Predicting extracapsular involvement in prostate cancer through the tumor contact length and the apparent diffusion coefficient

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A) Imagen axial en T2, en la cual la línea roja representa la medición de la longitud del contacto tumoral con la cápsula, que es de 26,5mm. B) Imagen axial del mapa de coeficiente de difusión aparente (b 800) con un valor de 0,798×10−3 mm2/s. Esta lesión presentó extensión extracapsular microscópica en el análisis de patología." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.F. Granja, C.M. Pedraza, D.C. Flórez, J.A. Romero, M.A. Palau, D.A. Aguirre" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M.F." "apellidos" => "Granja" ] 1 => array:2 [ "nombre" => "C.M." "apellidos" => "Pedraza" ] 2 => array:2 [ "nombre" => "D.C." "apellidos" => "Flórez" ] 3 => array:2 [ "nombre" => "J.A." "apellidos" => "Romero" ] 4 => array:2 [ "nombre" => "M.A." "apellidos" => "Palau" ] 5 => array:2 [ "nombre" => "D.A." 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(A) Significant stenosis (70 per cent of the vein reference diameter) of 15mm in length in the SRPV (superior right pulmonary vein). (B) Moderate stenosis (60 per cent) of 18.7mm in length in the SRPV (superior right pulmonary vein)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Revilla Orodea, I. Sánchez Lite, J.C. Gallego Beuth, T. Sevilla Ruiz, M.G. Sandín Fuentes, I.J. Amat Santos, J.A. San Román Calvar" "autores" => array:7 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Revilla Orodea" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Sánchez Lite" ] 2 => array:2 [ "nombre" => "J.C." "apellidos" => "Gallego Beuth" ] 3 => array:2 [ "nombre" => "T." "apellidos" => "Sevilla Ruiz" ] 4 => array:2 [ "nombre" => "M.G." "apellidos" => "Sandín Fuentes" ] 5 => array:2 [ "nombre" => "I.J." "apellidos" => "Amat Santos" ] 6 => array:2 [ "nombre" => "J.A." 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Comparative study among virtual spectral monochromatic imaging at 40keV (A); polychromatic imaging; and (B) virtual spectral monochromatic imaging at 70keV (C). The right lobe of the liver shows two (2) small simple adjacent cysts that are visible in the three (3) images (black arrow). Located immediately anterior to these cysts we can see one subtle hypoattenuated lesion that is only visible in the monochromatic image at 40keV (white arrow in B)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "K.N. Lago, J. Vallejos, C. Capuñay, E. Salas, E. Reynoso, J.B. Carpio, P.M. Carrascosa" "autores" => array:7 [ 0 => array:2 [ "nombre" => "K.N." "apellidos" => "Lago" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Vallejos" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Capuñay" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Salas" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Reynoso" ] 5 => array:2 [ "nombre" => "J.B." 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Granja, C.M. Pedraza, D.C. Flórez, J.A. Romero, M.A. Palau, D.A. Aguirre" "autores" => array:6 [ 0 => array:3 [ "nombre" => "M.F." "apellidos" => "Granja" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "C.M." "apellidos" => "Pedraza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "D.C." "apellidos" => "Flórez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.A." "apellidos" => "Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M.A." "apellidos" => "Palau" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:4 [ "nombre" => "D.A." "apellidos" => "Aguirre" "email" => array:1 [ 0 => "aguirreda@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Radiología e Imágenes Diagnósticas, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Patología y Laboratorio Clínico, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Predicción de la extensión extracapsular en el cáncer de próstata mediante la longitud del contacto tumoral y el coeficiente de difusión aparente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1155 "Ancho" => 2333 "Tamanyo" => 256004 ] ] "descripcion" => array:1 [ "en" => "Sixty-five year old-patient with Gleason 8 prostate cancer (4+4) located in the peripheral area of the middle third of the left side. (A) Axial T2-weighted image showing one red line as the measurement of tumor contact length with a 26.5mm capsule. (B) Axial image of the apparent diffusion coefficient map (b 800) with a value of 0.798×10−3mm2/s. This injury showed microscopic extracapsular spread in the pathology report." ] ] ] "textoCompleto" => "IntroductionProstate cancer is the second most common type of cancer in males worldwide (15 per cent) and the fifth cause of cancer mortality among this population (6.6 per cent).<a class="elsevierStyleCrossRef" href="#bib0135">1</a> In Colombia, the panorama is not any different and it is the second most common cause of cancer in men, with an incidence of 46.5 per 100,000 inhabitants and a mortality rate of 12.6 per 100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0140">2</a>Both choosing treatment and the prognosis of patients with prostate cancer depend on the presence of extracapsular spread (ECS). For the cases of localized prostate cancer, the radical prostatectomy is the treatment of choice, with high rates of survival.<a class="elsevierStyleCrossRef" href="#bib0145">3</a>Patients with localized prostate cancer undergo clinical staging of the risks based upon what decisions are made when it comes to management (radical prostatectomy with or without adjuvant therapy), ECS risk prediction and possible chemical relapse after the prostatectomy–reported in up to 15–40 per cent of the cases.<a class="elsevierStyleCrossRefs" href="#bib0150">4–7</a> This staging is performed based on the prostate-specific antigen (PSA), rectal examination, and Gleason grading group.<a class="elsevierStyleCrossRef" href="#bib0170">8</a> Gleason's grading system is based on the sum of the two (2) most prevalent patterns of growth of biopsied tissue, and this score is used to make a five (5) group-grade classification (1: ≤6; 2: 3+4=7; 3: 4+3=7; 4: 8; and 5: 9 and 10), where group-grade 1 is low risk, while groups-grades 4 through 5 are high risk.<a class="elsevierStyleCrossRefs" href="#bib0175">9,10</a>Unfortunately, with the use of these clinical parameters we find a 59 per cent substaging,<a class="elsevierStyleCrossRef" href="#bib0185">11</a> with presence of microscopic ECS in 20–50 per cent of the surgical pieces initially classified as localized prostate cancer.<a class="elsevierStyleCrossRefs" href="#bib0190">12,13</a> This is why it is recommended to perform one wide surgical resection including the neurovascular bundle that may lead to erectile dysfunction as a possible complication.<a class="elsevierStyleCrossRef" href="#bib0200">14</a> This is the reason why determining the ECS is essential to be able to achieve better surgical outcomes with a lower comorbidity rate and better oncological outomes.<a class="elsevierStyleCrossRef" href="#bib0205">15</a>The multiparametric magnetic resonance imaging (mp-MRI) is the best imaging modality for the tumor staging of this neoplasm. It uses anatomical sequences (T1 and T2-weighted images) and functional sequences (diffusion and dynamics after the administration of contrast). For the diagnosis of ECS we normally use T2-weighted imaging conventional criteria<a class="elsevierStyleCrossRefs" href="#bib0210">16,17</a>; this is how, in the year 2011, the European Society of Urogenital Radiology established the PI-RADS criteria and determined the score for the prediction of extracapsular involvement (1–5 points) using T2-weighted sequences. These criteria assess the following parameters: capsular contact (1 point); capsular irregularity (3 points); neurovascular bundle thickening (4 points); bulging or capsular loss (4 points); and overt extracapsular spread (5 points). Scores ≥4 regard the presence of ECS as likely.<a class="elsevierStyleCrossRef" href="#bib0170">8</a> In 2015, the PI-RADS criteria (versión 2) were updated, no changes to these ECS criteria were made, but the DWI sequences-appararent diffusion coefficient (ADC) map and tumor contact length (TCL) with the capsule were mentioned as important factors in the prediction of ECS.<a class="elsevierStyleCrossRef" href="#bib0220">18</a>In the medical literature we found great variability in the values of sensitivity and specificity when using these conventional criteria (T2-weighted sequences). One meta-analysis from 2015 showed low sensitivity–53 per cent (95 per cent confidence interval [95 per cent CI]: 44–63 per cent), and high specificity–91 per cent (95 per cent CI: 88–93 per cent).<a class="elsevierStyleCrossRef" href="#bib0225">19</a>In view of the clinical substaging and wide variability of sensitivity and specificity with the use of T2-weighted imaging conventional criteria for the preoperative diagnosis of ESC, during the last years new quantitative markers for mp-MRI have been studied like the TCL and the quantitative values of the ADC map. There are few studies in the medical literature and these imaging markers have only been assessed independently.Therefore, the goal of this study is to assess the diagnostic performance of the quantification of TCL and ADC map, both separately and together, for the prediction of microscopic ESC in patients with prostate cancer using the radial prostatectomy specimen as the standard of reference.MethodWe conducted one diagnostic test study with a retrospective review of the clinical histories of patients with confirmed diagnoses of moderate and high-risk prostate cancer treated with radical prostatectomy in a reference center on prostatic diseases from May, 2011 to December, 2013. The study was approved by the institutional research ethics committee which did not deem it necessary to obtain prior written informed consent given the observational and retrospective nature of the study.PatientsAll patients with prostate cancer treated at the institution with radical prostatectomy who also underwent mp-MRIs during their preoperative assessment were included in the study.The following patients were excluded from the study: 1) patients with prior prostate