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Computer-aided Detection of Prostate Cancer with MRI

One in six men will develop prostate cancer in his lifetime. Early detection and accurate diagnosis of the disease can improve cancer survival and reduce treatment costs. Recently, imaging of prostate cancer has greatly advanced since the introduction of multiparametric magnetic resonance imaging (mp-MRI). Mp-MRI consists of T2-weighted sequences combined with functional sequences including dynamic contrast-enhanced MRI, diffusion-weighted MRI, and magnetic resonance spectroscopy imaging. Because of the big data and variations in imaging sequences, detection can be affected by multiple factors such as observer variability and visibility and complexity of the lesions. To improve quantitative assessment of the disease, various computer-aided detection systems have been designed to help radiologists in their clinical practice. This review paper presents an overview of literatures on computer-aided detection of prostate cancer with mp-MRI, which include the technology and its applications. The aim of the survey is threefold: an introduction for those new to the field, an overview for those working in the field, and a reference for those searching for literature on a specific application.

Introduction

Prostate cancer (PCa) is currently the most common cancer in men and the second leading cause of cancer-related deaths among men in the United States . In 2015, it is estimated that the number of estimated new cases and deaths will be 220,800 and 27,540, respectively, accounting for 26.0% of new cancer cases and 8.8% of cancer deaths for American men .

The prostate is subdivided into the base, mid-gland, and apex from superior to inferior. The prostate also has four anatomic zones: the transition zone (TZ), which contains 5% of the glandular tissue and accounts for around 25% of PCa; the central zone, which contains 20% of the glandular tissue and accounts for around 5% of PCa; the peripheral zone (PZ), which contains 70–80% of the glandular tissue and accounts for about 70% of PCa; and the non-glandular anterior fibromuscular stroma. Accurate localization of PCa within the TZ or the PZ is extremely important as TZ PCa is associated with favorable pathologic features and better recurrence-free survival .

At present, the clinical standard for definitive diagnosis of PCa is transrectal ultrasound (TRUS)-guided sextant or systematic biopsy. The prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) results are considered to identify patients who need biopsy. The actual impact of magnetic resonance imaging (MRI) for PCa management is through guided biopsies and improved cancer diagnosis and staging yield. In recent years, MRI-targeted prostate biopsies have been showing better disease localization and more accurate sampling than conventional TRUS-guided biopsy in various studies . MRI-based computer-assisted sophisticated imaging for individual patients would offer such a significant role in defining an optimal targeted biopsy and interventional approach. Several approaches have been explored to improve the accuracy of image-guided targeted prostate biopsy, including in-bore MRI-guided, cognitive fusion, and MRI/TRUS fusion-guided biopsy .

MRI provides excellent soft-tissue contrast and has become an imaging modality of choice for localization of prostate tumors. Multiparametric MRI (mp-MRI) includes high-resolution T2-weighted (T2W) MRI, diffusion-weighted imaging (DWI), dynamic contrast-enhanced imaging (DCE-MR), and MR spectroscopy (MRS). The mp-MRI has proven to be an effective technique to localize high-risk PCa . The combined use of anatomic and functional information provided by the multiparametric approach increases the accuracy of MRI in detecting and staging PCa . It can also help guide biopsies to achieve a higher tumor detection rate and better reflect the true Gleason grade. The European Society of Urogenital Radiology in 2012 established the Prostate Imaging Reporting and Data System (PI-RADS) scoring system for mp-MRI of the prostate . The MR PI-RADS aims to enable consistent interpretation, communication, and reporting of prostate mp-MRI findings . A joint steering committee formed by the American College of Radiology, European Society of Urogenital Radiology, and the AdMeTech Foundation has recently announced an updated version of the proposals of PI-RADS Version 2 . Prostate mp-MRI at 3 T had been recommended in PI-RADS Version 2. Generally, computer-aided detection (CAD) systems are classified into two categories: CAD and computer-aided diagnosis (CADx) systems. Currently, most CAD systems in prostate MRI focus on local suspicious lesions and discrimination between benign and malignant lesions; most of them are CADx systems. As the combination of various MR images creates large amounts of data, supportive techniques or tools, such as CADx, are needed to make a clinical decision in a fast, effective, and reliable way.

