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This study is a multi-center RCT to compare the clinically significant prostate cancer (csPCa) detection and/or change in clinical management in MRI guided (MRI arm) biopsy and MRI+18F-PSMA guided (Combined arm) biopsies in men with equivocal MRI prostate scans. If additional clinical value is shown by adding 18F-PSMA PET to equivocal MRI, then this should be the new standard of care.
The investigators propose to conduct a phase III multi-center randomised controlled trial to evaluate the detection of clinically significant prostate cancer (csPCa) by MRI-guided biopsy approach (MRI arm) versus MRI+PSMA approach (COMBINED arm). Clinically significant prostate cancer (csPCa) is defined as prostate cancer classified as ISUP (International Society of Urogenital Pathology) Grade group 2 or higher. Patients with clinical suspicion of prostate cancer on MRI with PI-RADS (Prostate Imaging-Reporting and Data System, version 2.1) score 2 with red flag (PSA density >0.2 OR Prostate health index, PHI>35), PI-RADS 3, or PI-RADS 4 (and PSAd <0.1 OR PHI<35) will be randomised in a 1:1 manner to MRI arm or COMBINED arm. The detection rates of csPCa will be compared between arms. The study hypothesis is that COMBINED arm is superior to MRI arm in detecting csPCa and changing clinical management.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| COMBINED arm | Experimental | In the COMBINED arm, additional pelvis-only 18F-PSMA-1007 PET-CT is performed within 6 months from mpMRI and before biopsy. Nuclear Medicine specialist interpreting PET-CT is blinded to clinical or MRI information. |
|
| MRI arm | Active Comparator | In the MRI arm, MRI-guided biopsy plus more than 12-core systematic biopsy will be performed. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| MRI+PSMA-guided approach | Procedure | MRI+PSMA-guided approach prostate biopsy |
| |
| Measure | Description | Time Frame |
|---|---|---|
| Proportion of men with clinically significant Prostate cancer (csPCa) | ISUP Grade 2 or above prostate cancer diagnosed on biopsy | When histology results available, at an expected average of 30 days post-biopsy |
| Proportion of men with additional csPCa detected only in PET targets which will affect clinical management | Determined by an independent and blinded panel with 3 urologists, including:
| When histology results available, at an expected average of 30 days post-biopsy |
| Measure | Description | Time Frame |
|---|---|---|
| Proportion of men with csPCa detected in targeted and systematic biopsy | ISUP Grade 2 or above prostate cancer diagnosed on biopsy | When histology results available, at an expected average of 30 days post-biopsy |
| Proportion of men with diagnosis of clinically insignificant prostate cancer |
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Inclusion Criteria:
Men ≥18 years of age
Serum Prostate-specific antigen (PSA) 4-15 ng/mL, repeated at least once
Prostate mpMRI done within 6 months
MRI prostate with PI-RADS (11) scores of:
Normal Digital rectal examination
Patient agrees for targeted and systematic prostate biopsy
Exclusion Criteria:
Male
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Peter Ka-Fung CHIU | Contact | 35052625 | peterchiu@surgery.cuhk.edu.hk |
| Name | Affiliation | Role |
|---|---|---|
