Prostate Volume Estimation on MRI: Accuracy and Effects of Ellipsoid and Bullet-Shaped Measurements on PSA Density

Rationale and Objectives: PSA density (PSAd), an important decision-making parameter for patients with suspected prostate cancer (PCa), is dependent on magnetic resonance imaging prostate volume (PV) estimation. We aimed to compare the accuracy of the ellipsoid and bullet-shaped formulas with manual whole-gland segmentation as reference standard and to evaluate the corresponding PSAd diagnostic accuracy in predicting clinically significant PCa. Materials and Methods: We retrospectively analysed 195 patients with suspected PCa who underwent magnetic resonance imaging and prostate biopsy. Patients with PCa were categorized according to ISUP score. PV and corresponding PSAd were calculated with manual segmentation (mPV and mPSAd) as well as with ellipsoid (ePV and ePSAd) and bullet-shaped (bPV and bPSAd) formulas. Inter and intrareader reproducibility were assessed with Lin's concordance correlation coefficient and the intraclass correlation coefficient (ICC). A 2-way analysis of variance with post-hoc Bonferroni test was used for assessing PV differences. Predictive values of PSAd calculated with different methods for detecting clinically significant PCa were evaluated by receiver operating characteristic curve analysis and Youden's index. Results: Both intra (r = 0.99, ICC = 0.99) and inter-reader (r = 0.98, ICC = 0.98) reproducibility were excellent. No significant difference was found between ePV and reference standard (p = 1.00). bPV was significantly different from both (p = 0.00). PSAd (mPSAd/ePSAd cut-off > 0.15, bPSAd cut-off > 0.12) had sensitivity = 69-70%, specificity = 72-75%, areas under the curve = 0.757-0.760 (p = 0.70-0.88). Conclusions: Our work shows that when using bullet-shaped formula, a different PSAd cut-off must be considered to avoid PCa under diagnosis and inaccurate risk-stratification.