In the past 10 years, computer-aided techniques have developed rapidly. Automated CAD and diagnosis may help improve diagnostic accuracy of PCa, and reduce interpretation variation between and within observers . PCa diagnosis requires an experienced radiologist to read prostate MRI, and such expertise is not widely available. Addition of CADx may significantly improve the performance of less-experienced observers in PCa diagnosis. When less-experienced observers used CADx, they had a similar performance as those experienced observers in distinguishing benign from malignant lesions . In a more recent study, the use of CAD can also improve prostate mp-MRI study interpretation in experienced readers . For cases in which radiologists are less confident, they can get higher performance by using the computer output. A recent study showed that a pattern recognition system enables radiologists to have a lower variability in diagnosis, decreases false-negative rates, and reduces the time to recognize and delineate structures in the prostate . The benefit of CADx also includes guiding biopsy using cancer location information from MRI . Therefore, along with rapid development of MR technique, CADx of PCa has become an active field of research in the last 5 years.

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MR Image Acquisitions

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T2WI and T2 Mapping

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Figure 1, High-resolution T2-weighted magnetic resonance imaging (MRI). T2-weighted MR images can differentiate the normal intermediate- to high-signal-intensity peripheral zone (region 1) from the low-signal-intensity central and transition zones (region 2).

Figure 2, High-resolution T2-weighted magnetic resonance (MR) images of prostate cancer. (a) There is a low-signal intensity lesion on the right peripheral zone ( white arrows ) at the mid-gland of the prostate. At prostatectomy, the lesion was classified as a Gleason grade 7 (4 + 3) prostate adenocarcinoma. (b) An ill-defined homogeneous low-signal-intensity area at the left transition zone ( white arrows ) at mid-gland of the prostate in another patient. Transrectal ultrasound (TRUS)-guided biopsy showed a Gleason grade 8 (4 + 4) prostate adenocarcinoma on the corresponding position

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DCE-MRI

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Figure 3, Dynamic contrast-enhanced magnetic resonance imaging (MRI) (dynamic contrast-enhanced imaging [DCE-MRI]) of the prostate. (a) Axial T1 gradient echo (GRE) sequence unenhanced image. After contrast agent administration, an area with early enhancement is seen on the right in the peripheral zone ( b ), region of interest [ROI1]) with significant washout in the late-phase image (c) . The curve ( red ) with early enhancement is a typical finding in the case of prostate cancer, whereas healthy prostate tissue is characterized by a steady slow enhancement ( green ). High transport constants K trans (e) and k ep (f) can confirm suspicion of prostate cancer. Prostate adenocarcinoma with a Gleason score of 4 + 5 = 9 was diagnosed after prostatectomy

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Diffusion-weighted MRI

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Figure 4, Multiparametric MRI (mp-MRI) of the prostate. Axial T2 turbo spin echo (TSE) (a) and coronal T2 TSE (b) images show a well-defined T2 hypointense lesion in the peripheral zone ( arrow ) with corresponding high signal on diffusion-weighted imaging (DWI) (c) and low signal on the apparent diffusion coefficient (ADC) map (d) . Biopsy of this region was positive for Gleason 4 + 3 prostate cancer

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MRS

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Figure 5, Magnetic resonance spectroscopy (MRS) of prostate cancer. (a) Axial T2-weighted MR images at the level of the prostate mid-gland to apex shows a large hypointense lesion on the left peripheral zone. (b) A three-dimensional (3D) MRS shows a normal spectrum on the right peripheral zone ( red box ) with normal choline plus creatine-to-citrate ratio of 0.48. In the voxel placed over the lesion on the left peripheral zone ( blue box ), the curve shows an increased choline peak and the citrate peak is markedly reduced. Random systematic biopsy showed a Gleason grade 9 (4 + 5) prostate adenocarcinoma on the left apex

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Other Imaging Methods

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MR Image Quantification Methods

General Framework

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Figure 6, Flowchart for computer-aided detection of prostate cancer in multiparametric magnetic resonance imaging (mp-MRI).

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Preprocessing

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Segmentation

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Figure 7, Prostate segmentation on magnetic resonance (MR) images. Left : Two-dimensional (2D) MR image and segmentation results where the red curve represents the segmentation from a computer algorithm, whereas the blue curve is the ground truth labeled by a radiologist. Right : Three-dimensional (3D) visualization after segmentation. The gold region is the prostate surface obtained by the computer algorithm, whereas the red region is the ground truth.