cancers who had already received radiotherapy or hormone replacement therapy; 2) patients with overt signs of ECS in the T2-weighted sequences; 3) patients whose mp-MRIs did not show affectation of the prostatic capsule tumor; and 4) patients whose images showed technical artifacts that would not allow a precise estimation of the values of the ADC map.Imaging modalityAll patients underwent one prostate mp-MRI using one 1.5T, Signa Excite HDxT superonductor machine (GE Medical Systems®, Milwaukee, Wisconsin, USA) with pelvic antenna (16 channel phase array). We included high resolution T1-weighted images (axial cut, TR/TE, 500/11.48, cut thickness/gap 3mm/0mm, FOV 240mm and matrix 256×256), T1-weighted images (axial, sagittal and coronal cuts, TR/TE 4300/61, cut thickness/gap: 3mm/0mm, FOV: 180mm and matrix 256×256), dynamic sequences after the administration of contrast (axial cut, TR/TE 3.3/1.5, cut thickness: 3mm, FOV:180mm and matrix 256×192) and diffusion weighted imaging (DWI)-ADC map (axial cut, values b200, b500, b800s/mm2, TR/TE, 4725/91, cut thickness: 3mm, FOV: 280mm and matrix 256×256).One radiologist identified the disease-induced target lesion and then proceeded to locate it in the T2-weighted images and ADC b800. Using the Advantage WorkStation (GE Medical Systems®, Milwaukee, Wisconsin, USA) the ADC values were assessed using one region of interest (ROI) from the injury reported, while the ADC b800 value and standard deviation were obtained too. Also the TCL of the injury with larger surface of contact to the capsule seen in the axial T2-weighted images was measured in millimeters using one digitized metric function of the working station (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Anatomopathological studyAfter the radical prostatectomy, one pathologist with twelve years of experience in genitourinary diseases conducted one detailed study of the surgical piece using the following protocol: 3mm cut sections were obtained, first in the axial plane, then in the sagittal plane and eventually in apex-to-base quadrants. Three (3)μm cuts were performed and hematoxylin–eosin staining was used. The ESC was defined as the presence of cancer cells outside the prostatic capsule, then we determined if the ESC was focal/microscopic (radial spread <0.5mm), or overt/macroscopic (when exceeding such spread). In some studies of the actual medical literature, focal ESC are defined as the identification of cancer cells beyond the capsule in a radial spread <0.5mm, and in other studies <2mm.<a class="elsevierStyleCrossRefs" href="#bib0230">20,21</a>Also, the Gleason score ranges were determined based on the most prevalent growth patterns in the surgical piece categorizing it within one of the five (5) groups-grades established by the medical literature.<a class="elsevierStyleCrossRef" href="#bib0175">9</a>Statistical analysisFor the analysis of information the following softwares were used: STATA 13® (Stata Inc, College Station, Texas, USA) and SPSS 21® (SPSS, Chicago, Illinois, USA). One univariate analysis was conducted in order to establish the relative frequencies of categorical variables. The measurements of central tendency and dispersion of quantitative variables, including the age of the patients, the PSA, and the ADC and TCL values in patients classified into Gleason categories were taken. One bivariate analysis was conducted in order to assess the existing correlation using the Student's t test and eventually establish the differences between the measurements of ADC and TCL values in patients with and without ESC.The operative characteristics of ADC maps and TCL were determined using the microscopic ESC described in pathology reports as a reference. Using the area under the ROC curve, the optimal cut-off points could be established.One logistics regression analysis model was designed using as independent variables the values of ADC and TCL, and as the dependant variable the ESC defined using the specimen of pathology as a reference. The analysis of the ROC curves was conducted in order to assess the operative performance of the prediction model for microscopic ESCs. p<0.05 values were considered statistically significant.ResultsIn the total sample of 92 patients the average age was 61 years old (39–78 years old), the average value of the PSA, 9.25ng/ml (4.9 and 12ng/ml) and most patients (66 per cent) scored 7 in the Gleason grading system (groups-grades 2 and 3) as <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>When comparing ADC values and Gleason scores, we found that patients with Gleason group-grade 3 (4+3) showed the most negative ADC values, with an average of 0.84±0.24×10−3mm2/s, followed in descending order, by the ADC values that corresponded to scores from groups-grades 4 and 5, with an average of 0.85±0.18×10−3mm2/s and 0.88±0.27×10−3mm2/s, respectively. One significant difference was identified (p=0.03) between the ADC values of Gleason group-grade 2 (3+4) and Gleason group-grade 3 (4+3), with values of 1.0±0.31×10−3mm2/s and 0.84±0.24×10−3mm2/s, respectively (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>When assessing the average TCL and Gleason scores we found the lowest value in Gleason group-grade 1 (17.15±11.00mm), and the highest value in Gleason group-grade 5 (27.09±12.80mm); however, we did not find any significant differences in these values like <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows.When assessing the ADC values for the prediction of microscopic ESCs three (3) cut-off points were considered (0.59, 0.87, and 0.9×10−3mm2/s) and the area under the curve (AUC) was identified at 72 per cent of the cut-off point 0.87×10−3mm2/s (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Similarly, for that cut-off point (0.87×10−3mm2/s) the sensitivity and specificity for the prediction of microscopic ESCs were 83 per cent and 61 per cent, respectively, which was statistically significant (p=0.014). Similarly, we confirmed that with a cut-off point of 17.5mm for the TCL, the AUC for the prediction of microscopic ESC is larger (74 per cent), and when comparing it to 20mm2 cut-off point, a much smaller AUC of 61 per cent was found. With the 17.5mm2 cut-off point we identified high sensitivity (91 per cent) and specificity (57 per cent)–also statistically significant (p=0.007) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>We did not find any significant differences in ADC values between patients with microscopic ESCs (average: 0.82; standard deviation [SD]: 0.26×10−3mm2/s) and those without microscopic ESCs (average: 0.94; DE: 0.29×10−3mm2/s) (p=0.11), but we could identify significant differences in the TLC values between patients with microscopic ESCs (average: 23.48; DE: 6.96mm) and those without microscopic ESCs (average: 18.4; SD: 9.68mm) (p=0.03). However, when conducting one binominal logistics regression analysis we confirmed that when it comes to ADC values, one cut-off point of 0.87×10−3mm2/s is a predictor of microscopic ESC with statistically significant results (p=0.02) (coefficient: 1.89; 95 per cent confidence interval [95 per cent IC]: 0.27±3.52); when it comes to TLC values, one cut-off point of 17.5mm is also a predictor of microscopic ESC with statistically significant results (p=0.037) (coefficient: 2.26; 95 per cent IC: 0.13±4.39).When combining the cut-off points of ADC (0.87×10−3mm2/s) and TLC (17.5mm) values, one AUC larger than the one found independently was obtained: of 77 per cent (77 per cent sensitivity; 61 per cent specificity). However when these cut-off points were assessed together using one logistics regression model, the AUC reached 82 per cent. These values were statistically significant with p<0.0001, like <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> and <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a> show.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>DiscussionThe election of treatment and prognosis of patients with prostate cancer depend on the presence or absence of ESC, being the radical prostatectomy reserved for patients with localized prostate cancer (without ESC). Currently, preoperative diagnoses using clinical criteria only in moderate and high-risk prostate cancers show 59 per cent substaging,<a class="elsevierStyleCrossRef" href="#bib0185">11</a> while, postoperatively, in 20–50 per cent of the cases findings of microscopic ESCs have been reported.<a class="elsevierStyleCrossRefs" href="#bib0190">12,13</a> Even the use of mp-MRI conventional criteria (T2-weighted images) for the diagnosis of ESC has shown great variability in the sensitivity and specificity of different studies. One meta-analysis (30 studies) showed low sensitivity (53 per cent) (95 per cent CI: 44–63 per cent), and high specificity (91 per cent) (95 per cent CI: 88–93 per cent).<a class="elsevierStyleCrossRef" href="#bib0225">19</a> Other studies have shown greater variability, with sensitivities ranging from 13 per cent to 95 per cent and specificities ranging from 49 per cent to 97 per cent.<a class="elsevierStyleCrossRef" href="#bib0245">23</a> The diagnosis of microscopic (focal) ESCs using T2-weighted imaging conventional criteria is much lower than the diagnosis of established or macroscopic ESCs (50 per cent vs 69 per cent)<a class="elsevierStyleCrossRef" href="#bib0250">24</a>; this is why it is very important to improve the preoperative diagnosis in the local staging of these patients when using new mp-MRI quantitative tools.In this study two (2) quantitative criteria for the prediction of microscopic ECS, TCL, and quantification of the ADC map were assessed, since we have been able to see that adding these quantitative measures to T2-weighted imaging conventional criteria improves the diagnosis of ECS as recent studies have confirmed.<a class="elsevierStyleCrossRefs" href="#bib0230">20–22,25</a> This is why in the update of the 2015 PI-RADS criteria (version 2) it has been included that the use of TCL and the quantification of the ADC map may be used as good predictors of ECS.