| Peter Ka-Fung CHIU | Chinese University of Hong Kong | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Prince of Wales Hospital | Hong Kong | Hong Kong |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 25201460 | Background | Chiu PK, Teoh JY, Chan SY, Chu PS, Man CW, Hou SM, Ng CF. Role of PSA density in diagnosis of prostate cancer in obese men. Int Urol Nephrol. 2014 Dec;46(12):2251-4. doi: 10.1007/s11255-014-0826-7. Epub 2014 Sep 9. | |
| 27617315 | Background | Chiu PK, Teoh JY, Lee WM, Yee CH, Chan ES, Hou SM, Ng CF. Extended use of Prostate Health Index and percentage of [-2]pro-prostate-specific antigen in Chinese men with prostate specific antigen 10-20 ng/mL and normal digital rectal examination. Investig Clin Urol. 2016 Sep;57(5):336-42. doi: 10.4111/icu.2016.57.5.336. Epub 2016 Aug 31. |
| Label | URL |
|---|---|
| Hong Kong Cancer Statistics. | View source |
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| ID | Term |
|---|---|
| D011471 | Prostatic Neoplasms |
| ID | Term |
|---|---|
| D005834 | Genital Neoplasms, Male |
| D014565 | Urogenital Neoplasms |
| D009371 | Neoplasms by Site |
| D009369 | Neoplasms |
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| MRI-guided approach |
| Procedure |
MRI-guided approach prostate biopsy |
|
ISUP grade group 1 Prostate cancer diagnosed on biopsy |
| When histology results available, at an expected average of 30 days post-biopsy |
| Proportion of men in combined arm with negative PET who could avoid a biopsy | When PET results available, at an expected average of 7 days post-scan |
| Correlation Between PET SUVmax of Targeted Lesion and Histologically Confirmed Clinically Significant Prostate Cancer (csPCa) | This outcome will quantify the correlation between:
| When histology results available, at an expected average of 30 days post-biopsy |
| Proportion of men with post-biopsy adverse events within 30 days after biopsy | The severity of Adverse event is grade by Clavien-Dindo classification | 30 days post biopsy |
| Health-related Quality of life scores | Health-related quality of life will be assessed using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire. This instrument includes:
| Assessed at baseline and at 30 days after intervention |
| 27349564 | Background | Chiu PK, Roobol MJ, Teoh JY, Lee WM, Yip SY, Hou SM, Bangma CH, Ng CF. Prostate health index (PHI) and prostate-specific antigen (PSA) predictive models for prostate cancer in the Chinese population and the role of digital rectal examination-estimated prostate volume. Int Urol Nephrol. 2016 Oct;48(10):1631-7. doi: 10.1007/s11255-016-1350-8. Epub 2016 Jun 27. |
| 23104005 | Background | Gudmundsson J, Sulem P, Gudbjartsson DF, Masson G, Agnarsson BA, Benediktsdottir KR, Sigurdsson A, Magnusson OT, Gudjonsson SA, Magnusdottir DN, Johannsdottir H, Helgadottir HT, Stacey SN, Jonasdottir A, Olafsdottir SB, Thorleifsson G, Jonasson JG, Tryggvadottir L, Navarrete S, Fuertes F, Helfand BT, Hu Q, Csiki IE, Mates IN, Jinga V, Aben KK, van Oort IM, Vermeulen SH, Donovan JL, Hamdy FC, Ng CF, Chiu PK, Lau KM, Ng MC, Gulcher JR, Kong A, Catalona WJ, Mayordomo JI, Einarsson GV, Barkardottir RB, Jonsson E, Mates D, Neal DE, Kiemeney LA, Thorsteinsdottir U, Rafnar T, Stefansson K. A study based on whole-genome sequencing yields a rare variant at 8q24 associated with prostate cancer. Nat Genet. 2012 Dec;44(12):1326-9. doi: 10.1038/ng.2437. Epub 2012 Oct 28. |
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| 37924154 | Background | Luo L, Zheng A, Chang R, Li Y, Gao J, Wang Z, Duan X. Evaluating the value of 18F-PSMA-1007 PET/CT in the detection and identification of prostate cancer using histopathology as the standard. Cancer Imaging. 2023 Nov 3;23(1):108. doi: 10.1186/s40644-023-00627-x. |