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Registration

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Feature Extraction

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Figure 8, Flowchart for a computer-aided detection (CAD) system based on a multiparametric magnetic resonance imaging (mp-MRI). The cancer probability map is the final outcome of the algorithm

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Figure 9, Image features for prostate cancer detection. (a) Prostate cancer superposed in green. (b) First-order statistics (standard deviation). (c) Sobel-Kirsch feature. (d) Second-order statistics (contrast inverse moment). (e) Corresponding time-intensity curves for CaP ( red ) and benign ( blue ) regions are shown based on dynamic contrast-enhanced imaging (DCE-MRI) data

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Classification

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Validation

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Table 1

Validation of CADx Systems

Reference Ground Truth on the Histology Candidate on MR Image Image Registration Chan et al. Biopsy MO NA Puech et al. Needle biopsy or prostatectomy MO NA Tiwari et al. Biopsy Sextant location determined by radiologist NA Vos et al. WMHS + MO MO 3D rendering mode Viswanath et al. WMHS + MO MANTRA Multimodal image registration Viswanath et al. WMHS MANTRA Multimodal image registration Vos et al. WMHS Not specified Not specified Liu et al. WMHS + MO MO + ex vivo MRI Manual Tiwari et al. WMHS + sextant boundaries A joint review session of trial imagers and pathologists NA Artan et al. WMHS + MO Tumor location is transferred to the in vivo MRI from histologic images + ex vivo MRI NA Vos et al. WMHS + MO MO Mutual information registration Viswanath et al. WMHS + MO Registration from histologic images MACMI Lopes et al. WMHS + drawn by urologists Drawn by urologists Manual correspondence Liu and Yetik WMHS + MO MO + ex vivo MRI Manual registration Sung et al. Radical prostatectomy + MO The radiologist matched the pathologic slices with corresponding MRI NA Tiwari et al. WMHS MO + ex vivo MRI Manual registration Viswanath et al. WMHS + MO Registration from histologic images Multimodal elastic registration Vos et al. Needle biopsy Combining the findings with, histopathology of MR-guided samples by radiologist. NA Niaf et al. WMHS + MO MO Manual registration Artan and Yetik WMHS + MO MO + ex vivo MRI Manual registration Shah et al. WMHS + MO Not specified PSM Matulewicz et al. WMHS + MO MO Manual registration Hambrock et al. WMHS + MO MO Manual registration Tiwari et al. WMHS + MO MO Manual registration Peng et al. WMHS MO Manual registration Ginsburg et al. WMHS + MO Registration from histologic images Nonlinear registration Stember et al. Needle biopsy Not specified NA Niaf et al. Prostatectomy + MO MO Manual registration Garcia Molina et al. Prostatectomy + MO MO Manual registration Litjens et al. Needle biopsy Not specified NA Kwak et al. Needle biopsy Determined by radiologists NA Zhao et al. Biopsy MO NA

3D, three-dimensional; CADx, computer-aided diagnosis; MACMI, multi-attribute, higher order mutual information based elastic registration scheme; MANTRA, multi-attribute, non-initializing, texture reconstruction based active shape model (ASM); MO, manual outlined regions of lesions; MR, magnetic resonance; NA, no registration was used; PSM, patient-specific molds; WMHS, whole-mount histologic sections.

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Figure 10, Registration between multiparametric magnetic resonance imaging (mp-MRI) and histology.

Figure 11, Registration between magnetic resonance imaging (MRI) and histology. Top : Workflow for pathology-multiparametric (mp)-MRI registration in a surgical three-dimensional (3D) space. Bottom : 3D deformable registration of virtual whole-mount histology (1), fresh specimen (2), T2-weighted MRI (3), perfusion (4), and diffusion (5) sequences (apparent diffusion coefficient [ADC]) applied to prostate cancer