<a class="elsevierStyleCrossRef" href="#bib0220">18</a>In this study significant differences were found in the TCL averages between patients with and without microscopic ECS (p=0.03), but not in the ADC averages (p=0.11). The optimal cut-off point for the ADC value was 0.87×10−3mm2/s, with an AUC of 72 per cent (83 per cent sensitivity; 61 per cent specificity) while the optimal cut-off point for the TCL was 17.5mm, with an AUC of 74 per cent (91 per cent sensitivity; 57 per cent specificity)–both statistically significant (p=0.014 and p=0.007, respectively).The results from our study are similar to those from the medical literature. Baco et al.’s study<a class="elsevierStyleCrossRef" href="#bib0240">22</a> (111 patients, 1.5T machine and pelvic antenna) found a similar cut-off point for the TCL (20mm), with AUCs of 88 per cent (79 per cent sensitivity; 85 per cent specificity). However, in another study conducted by Rosenkrantz et al.<a class="elsevierStyleCrossRef" href="#bib0230">20</a> (90 patients, 3T machine and pelvic antenna), the cut-off point for the TCL (6mm) was lower than the cut-off point from our study and also lower than Baco et al.’s study,<a class="elsevierStyleCrossRef" href="#bib0240">22</a> with AUCs of 81.3 per cent (80.4–89.1 per cent sensitivity; 73.1–74.6 per cent specificity)<a class="elsevierStyleCrossRef" href="#bib0230">20</a>–a finding that seems hard to replicate in a clinical setting yet despite the differences reported in the image acquisition machines. The reasons for these different cut-off points for the TCL are not quite clear.<a class="elsevierStyleCrossRef" href="#bib0230">20</a>The ADC values are also similar to the ones reported in the medical literature. In a study conducted by Woo et al.,<a class="elsevierStyleCrossRef" href="#bib0255">25</a> one cut-off point of 0.893×10−3mm2/s presents a 75 per cent ADC (92 per cent sensitivity; 55 per cent specificity). Another study conducted by Chong et al.,<a class="elsevierStyleCrossRef" href="#bib0260">26</a> confirmed similar ADC values with an average 0.883±0.18×10−3mm2/s, with significant differences (p<0.001) between patients with ECS (0.729±0.15×10−3mm2/s) and those without ECS (0.985±0.23×10−3mm2/s).When comparing the characteristics of this study with other studies from the aforementioned medical literature we realized that the studies are similar. They were all retrospective studies. When it comes to the number of patients, this study included 92 patients while other studies ranged from 69 to 117 patients. Similarly, in these studies the pelvic antenna was used the same way it was used in this study. When it comes to the mp-MRI used, Baco et al.’s study<a class="elsevierStyleCrossRef" href="#bib0240">22</a> also used a 1.5T MRI scanner while the other three (3) studies used a 3T MRI scanner.<a class="elsevierStyleCrossRefs" href="#bib0230">20,25,26</a> The benefits derived from using 3T MRI scanners instead of 1.5T MRI scanner, and the pelvic antenna instead of the endorectal antenna have been widely discussed. The last PI-RADS consensus from 2015 (versión 2) claimed that although the 3T MRI scanner is superior to the 1.5T MRI scanner, both machines provide an adequate diagnosis when used with the appropriate optimized parameters. Nevertheless, the systematic use of the endorectal antenna is not recommended but it is suggested in 1.5T MRI scanners for image quality enhancement.<a class="elsevierStyleCrossRef" href="#bib0220">18</a>No studies assessing these quantitative criteria have ever been published (TCL+ADC). In this study we found that the sum of both criteria improved the AUC (77 per cent), and that the use of one logistics regression model improved the AUC even more (to 82 per cent), which is a larger (and statistically significant) percentage than the AUCs obtained using each criterion separately.With the evidence presented it may be deemed possible to use ADC and TCL for their systematic measurement in mp-MRIs in patients with prostate cancer for a better preoperative staging and more precise surgical planning in an effort to reduce local and postoperative side effects such as erectile dysfunction and incontinence.As a strong point here we have to say that we did not find any studies in the medical literature assessing TCL or ADC values as quantitative values for the prediction of microscopic ECS, so in this regard, our study would be the first one to make correlations between these parameters.Some of the limitations of this study are that it is retrospective and that the number of patients was low. Future research should include larger populations and prospective studies; also image assessment should be performed by more than just one radiologist.We think that the results coming from this study allow us to apply new quantitative criteria in mp-MRIs for the diagnosis of ECS, in particular ECS microscopic affectation, for a better surgical planning and prognosis of these patients with moderate and high-risk prostate cancers.Ethical disclosuresProtection of people and animalsThe authors declare that the procedures followed abide by the ethics and regulations of the Human Research Committee, the World Health Organization and the Declaration of Helsinki.Confidentiality of dataThe authors declare that they have followed the protocols from their centres on the disclosure of data from patients.Right to privacy and informed consentThe authors have obtained prior written informed consent from the aforementioned patients. This document belongs to the corresponding author.Authors<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Manager of the integrity of the study: DCFC, DAA.</li><li class="elsevierStyleListItem" id="lsti0010">2.Study idea: MFGS, CMPA, DCFC, DAA and JR.</li><li class="elsevierStyleListItem" id="lsti0015">3.Study design: MFGS, CMPA, DCFC and DAA.</li><li class="elsevierStyleListItem" id="lsti0020">4.Data mining: DCFC, DAA, JR and MP.</li><li class="elsevierStyleListItem" id="lsti0025">5.Data analysis and interpretation: MFGS, DAA and CMPA.</li><li class="elsevierStyleListItem" id="lsti0030">6.Statistical analysis: MFGS, DAA and CMPA.</li><li class="elsevierStyleListItem" id="lsti0035">7.Reference: DAA.</li><li class="elsevierStyleListItem" id="lsti0040">8.Writing: MFGS, CMPA, DCFC, DAA, JR and MP.</li><li class="elsevierStyleListItem" id="lsti0045">9.Critical review of the manuscript with intellectually relevant remarks: MFGS, CMPA, DCFC, DAA, JR and MP.</li><li class="elsevierStyleListItem" id="lsti0050">10.Approval of final version: MFGS, CMPA, DCFC, DAA, JR and MP.</li></ul>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres866571" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec855853" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres866570" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec855852" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Method" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Imaging modality" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Anatomopathological study" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Authors" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-24" "fechaAceptado" => "2017-03-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec855853" "palabras" => array:4 [ 0 => "Prostate cancer" 1 => "Magnetic resonance imaging" 2 => "Prostatectomy" 3 => "Diffusion sequences" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec855852" "palabras" => array:4 [ 0 => "Cáncer de próstata" 1 => "Resonancia magnética" 2 => "Prostatectomía" 3 => "Secuencias de difusión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo evaluate the diagnostic performance of the length of the tumor contact with the capsule (LTC) and the apparent diffusion coefficient (ADC) map in the prediction of microscopic extracapsular extension in patients with prostate cancer who are candidates for radical prostatectomy. Material and methodsWe used receiver operating curves to retrospectively study the diagnostic performance of the ADC map and the LTC as predictors of microscopic extracapsular extension in 92 patients with prostate cancer and moderate to high risk who were examined between May 2011 and December 2013. ResultsThe optimal cutoff for the ADC map was 0.87×10−3mm2/s, which yielded an area under the ROC curve of 72% (95% CI: 57%–86%), corresponding to a sensitivity of 83% and a specificity of 61%. The optimal cutoff for the LTC was 17.5mm, which yielded an area under the ROC curve of 74% (95% CI: 61%–87%), corresponding to a sensitivity of 91% and a specificity of 57%. Combining the two criteria improved the diagnostic performance, yielding an area under the ROC curve of 77% (95% CI: 62%–92%), corresponding to a sensitivity of 77% and a specificity of 61%. We elaborated a logistic regression model, obtaining an area under the ROC curve of 82% (95% CI: 73%–93%). ConclusionsUsing quantitative measures improves the diagnostic accuracy of multiparametric magnetic resonance imaging in the staging of prostate cancer. The values of the ADC and LTC were predictors of microscopic extracapsular extension, and the best results were obtained when both values were used in combination." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEvaluar el rendimiento diagnóstico de la longitud del contacto tumoral con la cápsula (LCT) y la cuantificación del mapa del coeficiente de difusión aparente (ADC) en la predicción de la extensión extracapsular (EEC) microscópica en pacientes con cáncer de próstata candidatos a prostatectomía radical. MétodoSe realizó un estudio retrospectivo de prueba diagnóstica con curvas receptor-operador (ROC) evaluando el rendimiento diagnóstico del valor de ADC y LCT como predictores de EEC microscópica en 92 pacientes con cáncer de próstata de moderado y alto riesgo, entre mayo de 2011 y diciembre de 2013. ResultadosEl punto de corte óptimo para el valor del mapa de ADC fue de 0,87 × 10−3 mm2/s, con un área bajo la curva ROC del 72% (intervalo de confianza del 95% [IC95%]: 57-86%), una sensibilidad del 83% y una especificidad del 61%. Para la LCT, el punto de corte óptimo fue de 17,5mm, con un área bajo la curva ROC del 74% (IC95%: 61-87%), una sensibilidad del 91% y una especificidad del 57%. Empleando ambos criterios, el rendimiento diagnóstico mejoró con un área bajo la curva ROC del 77% (IC95%: 62-92%), una sensibilidad del 77% y una especificidad del 61%. Se calculó un modelo de regresión logística y se obtuvo un área bajo la curva ROC del 82% (IC95%: 73-93%). ConclusionesEl uso de criterios cuantitativos mejora la exactitud diagnóstica de la resonancia magnética multiparamétrica en la estadificación del cáncer de próstata. Se encontró que los valores de ADC y de LCT son predictores de EEC microscópica, y que se obtienen mejores resultados si se usan de manera conjunta." