Since the inception of prostate MRI by Steyn and Smith in 1982, significant advancements have been made.1 With the advent of multiparametric MRIs, including dynamic-contrast enhanced (DCE) imaging and diffusion weighted image (DWI), 3T technology, and the PI-RADS scoring method in 2012, prostate MRIs have become a mainstay in prostate cancer counseling and treatment.2,3
Prostate MRIs not only assist with initial diagnosis with targeted biopsies via the MRI-fusion technique but also with surgical planning. An MRI can more definitively provide information on the extent of disease. A number of scoring systems have been developed to determine presence of ‘extraprostatic extension’ or EPE, but none have performed as well as the Mehralivand EPE scoring system developed in 2019.4
Upon surveying multiple academic institutions within the Northeast, we found that our institution is unique in employing this scoring system. Since its initial implementation in 2020, we have performed well over 600 prostate MRIs with EPE score.
Our study objective was two-fold: (1) to further validate the EPE score and potential surgical implications and (2) to increase exposure to the scoring system among radiologists and urologists alike. In our study, we found among patients with an EPE score of 3 on preoperative MRI, 96% were at least pT3a on post-prostatectomy pathology. On the other hand, 66% of patients with EPE score 2 were pT3a post-operatively. With further studies, we anticipate EPE score will assist surgeons in their preoperative counseling of nerve sparing approach.
Our secondary objective was to promote the EPE score as a useful tool for both radiologists and urologists. We are fortunate to work with specialty-trained radiologists who are adept at prostate MRIs. In addition, they underwent a lecture-based training on the application of EPE score. However, the benefit of the Mehralivand scoring system is its minimal learning curve allowing for swift adoption, given its use of objective measures. As for the urologist, the four-point system facilitates interpretation and can aid in pre-operative counseling. With the assistance of preoperative PSA, prostate biopsy results, and MRI EPE score, we have been better able to tailor nerve sparing approach to each individual. This is a step toward the integration of MRI-based EPE scoring system into routine clinical practice, leading to more refined and personalized approaches in prostate cancer care.
Written by:
- Utsav Bansal, MD, Division of Urology, Memorial Physicians Group, Memorial Healthcare System, Hollywood, Florida
- Angela Estevez, MD, Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Peter Chang, MD, MPH, Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Andrew Wagner, MD, Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Steyn JH, Smith FW. Nuclear magnetic resonance imaging of the prostate. Br J Urol. 1982;54(6):726-728.
- Richenberg J, Løgager V, Panebianco V, Rouviere O, Villeirs G, Schoots IG. The primacy of multiparametric MRI in men with suspected prostate cancer. Eur Radiol. 2019;29(12):6940-6952.
- Barrett T, Turkbey B, Choyke PL. PI-RADS version 2: what you need to know. Clin Radiol. 2015;70(11):1165-1176.
- Mehralivand S, Shih JH, Harmon S, et al. A grading system for the assessment of risk of extraprostatic extension of prostate cancer at multiparametric mri. Radiology. 2019;290(3):709-719.