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Clinical Applications

Diagnosis

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Table 2

Summary of Representative Studies in the Literature

Reference Modality Validation Region Classifier Data Size Performance Chan et al. T2WI, ADC, T2 Biopsy PZ SVM, FLD 15 FLD, AUC = 0.839; SVM, AUC = 0.761 Puech et al. DCE Prostatectomy PZ and TZ Software titled “ProCAD” 100 PZ, Se/Sp = 100/49%; TZ, Se/Sp = 100/40% Tiwari et al. MRS Biopsy WP Spectral clustering 14 Se = 77.8%, FP = 28.92%, and FN = 20.88% Vos et al. DCE WMHS PZ SVM 34 AUC = 0.83 Viswanath et al. DCE WMHS WP LLE and consensus clustering 6 Se = 60.72%, Sp = 83.24% Viswanath et al. T2WI, DCE WMHS WP Random forest 6 AUC = 0.815 Vos et al. DCE WMHS PZ SVM 38 AUC = 0.80 Liu et al. T2W, T2, ADC, DCE WMHS PZ Fuzzy MRF model 11 Se = 89.58%, Sp = 87.50% Tiwari et al. MRS Prostatectomy WP NLDR 18 Se = 89.33%, Sp = 79.79% Artan et al. T2, ADC, DCE Biopsy PZ Cost-sensitive CRF 21 AUC = 0.79 Vos et al. T2WI, DCE WMHS PZ SVM 29 AUC = 0.89 Viswanath et al. T2W, DWI, DCE WMHS WP EMPrAvISE 12 AUC = 0.77 Lopes et al. T2WI WMHS WP SVM, AdaBoost 17 SVM, Se/Sp = 83/91%; AdaBoost, Se/Sp = 85/93% Liu and Yetik T2W, DWI, DCE WMHS WP SVM 20 AUC = 0.89 Sung et al. DCE Prostatectomy PZ and TZ SVM 42 PZ, Se/Sp = 89/89%; TZ, Se/Sp = 91/64% Tiwari et al. T2WI, MRS WMHS WP Random forest 36 AUC = 0.89 Viswanath et al. T2WI WMHS PZ and CG QDA 22 CG, AUC = 0.86; PZ, AUC = 0.73 Vos et al. T1, T2, ADC, DCE Biopsy WP LDA 200 Se = 0.74, at an FP level of 5 per patient Niaf et al. T2W, DWI, DCE WMHS PZ SVM 30 AUC = 0.89 Artan and Yetik T2, ADC, T1-PC WMHS WP SVM 15 Se = 76%, Sp = 86% Shah et al. T2WI, ADC, DCE WMHS PZ SVM 31 f-measure = 89% Matulewicz et al. MRS WMHS WP ANN 18 AUC = 0.968 Hambrock et al. T2WI, DWI, DCE Prostatectomy PZ and TZ In-house–developed CAD system 34 Experienced observers, AUC = 0.91 Tiwari et al. T2WI, MRS WMHS WP SeSMiK-GE 29 AUC = 0.89 Peng et al. T2WI, ADC, DCE Prostatectomy WP LDA 48 AUC = 0.95 Ginsburg et al. T2WI, DWI, DCE WMHS PZ and CG PCA-VIP 108 CG, AUC = 0.85; PZ, AUC = 0.79 Stember et al. T2WI, ADC Biopsy TZ Naive Bayes classifier 18 Predicted TZ tumor in all test patients Niaf et al. T2WI, DWI, DCE Prostatectomy WP P-SVM 48 AUC = 0.889 Garcia Molina et al. T2WI, ADC, DCE Prostatectomy PZ Incremental learning ensemble SVM 12 Se = 84.4%,Sp = 78.0% Litjens et al. T2WI, DWI, DCE, PDWI Biopsy WP Random forest 347 AUC = 0.889 Kwak et al. T2WI, DWI Biopsy PZ and TZ SVM 244 AUC of 0.89 Zhao et al. T2WI Biopsy/follow-up PZ and CG ANN 71 CG, AUC = 0.821; PZ, AUC = 0.849

ADC, apparent diffusion coefficient; ANN, artificial neural network; AUC, area under a receiver operating characteristic curve; CAD, computer-aided detection; CG, central gland; CRF, conditional random fields; DCE, dynamic contrast-enhanced; EMPrAvISE, Enhanced Multi-Protocol Analysis via Intelligent Supervised Embedding; FLD, Fisher linear discriminant; FN, false negative; FP, false positive; LDA, linear discriminant analysis; LLE, locally linear embedding; MRS, magnetic resonance spectroscopy; NLDR, nonlinear dimensionality reduction; PCA, principal component analysis; PCA-VIP, variable importance on projection measure for PCA; P-SVM, probabilistic SVM; PZ, peripheral zone; QDA, quadratic discriminant analysis; Se, sensitivity; SeSMiK-GE, Semi Supervised Multi Kernel Graph Embedding; Sp, specificity; SVM, support vector machine; T1-PC, principal component of T1-weighted dynamic series; T2WI, T2-weighted imaging; TZ, transition zone; WMHS, whole-mount histologic sections; WP, whole prostate.

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Aggressiveness

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Biopsy Guidance

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Figure 12, Magnetic resonance imaging (MRI) and ultrasound fusion for targeted biopsy of the prostate. (a, b) Anterior lesion of the high suspicious lesion identified on multiparametric (mp)-MRI. (c) Real-time ultrasound targeting the corresponding lesion. (d, e) Three-dimensional (3D) models demonstrate the target ( blue ), prostate ( brown ), and biopsy cores ( tan cylinders ). (f) Radical prostatectomy pathology confirmed a 2.3 cm Gleason 8 (4 + 4) cancer centered in the right anterior prostate

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Treatment Planning and Therapeutic Response Assessment

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Discussion and Future Directions

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Conclusion

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Acknowledgments

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