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Granja MF, Pedraza CM, Flórez DC, Romero JA, Palau MA, Aguirre DA. Predicción de la extensión extracapsular en el cáncer de próstata mediante la longitud del contacto tumoral y el coeficiente de difusión aparente. Radiología. 2017;59:313–320." ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1157 "Ancho" => 2333 "Tamanyo" => 246877 ] ] "descripcion" => array:1 [ "en" => "Fifty-one year old-patient with Gleason 8 prostate cancer (4+4), located in the peripheral area of the middle third of the left side. (A) Axial T2-weighted image showing one red line as the measurement of tumor contact length with a 19.7mm capsule. (B) Axial image of the apparent diffusion coefficient map (b 800) with a value of 0.645×10−3mm2/s. This injury showed microscopic extracapsular spread in the pathology report." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1155 "Ancho" => 2333 "Tamanyo" => 256004 ] ] "descripcion" => array:1 [ "en" => "Sixty-five year old-patient with Gleason 8 prostate cancer (4+4) located in the peripheral area of the middle third of the left side. (A) Axial T2-weighted image showing one red line as the measurement of tumor contact length with a 26.5mm capsule. (B) Axial image of the apparent diffusion coefficient map (b 800) with a value of 0.798×10−3mm2/s. This injury showed microscopic extracapsular spread in the pathology report." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1099 "Ancho" => 1651 "Tamanyo" => 77026 ] ] "descripcion" => array:1 [ "en" => "ROC curves to predict extracapsular spread using different cut-off points of the quantitative values of the apparent diffusion coefficient map." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1199 "Ancho" => 1548 "Tamanyo" => 86180 ] ] "descripcion" => array:1 [ "en" => "ROC curves to predict extracapsular spread using different cut-off points of the quantitative values of the tumor contact length with the capsule." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1099 "Ancho" => 1627 "Tamanyo" => 100516 ] ] "descripcion" => array:1 [ "en" => "ROC curves to predict extracapsular spread using optimal cut-off points obtained for the quantitative values of the apparent diffusion coefficient map and tumor contact length with the capsule, use of both criteria, and estimated logistics regression model." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SD: standard deviation; PSA: prostate-specific antigen." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years), average±(SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61±7.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PSA at the moment of diagnosis (ng/ml), average±SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.25±7.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Group-grade (Gleason) based on surgical specimen (No.=92), n (per cent)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 1 (≤6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (9.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 2 (3+4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34(36.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 3 (4+3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27(29.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 4 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 5 (≥9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (10.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1457465.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical characteristics of patients." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "ADC: apparent diffusion coefficient; SD: standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gleason grade (No.=92) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade (Gleason 1+Gleason 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ADC (10−3mm2/s), average±SD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 1 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.19±0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 2 (3+4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.01±0.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 3 (4+3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84±0.24<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 4 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84±0.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 5 (≥9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.85±0.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade (Gleason 1+Gleason 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumor contact length (mm), average±SD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 1 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.15±11.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 2 (3+4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.24±6.44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 3 (4+3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.58±9.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 4 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.50±10.51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Group-grade 5 (≥9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.09±12.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1457467.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The difference between the average values of ADC for Gleason scores 3+4 and Gleason scores 4+3 is statistically significant (p=0.03)." ] ] ] "descripcion" => array:1 [ "en" => "Distribution of the apparent diffusion coefficient and tumor contact length according to Gleason's grading system." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "AUC: area under the curve; ADC: apparent diffusion coefficient; 95 per cent CI: 95 per cent confidence interval." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AUC (95 per cent CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sensitivity/Specificity (per cent) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">ADC value (10−3mm2/s)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.54 (0.35–0.72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16/91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.66 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.72 (0.57–0.86) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83/61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.014<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.70 (0.55–0.84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83/57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.025<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Tumor contact length (mm)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 (0.44–0.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58/65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.203 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">17.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.74 (0.61–0.87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91/57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.007<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1457468.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "The AUC estimator is statistically significant." ] ] ] "descripcion" => array:1 [ "en" => "Receiver–operator characteristics and areas under the curve for the diagnosis of microscopic extracapsular spread." ] ] 8 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "AUC: area under the curve; ADC: apparent diffusion coefficient; 95 per cent CI: 95 per cent confidence interval." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Model \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AUC (95 per cent CI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Logistics regression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.828 (0.726–0.929) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ADC value ≤8.7×10−3mm2/s and TCL ≥17.5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.774 (0.622–0.925) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1457466.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Estimator with significance level of 0.05." ] ] ] "descripcion" => array:1 [ "en" => "Receiver–operator characteristics and areas under the curve for the diagnosis of microscopic extracapsular spread using one logistics regression model and the presence of an apparent diffusion coefficient ≤0.87×10−3mm2/s and a tumor contact length ≥17.5mm." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0135" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global incidence and mortality for prostate cancer: analysis of temporal patterns and trends in 36 countries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.C. Wong" 1 => "W.B. Goggins" 2 => "H.H. Wang" 3 => "F.D. Fung" 4 => "C. Leung" 5 => "S.Y. Wong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Radiol" "fecha" => "2016" "volumen" => "70" "paginaInicial" => "862" "paginaFinal" => "874" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0140" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidencia, mortalidad y prevalencia de cáncer en Colombia, 2007–2011" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.C.R. 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Predicción de la extensión extracapsular en el cáncer de próstata mediante la longitud del contacto tumoral y el coeficiente de difusión aparente

M.F. Granjaa,b, C.M. Pedrazaa, D.C. Flóreza, J.A. Romeroa, M.A. Palaub, D.A. Aguirrea,

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aguirreda@yahoo.com

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a Departamento de Radiología e Imágenes Diagnósticas, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia