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| 38771185 | Background | Prive BM, Israel B, Janssen MJR, van der Leest MMG, de Rooij M, van Ipenburg JA, Jonker M, Peters SMB, de Groot M, Zamecnik P, Hoepping A, Bomers JG, Gotthardt M, Sedelaar JPM, Barentsz JO, van Oort IM, Nagarajah J. Multiparametric MRI and 18F-PSMA-1007 PET/CT for the Detection of Clinically Significant Prostate Cancer. Radiology. 2024 May;311(2):e231879. doi: 10.1148/radiol.231879. |
| 34463555 | Background | Margel D, Bernstine H, Groshar D, Ber Y, Nezrit O, Segal N, Yakimov M, Baniel J, Domachevsky L. Diagnostic Performance of 68Ga Prostate-specific Membrane Antigen PET/MRI Compared with Multiparametric MRI for Detecting Clinically Significant Prostate Cancer. Radiology. 2021 Nov;301(2):379-386. doi: 10.1148/radiol.2021204093. Epub 2021 Aug 31. |
| 38061976 | Background | Buteau JP, Moon D, Fahey MT, Roberts MJ, Thompson J, Murphy DG, Papa N, Mitchell C, De Abreu Lourenco R, Dhillon HM, Kasivisvanathan V, Francis RJ, Stricker P, Agrawal S, O'Brien J, McVey A, Sharma G, Levy S, Ayati N, Nguyen A, Lee SF, Pattison DA, Sivaratnam D, Frydenberg M, Du Y, Titus J, Lee ST, Ischia J, Jack G, Hofman MS, Emmett L. Clinical Trial Protocol for PRIMARY2: A Multicentre, Phase 3, Randomised Controlled Trial Investigating the Additive Diagnostic Value of [68Ga]Ga-PSMA-11 Positron Emission Tomography/Computed Tomography in Men with Negative or Equivocal Multiparametric Magnetic Resonance Imaging for the Diagnosis of Clinically Significant Prostate Cancer. Eur Urol Oncol. 2024 Jun;7(3):544-552. doi: 10.1016/j.euo.2023.11.008. Epub 2023 Dec 6. |
| 34465492 | Background | Emmett L, Buteau J, Papa N, Moon D, Thompson J, Roberts MJ, Rasiah K, Pattison DA, Yaxley J, Thomas P, Hutton AC, Agrawal S, Amin A, Blazevski A, Chalasani V, Ho B, Nguyen A, Liu V, Lee J, Sheehan-Dare G, Kooner R, Coughlin G, Chan L, Cusick T, Namdarian B, Kapoor J, Alghazo O, Woo HH, Lawrentschuk N, Murphy D, Hofman MS, Stricker P. The Additive Diagnostic Value of Prostate-specific Membrane Antigen Positron Emission Tomography Computed Tomography to Multiparametric Magnetic Resonance Imaging Triage in the Diagnosis of Prostate Cancer (PRIMARY): A Prospective Multicentre Study. Eur Urol. 2021 Dec;80(6):682-689. doi: 10.1016/j.eururo.2021.08.002. Epub 2021 Aug 28. |
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| 31184561 | Background | Padhani AR, Barentsz J, Villeirs G, Rosenkrantz AB, Margolis DJ, Turkbey B, Thoeny HC, Cornud F, Haider MA, Macura KJ, Tempany CM, Verma S, Weinreb JC. PI-RADS Steering Committee: The PI-RADS Multiparametric MRI and MRI-directed Biopsy Pathway. Radiology. 2019 Aug;292(2):464-474. doi: 10.1148/radiol.2019182946. Epub 2019 Jun 11. |
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| 30082150 | Background | Alberts AR, Roobol MJ, Verbeek JFM, Schoots IG, Chiu PK, Osses DF, Tijsterman JD, Beerlage HP, Mannaerts CK, Schimmoller L, Albers P, Arsov C. Prediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators. Eur Urol. 2019 Feb;75(2):310-318. doi: 10.1016/j.eururo.2018.07.031. Epub 2018 Aug 3. |
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| D005832 |
| Genital Diseases, Male |
| D000091662 | Genital Diseases |
| D000091642 | Urogenital Diseases |
| D011469 | Prostatic Diseases |
| D052801 | Male Urogenital Diseases |