement in lower urinary tract symptoms, assessed by International Prostate Symptom Score (IPSS), between baseline and 12 months (p=0·026), but the IPSS-quality of life score showed no difference between baseline and 12 months (p=0·655). All 38 men with no baseline urinary incontinence were leak-free and pad-free by 9 months. All 40 men pad-free at baseline were pad-free by 3 months and maintained pad-free continence at 12 months. No significant difference was reported in median Trial Outcomes Index scores between baseline and 12 months (p=0·113) but significant improvement was shown in median Functional Assessment of Canc...

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| The current diagnostic pathway for prostate cancer has resulted in 19 overdiagnosis and consequent overtreatment as well underdiagnosis and 20 missed diagnoses in many men. Multiparametric MRI (mpMRI) of the 21 prostate has been identified as a test that could mitigate these diagnostic 22This Review, will describe the current status of the role of mpMRI in 86 prostate cancer diagnosis, starting with the basic principles of MRI, and its 87 clinical application and finally considering the future direction of this 88 technology in prostate cancer. 89 90[H1] Basics of multiparametric MRI 91 [H2] Principles and sequences 92When mpMRI was first considered for prostate cancer diagnosis, in 93 the middle 1980s, its use was focused on to T1-weighted and T2-weighted 94 sequences 23 . The rapid improvement of mpMRI technology has led to the 95 addition of further sequences such as diffusion-weighted imaging (DWI), 96 dynamic contrast-enhanced imaging (DCEI) (Fig 1, 2), and/or magnetic 97 resonance spectroscopy imaging (MRSI) 23 (Fig 2, 3). These advances 98 resulted in a multitude of contrast mechanisms that can be considered 99 together for improved diagnostic accuracy for prostate cancer 24 . 100 101[H3] T1-weighted imaging 102 T1-weighted imaging is used mainly for evaluation of regional lymph 103 nodes and bone structures 25 . In the context of prostate evaluation, its utility 104 is the ability to detect biopsy-related haemorrhage that can obscure or mimic 105 cancers 26 . In order to reduce postbiopsy artifacts, a delay of at least 6-8 106 weeks after biopsy is typically recommended. Currently, no consensus exists 107 concerning this clinical practice, indeed haemorrhage artifacts can still 108 persist beyond this time period. 25 . This sequence is of limited value for 109 detection of prostate cancer foci as presence of prostate cancer is not 110 associated with notableT1-weighted imaging changes 21 . 111 7 112[H3] T2-weighted imaging 113 T2-weighted imaging is a fundamental sequence in mpMRI of the 114 prostate, providing a highly defined anatomical image of the zonal 115 architecture of the prostate gland with excellent soft-tissue contrast 27 (Fig 4). 116 T2-weighted imaging reflects the water content of the tissue, which is related 117 to the cellularity 21 . 118In the normal prostate, the peripheral zonethe part of the prostate 119 present at birthappears homogeneously hyperintense on T2-weighted 120 imaging owing to its high glandular ductal tissue content 21 . Prostate cancer 121 is characterized by high cellularity and low water content and, therefore, will 122 appear hypointense on imaging 21 (Fig 2Aa, 2Ba). The decrease in intensity 123 is positively associated with the aggressiveness of cancer 28 . The transition 124 zone, which starts to form after puberty through the process of prostatic 125 epithelial and stromal hyperplasia, tends to exhibit high cellular density, and 126 appears heterogeneously hypointense 25 . For this reason, and because there is 127 no nonmalignant prostate against which to refe...