b Departamento de Patología y Laboratorio Clínico, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prostate cancer is the second most common type of cancer in males worldwide &#40;15 per cent&#41; and the fifth cause of cancer mortality among this population &#40;6&#46;6 per cent&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">1</span></a> In Colombia&#44; the panorama is not any different and it is the second most common cause of cancer in men&#44; with an incidence of 46&#46;5 per 100&#44;000 inhabitants and a mortality rate of 12&#46;6 per 100&#44;000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Both choosing treatment and the prognosis of patients with prostate cancer depend on the presence of extracapsular spread &#40;ECS&#41;&#46; For the cases of localized prostate cancer&#44; the radical prostatectomy is the treatment of choice&#44; with high rates of survival&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with localized prostate cancer undergo clinical staging of the risks based upon what decisions are made when it comes to management &#40;radical prostatectomy with or without adjuvant therapy&#41;&#44; ECS risk prediction and possible chemical relapse after the prostatectomy&#8211;reported in up to 15&#8211;40 per cent of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">4&#8211;7</span></a> This staging is performed based on the prostate-specific antigen &#40;PSA&#41;&#44; rectal examination&#44; and Gleason grading group&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">8</span></a> Gleason&#39;s grading system is based on the sum of the two &#40;2&#41; most prevalent patterns of growth of biopsied tissue&#44; and this score is used to make a five &#40;5&#41; group-grade classification &#40;1&#58; &#8804;6&#59; 2&#58; 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#59; 3&#58; 4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#59; 4&#58; 8&#59; and 5&#58; 9 and 10&#41;&#44; where group-grade 1 is low risk&#44; while groups-grades 4 through 5 are high risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Unfortunately&#44; with the use of these clinical parameters we find a 59 per cent substaging&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a> with presence of microscopic ECS in 20&#8211;50 per cent of the surgical pieces initially classified as localized prostate cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">12&#44;13</span></a> This is why it is recommended to perform one wide surgical resection including the neurovascular bundle that may lead to erectile dysfunction as a possible complication&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">14</span></a> This is the reason why determining the ECS is essential to be able to achieve better surgical outcomes with a lower comorbidity rate and better oncological outomes&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The multiparametric magnetic resonance imaging &#40;mp-MRI&#41; is the best imaging modality for the tumor staging of this neoplasm&#46; It uses anatomical sequences &#40;T1 and T2-weighted images&#41; and functional sequences &#40;diffusion and dynamics after the administration of contrast&#41;&#46; For the diagnosis of ECS we normally use T2-weighted imaging conventional criteria<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">16&#44;17</span></a>&#59; this is how&#44; in the year 2011&#44; the European Society of Urogenital Radiology established the PI-RADS criteria and determined the score for the prediction of extracapsular involvement &#40;1&#8211;5 points&#41; using T2-weighted sequences&#46; These criteria assess the following parameters&#58; capsular contact &#40;1 point&#41;&#59; capsular irregularity &#40;3 points&#41;&#59; neurovascular bundle thickening &#40;4 points&#41;&#59; bulging or capsular loss &#40;4 points&#41;&#59; and overt extracapsular spread &#40;5 points&#41;&#46; Scores &#8805;4 regard the presence of ECS as likely&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">8</span></a> In 2015&#44; the PI-RADS criteria &#40;versi&#243;n 2&#41; were updated&#44; no changes to these ECS criteria were made&#44; but the DWI sequences-appararent diffusion coefficient &#40;ADC&#41; map and tumor contact length &#40;TCL&#41; with the capsule were mentioned as important factors in the prediction of ECS&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the medical literature we found great variability in the values of sensitivity and specificity when using these conventional criteria &#40;T2-weighted sequences&#41;&#46; One meta-analysis from 2015 showed low sensitivity&#8211;53 per cent &#40;95 per cent confidence interval &#91;95 per cent CI&#93;&#58; 44&#8211;63 per cent&#41;&#44; and high specificity&#8211;91 per cent &#40;95 per cent CI&#58; 88&#8211;93 per cent&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">19</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In view of the clinical substaging and wide variability of sensitivity and specificity with the use of T2-weighted imaging conventional criteria for the preoperative diagnosis of ESC&#44; during the last years new quantitative markers for mp-MRI have been studied like the TCL and the quantitative values of the ADC map&#46; There are few studies in the medical literature and these imaging markers have only been assessed independently&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; the goal of this study is to assess the diagnostic performance of the quantification of TCL and ADC map&#44; both separately and together&#44; for the prediction of microscopic ESC in patients with prostate cancer using the radial prostatectomy specimen as the standard of reference&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0045" class="elsevierStylePara elsevierViewall">We conducted one diagnostic test study with a retrospective review of the clinical histories of patients with confirmed diagnoses of moderate and high-risk prostate cancer treated with radical prostatectomy in a reference center on prostatic diseases from May&#44; 2011 to December&#44; 2013&#46; The study was approved by the institutional research ethics committee which did not deem it necessary to obtain prior written informed consent given the observational and retrospective nature of the study&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients with prostate cancer treated at the institution with radical prostatectomy who also underwent mp-MRIs during their preoperative assessment were included in the study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The following patients were excluded from the study&#58; 1&#41; patients with prior prostate cancers who had already received radiotherapy or hormone replacement therapy&#59; 2&#41; patients with overt signs of ECS in the T2-weighted sequences&#59; 3&#41; patients whose mp-MRIs did not show affectation of the prostatic capsule tumor&#59; and 4&#41; patients whose images showed technical artifacts that would not allow a precise estimation of the values of the ADC map&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Imaging modality</span><p id="par0060" class="elsevierStylePara elsevierViewall">All patients underwent one prostate mp-MRI using one 1&#46;5<span class="elsevierStyleHsp" style=""></span>T&#44; Signa Excite HDxT superonductor machine &#40;GE Medical Systems<span class="elsevierStyleSup">&#174;</span>&#44; Milwaukee&#44; Wisconsin&#44; USA&#41; with pelvic antenna &#40;16 channel phase array&#41;&#46; We included high resolution T1-weighted images &#40;axial cut&#44; TR&#47;TE&#44; 500&#47;11&#46;48&#44; cut thickness&#47;gap 3<span class="elsevierStyleHsp" style=""></span>mm&#47;0<span class="elsevierStyleHsp" style=""></span>mm&#44; FOV 240<span class="elsevierStyleHsp" style=""></span>mm and matrix 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>256&#41;&#44; T1-weighted images &#40;axial&#44; sagittal and coronal cuts&#44; TR&#47;TE 4300&#47;61&#44; cut thickness&#47;gap&#58; 3<span class="elsevierStyleHsp" style=""></span>mm&#47;0<span class="elsevierStyleHsp" style=""></span>mm&#44; FOV&#58; 180<span class="elsevierStyleHsp" style=""></span>mm and matrix 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>256&#41;&#44; dynamic sequences after the administration of contrast &#40;axial cut&#44; TR&#47;TE 3&#46;3&#47;1&#46;5&#44; cut thickness&#58; 3<span class="elsevierStyleHsp" style=""></span>mm&#44; FOV&#58;180<span class="elsevierStyleHsp" style=""></span>mm and matrix 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>192&#41; and diffusion weighted imaging &#40;DWI&#41;-ADC map &#40;axial cut&#44; values b200&#44; b500&#44; b800<span class="elsevierStyleHsp" style=""></span>s&#47;mm<span class="elsevierStyleSup">2</span>&#44; TR&#47;TE&#44; 4725&#47;91&#44; cut thickness&#58; 3<span class="elsevierStyleHsp" style=""></span>mm&#44; FOV&#58; 280<span class="elsevierStyleHsp" style=""></span>mm and matrix 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>256&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">One radiologist identified the disease-induced target lesion and then proceeded to locate it in the T2-weighted images and ADC b800&#46; Using the Advantage WorkStation &#40;GE Medical Systems<span class="elsevierStyleSup">&#174;</span>&#44; Milwaukee&#44; Wisconsin&#44; USA&#41; the ADC values were assessed using one region of interest &#40;ROI&#41; from the injury reported&#44; while the ADC b800 value and standard deviation were obtained too&#46; Also the TCL of the injury with larger surface of contact to the capsule seen in the axial T2-weighted images was measured in millimeters using one digitized metric function of the working station &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Anatomopathological study</span><p id="par0070" class="elsevierStylePara elsevierViewall">After the radical prostatectomy&#44; one pathologist with twelve years of experience in genitourinary diseases conducted one detailed study of the surgical piece using the following protocol&#58; 3<span class="elsevierStyleHsp" style=""></span>mm cut sections were obtained&#44; first in the axial plane&#44; then in the sagittal plane and eventually in apex-to-base quadrants&#46; Three &#40;3&#41;<span class="elsevierStyleHsp" style=""></span>&#956;m cuts were performed and hematoxylin&#8211;eosin staining was used&#46; The ESC was defined as the presence of cancer cells outside the prostatic capsule&#44; then we determined if the ESC was focal&#47;microscopic &#40;radial spread &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; or overt&#47;macroscopic &#40;when exceeding such spread&#41;&#46; In some studies of the actual medical literature&#44; focal ESC are defined as the identification of cancer cells beyond the capsule in a radial spread &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; and in other studies &#60;2<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Also&#44; the Gleason score ranges were determined based on the most prevalent growth patterns in the surgical piece categorizing it within one of the five &#40;5&#41; groups-grades established by the medical literature&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">For the analysis of information the following softwares were used&#58; STATA 13<span class="elsevierStyleSup">&#174;</span> &#40;Stata Inc&#44; College Station&#44; Texas&#44; USA&#41; and SPSS 21<span class="elsevierStyleSup">&#174;</span> &#40;SPSS&#44; Chicago&#44; Illinois&#44; USA&#41;&#46; One univariate analysis was conducted in order to establish the relative frequencies of categorical variables&#46; The measurements of central tendency and dispersion of quantitative variables&#44; including the age of the patients&#44; the PSA&#44; and the ADC and TCL values in patients classified into Gleason categories were taken&#46; One bivariate analysis was conducted in order to assess the existing correlation using the Student&#39;s t test and eventually establish the differences between the measurements of ADC and TCL values in patients with and without ESC&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The operative characteristics of ADC maps and TCL were determined using the microscopic ESC described in pathology reports as a reference&#46; Using the area under the ROC curve&#44; the optimal cut-off points could be established&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">One logistics regression analysis model was designed using as independent variables the values of ADC and TCL&#44; and as the dependant variable the ESC defined using the specimen of pathology as a reference&#46; The analysis of the ROC curves was conducted in order to assess the operative performance of the prediction model for microscopic ESCs&#46; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 values were considered statistically significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">In the total sample of 92 patients the average age was 61 years old &#40;39&#8211;78 years old&#41;&#44; the average value of the PSA&#44; 9&#46;25<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;4&#46;9 and 12<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; and most patients &#40;66 per cent&#41; scored 7 in the Gleason grading system &#40;groups-grades 2 and 3&#41; as <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">When comparing ADC values and Gleason scores&#44; we found that patients with Gleason group-grade 3 &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#41; showed the most negative ADC values&#44; with an average of 0&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;24<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; followed in descending order&#44; by the ADC values that corresponded to scores from groups-grades 4 and 5&#44; with an average of 0&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;18<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s and 0&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;27<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; respectively&#46; One significant difference was identified &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; between the ADC values of Gleason group-grade 2 &#40;3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41; and Gleason group-grade 3 &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; with values of 1&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;31<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s and 0&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;24<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">When assessing the average TCL and Gleason scores we found the lowest value in Gleason group-grade 1 &#40;17&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;00<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; and the highest value in Gleason group-grade 5 &#40;27&#46;09<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;80<span class="elsevierStyleHsp" style=""></span>mm&#41;&#59; however&#44; we did not find any significant differences in these values like <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">When assessing the ADC values for the prediction of microscopic ESCs three &#40;3&#41; cut-off points were considered &#40;0&#46;59&#44; 0&#46;87&#44; and 0&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41; and the area under the curve &#40;AUC&#41; was identified at 72 per cent of the cut-off point 0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Similarly&#44; for that cut-off point &#40;0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41; the sensitivity and specificity for the prediction of microscopic ESCs were 83 per cent and 61 per cent&#44; respectively&#44; which was statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46; Similarly&#44; we confirmed that with a cut-off point of 17&#46;5<span class="elsevierStyleHsp" style=""></span>mm for the TCL&#44; the AUC for the prediction of microscopic ESC is larger &#40;74 per cent&#41;&#44; and when comparing it to 20<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> cut-off point&#44; a much smaller AUC of 61 per cent was found&#46; With the 17&#46;5<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> cut-off point we identified high sensitivity &#40;91 per cent&#41; and specificity &#40;57 per cent&#41;&#8211;also statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">We did not find any significant differences in ADC values between patients with microscopic ESCs &#40;average&#58; 0&#46;82&#59; standard deviation &#91;SD&#93;&#58; 0&#46;26<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41; and those without microscopic ESCs &#40;average&#58; 0&#46;94&#59; DE&#58; 0&#46;29<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#41;&#44; but we could identify significant differences in the TLC values between patients with microscopic ESCs &#40;average&#58; 23&#46;48&#59; DE&#58; 6&#46;96<span class="elsevierStyleHsp" style=""></span>mm&#41; and those without microscopic ESCs &#40;average&#58; 18&#46;4&#59; SD&#58; 9&#46;68<span class="elsevierStyleHsp" style=""></span>mm&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; However&#44; when conducting one binominal logistics regression analysis we confirmed that when it comes to ADC values&#44; one cut-off point of 0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s is a predictor of microscopic ESC with statistically significant results &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41; &#40;coefficient&#58; 1&#46;89&#59; 95 per cent confidence interval &#91;95 per cent IC&#93;&#58; 0&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;52&#41;&#59; when it comes to TLC values&#44; one cut-off point of 17&#46;5<span class="elsevierStyleHsp" style=""></span>mm is also a predictor of microscopic ESC with statistically significant results &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;037&#41; &#40;coefficient&#58; 2&#46;26&#59; 95 per cent IC&#58; 0&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;39&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">When combining the cut-off points of ADC &#40;0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41; and TLC &#40;17&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#41; values&#44; one AUC larger than the one found independently was obtained&#58; of 77 per cent &#40;77 per cent sensitivity&#59; 61 per cent specificity&#41;&#46; However when these cut-off points were assessed together using one logistics regression model&#44; the AUC reached 82 per cent&#46; These values were statistically significant with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#44; like <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> and <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> show&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The election of treatment and prognosis of patients with prostate cancer depend on the presence or absence of ESC&#44; being the radical prostatectomy reserved for patients with localized prostate cancer &#40;without ESC&#41;&#46; Currently&#44; preoperative diagnoses using clinical criteria only in moderate and high-risk prostate cancers show 59 per cent substaging&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a> while&#44; postoperatively&#44; in 20&#8211;50 per cent of the cases findings of microscopic ESCs have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">12&#44;13</span></a> Even the use of mp-MRI conventional criteria &#40;T2-weighted images&#41; for the diagnosis of ESC has shown great variability in the sensitivity and specificity of different studies&#46; One meta-analysis &#40;30 studies&#41; showed low sensitivity &#40;53 per cent&#41; &#40;95 per cent CI&#58; 44&#8211;63 per cent&#41;&#44; and high specificity &#40;91 per cent&#41; &#40;95 per cent CI&#58; 88&#8211;93 per cent&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">19</span></a> Other studies have shown greater variability&#44; with sensitivities ranging from 13 per cent to 95 per cent and specificities ranging from 49 per cent to 97 per cent&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">23</span></a> The diagnosis of microscopic &#40;focal&#41; ESCs using T2-weighted imaging conventional criteria is much lower than the diagnosis of established or macroscopic ESCs &#40;50 per cent <span class="elsevierStyleItalic">vs</span> 69 per cent&#41;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">24</span></a>&#59; this is why it is very important to improve the preoperative diagnosis in the local staging of these patients when using new mp-MRI quantitative tools&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In this study two &#40;2&#41; quantitative criteria for the prediction of microscopic ECS&#44; TCL&#44; and quantification of the ADC map were assessed&#44; since we have been able to see that adding these quantitative measures to T2-weighted imaging conventional criteria improves the diagnosis of ECS as recent studies have confirmed&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">20&#8211;22&#44;25</span></a> This is why in the update of the 2015 PI-RADS criteria &#40;version 2&#41; it has been included that the use of TCL and the quantification of the ADC map may be used as good predictors of ECS&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In this study significant differences were found in the TCL averages between patients with and without microscopic ECS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#44; but not in the ADC averages &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#41;&#46; The optimal cut-off point for the ADC value was 0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; with an AUC of 72 per cent &#40;83 per cent sensitivity&#59; 61 per cent specificity&#41; while the optimal cut-off point for the TCL was 17&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; with an AUC of 74 per cent &#40;91 per cent sensitivity&#59; 57 per cent specificity&#41;&#8211;both statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#44; respectively&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The results from our study are similar to those from the medical literature&#46; Baco et al&#46;&#8217;s study<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> &#40;111 patients&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>T machine and pelvic antenna&#41; found a similar cut-off point for the TCL &#40;20<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with AUCs of 88 per cent &#40;79 per cent sensitivity&#59; 85 per cent specificity&#41;&#46; However&#44; in another study conducted by Rosenkrantz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">20</span></a> &#40;90 patients&#44; 3<span class="elsevierStyleHsp" style=""></span>T machine and pelvic antenna&#41;&#44; the cut-off point for the TCL &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41; was lower than the cut-off point from our study and also lower than Baco et al&#46;&#8217;s study&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> with AUCs of 81&#46;3 per cent &#40;80&#46;4&#8211;89&#46;1 per cent sensitivity&#59; 73&#46;1&#8211;74&#46;6 per cent specificity&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">20</span></a>&#8211;a finding that seems hard to replicate in a clinical setting yet despite the differences reported in the image acquisition machines&#46; The reasons for these different cut-off points for the TCL are not quite clear&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">20</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The ADC values are also similar to the ones reported in the medical literature&#46; In a study conducted by Woo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">25</span></a> one cut-off point of 0&#46;893<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s presents a 75 per cent ADC &#40;92 per cent sensitivity&#59; 55 per cent specificity&#41;&#46; Another study conducted by Chong et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">26</span></a> confirmed similar ADC values with an average 0&#46;883<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;18<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; with significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; between patients with ECS &#40;0&#46;729<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;15<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41; and those without ECS &#40;0&#46;985<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;23<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">When comparing the characteristics of this study with other studies from the aforementioned medical literature we realized that the studies are similar&#46; They were all retrospective studies&#46; When it comes to the number of patients&#44; this study included 92 patients while other studies ranged from 69 to 117 patients&#46; Similarly&#44; in these studies the pelvic antenna was used the same way it was used in this study&#46; When it comes to the mp-MRI used&#44; Baco et al&#46;&#8217;s study<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> also used a 1&#46;5<span class="elsevierStyleHsp" style=""></span>T MRI scanner while the other three &#40;3&#41; studies used a 3<span class="elsevierStyleHsp" style=""></span>T MRI scanner&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">20&#44;25&#44;26</span></a> The benefits derived from using 3<span class="elsevierStyleHsp" style=""></span>T MRI scanners instead of 1&#46;5<span class="elsevierStyleHsp" style=""></span>T MRI scanner&#44; and the pelvic antenna instead of the endorectal antenna have been widely discussed&#46; The last PI-RADS consensus from 2015 &#40;versi&#243;n 2&#41; claimed that although the 3<span class="elsevierStyleHsp" style=""></span>T MRI scanner is superior to the 1&#46;5<span class="elsevierStyleHsp" style=""></span>T MRI scanner&#44; both machines provide an adequate diagnosis when used with the appropriate optimized parameters&#46; Nevertheless&#44; the systematic use of the endorectal antenna is not recommended but it is suggested in 1&#46;5<span class="elsevierStyleHsp" style=""></span>T MRI scanners for image quality enhancement&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">18</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">No studies assessing these quantitative criteria have ever been published &#40;TCL<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ADC&#41;&#46; In this study we found that the sum of both criteria improved the AUC &#40;77 per cent&#41;&#44; and that the use of one logistics regression model improved the AUC even more &#40;to 82 per cent&#41;&#44; which is a larger &#40;and statistically significant&#41; percentage than the AUCs obtained using each criterion separately&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">With the evidence presented it may be deemed possible to use ADC and TCL for their systematic measurement in mp-MRIs in patients with prostate cancer for a better preoperative staging and more precise surgical planning in an effort to reduce local and postoperative side effects such as erectile dysfunction and incontinence&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">As a strong point here we have to say that we did not find any studies in the medical literature assessing TCL or ADC values as quantitative values for the prediction of microscopic ECS&#44; so in this regard&#44; our study would be the first one to make correlations between these parameters&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Some of the limitations of this study are that it is retrospective and that the number of patients was low&#46; Future research should include larger populations and prospective studies&#59; also image assessment should be performed by more than just one radiologist&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">We think that the results coming from this study allow us to apply new quantitative criteria in mp-MRIs for the diagnosis of ECS&#44; in particular ECS microscopic affectation&#44; for a better surgical planning and prognosis of these patients with moderate and high-risk prostate cancers&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of people and animals</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed abide by the ethics and regulations of the Human Research Committee&#44; the World Health Organization and the Declaration of Helsinki&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols from their centres on the disclosure of data from patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have obtained prior written informed consent from the aforementioned patients&#46; This document belongs to the corresponding author&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authors</span><p id="par0195" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; DCFC&#44; DAA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Study idea&#58; MFGS&#44; CMPA&#44; DCFC&#44; DAA and JR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Study design&#58; MFGS&#44; CMPA&#44; DCFC and DAA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Data mining&#58; DCFC&#44; DAA&#44; JR and MP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; MFGS&#44; DAA and CMPA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; MFGS&#44; DAA and CMPA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Reference&#58; DAA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Writing&#58; MFGS&#44; CMPA&#44; DCFC&#44; DAA&#44; JR and MP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; MFGS&#44; CMPA&#44; DCFC&#44; DAA&#44; JR and MP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Approval of final version&#58; MFGS&#44; CMPA&#44; DCFC&#44; DAA&#44; JR and MP&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the diagnostic performance of the length of the tumor contact with the capsule &#40;LTC&#41; and the apparent diffusion coefficient &#40;ADC&#41; map in the prediction of microscopic extracapsular extension in patients with prostate cancer who are candidates for radical prostatectomy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We used receiver operating curves to retrospectively study the diagnostic performance of the ADC map and the LTC as predictors of microscopic extracapsular extension in 92 patients with prostate cancer and moderate to high risk who were examined between May 2011 and December 2013&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The optimal cutoff for the ADC map was 0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#44; which yielded an area under the ROC curve of 72&#37; &#40;95&#37; <span class="elsevierStyleSmallCaps">CI</span>&#58; 57&#37;&#8211;86&#37;&#41;&#44; corresponding to a sensitivity of 83&#37; and a specificity of 61&#37;&#46; The optimal cutoff for the LTC was 17&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; which yielded an area under the ROC curve of 74&#37; &#40;95&#37; CI&#58; 61&#37;&#8211;87&#37;&#41;&#44; corresponding to a sensitivity of 91&#37; and a specificity of 57&#37;&#46; Combining the two criteria improved the diagnostic performance&#44; yielding an area under the ROC curve of 77&#37; &#40;95&#37; CI&#58; 62&#37;&#8211;92&#37;&#41;&#44; corresponding to a sensitivity of 77&#37; and a specificity of 61&#37;&#46; We elaborated a logistic regression model&#44; obtaining an area under the ROC curve of 82&#37; &#40;95&#37; CI&#58; 73&#37;&#8211;93&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Using quantitative measures improves the diagnostic accuracy of multiparametric magnetic resonance imaging in the staging of prostate cancer&#46; The values of the ADC and LTC were predictors of microscopic extracapsular extension&#44; and the best results were obtained when both values were used in combination&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar el rendimiento diagn&#243;stico de la longitud del contacto tumoral con la c&#225;psula &#40;LCT&#41; y la cuantificaci&#243;n del mapa del coeficiente de difusi&#243;n aparente &#40;ADC&#41; en la predicci&#243;n de la extensi&#243;n extracapsular &#40;EEC&#41; microsc&#243;pica en pacientes con c&#225;ncer de pr&#243;stata candidatos a prostatectom&#237;a radical&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio retrospectivo de prueba diagn&#243;stica con curvas receptor-operador &#40;ROC&#41; evaluando el rendimiento diagn&#243;stico del valor de ADC y LCT como predictores de EEC microsc&#243;pica en 92 pacientes con c&#225;ncer de pr&#243;stata de moderado y alto riesgo&#44; entre mayo de 2011 y diciembre de 2013&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El punto de corte &#243;ptimo para el valor del mapa de ADC fue de 0&#44;87 &#215; 10<span class="elsevierStyleSup">&#8722;3</span> mm<span class="elsevierStyleSup">2</span>&#47;s&#44; con un &#225;rea bajo la curva ROC del 72&#37; &#40;intervalo de confianza del 95&#37; &#91;IC95&#37;&#93;&#58; 57-86&#37;&#41;&#44; una sensibilidad del 83&#37; y una especificidad del 61&#37;&#46; Para la LCT&#44; el punto de corte &#243;ptimo fue de 17&#44;5<span class="elsevierStyleHsp" style=""></span>mm&#44; con un &#225;rea bajo la curva ROC del 74&#37; &#40;IC95&#37;&#58; 61-87&#37;&#41;&#44; una sensibilidad del 91&#37; y una especificidad del 57&#37;&#46; Empleando ambos criterios&#44; el rendimiento diagn&#243;stico mejor&#243; con un &#225;rea bajo la curva ROC del 77&#37; &#40;IC95&#37;&#58; 62-92&#37;&#41;&#44; una sensibilidad del 77&#37; y una especificidad del 61&#37;&#46; Se calcul&#243; un modelo de regresi&#243;n log&#237;stica y se obtuvo un &#225;rea bajo la curva ROC del 82&#37; &#40;IC95&#37;&#58; 73-93&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso de criterios cuantitativos mejora la exactitud diagn&#243;stica de la resonancia magn&#233;tica multiparam&#233;trica en la estadificaci&#243;n del c&#225;ncer de pr&#243;stata&#46; Se encontr&#243; que los valores de ADC y de LCT son predictores de EEC microsc&#243;pica&#44; y que se obtienen mejores resultados si se usan de manera conjunta&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Granja MF&#44; Pedraza CM&#44; Fl&#243;rez DC&#44; Romero JA&#44; Palau MA&#44; Aguirre DA&#46; Predicci&#243;n de la extensi&#243;n extracapsular en el c&#225;ncer de pr&#243;stata mediante la longitud del contacto tumoral y el coeficiente de difusi&#243;n aparente&#46; Radiolog&#237;a&#46; 2017&#59;59&#58;313&#8211;320&#46;</p>"
      ]
    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fifty-one year old-patient with Gleason 8 prostate cancer &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; located in the peripheral area of the middle third of the left side&#46; &#40;A&#41; Axial T2-weighted image showing one red line as the measurement of tumor contact length with a 19&#46;7<span class="elsevierStyleHsp" style=""></span>mm capsule&#46; &#40;B&#41; Axial image of the apparent diffusion coefficient map &#40;b 800&#41; with a value of 0&#46;645<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#46; This injury showed microscopic extracapsular spread in the pathology report&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sixty-five year old-patient with Gleason 8 prostate cancer &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41; located in the peripheral area of the middle third of the left side&#46; &#40;A&#41; Axial T2-weighted image showing one red line as the measurement of tumor contact length with a 26&#46;5<span class="elsevierStyleHsp" style=""></span>mm capsule&#46; &#40;B&#41; Axial image of the apparent diffusion coefficient map &#40;b 800&#41; with a value of 0&#46;798<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#46; This injury showed microscopic extracapsular spread in the pathology report&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ROC curves to predict extracapsular spread using different cut-off points of the quantitative values of the apparent diffusion coefficient map&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ROC curves to predict extracapsular spread using different cut-off points of the quantitative values of the tumor contact length with the capsule&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ROC curves to predict extracapsular spread using optimal cut-off points obtained for the quantitative values of the apparent diffusion coefficient map and tumor contact length with the capsule&#44; use of both criteria&#44; and estimated logistics regression model&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; average</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">PSA at the moment of diagnosis &#40;ng&#47;ml&#41;&#44; average</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Group-grade &#40;Gleason&#41; based on surgical specimen &#40;No&#46;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">92&#41;&#44; n &#40;per cent&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 1 &#40;&#8804;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 2 &#40;3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#40;36&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 3 &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#40;29&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 4 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 5 &#40;&#8805;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;10&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gleason grade &#40;No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Group-grade &#40;Gleason 1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Gleason 2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">ADC &#40;10</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">&#8722;3</span></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#47;s&#41;&#44; average</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 1 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 2 &#40;3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;01<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 3 &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;24<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 4 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 5 &#40;&#8805;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Group-grade &#40;Gleason 1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Gleason 2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Tumor contact length &#40;mm&#41;&#44; average</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 1 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 2 &#40;3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 3 &#40;4<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 4 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Group-grade 5 &#40;&#8805;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;09<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;80&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Receiver&#8211;operator characteristics and areas under the curve for the diagnosis of microscopic extracapsular spread using one logistics regression model and the presence of an apparent diffusion coefficient &#8804;0&#46;87<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s and a tumor contact length &#8805;17&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:26 [
            0 => array:3 [
              "identificador" => "bib0135"
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                  "host" => array:1 [
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                      "Revista" => array:5 [
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            1 => array:3 [
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                  "host" => array:1 [
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            2 => array:3 [
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            3 => array:3 [
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                          "etal" => true
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                            0 => "K&#46;K&#46; Chao"
                            1 => "N&#46;S&#46; Goldstein"
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                            0 => "M&#46;W&#46; Ball"
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                            1 => "J&#46; Richenberg"
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                            3 => "B&#46;K&#46; Park"
                            4 => "G&#46;Y&#46; Kwon"
                            5 => "J&#46;J&#46; Park"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2017.06.003

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Year/Month	Html	Pdf	Total

2024 October	2	0	2
2024 September	1	0	1
2024 August	3	0	3
2024 July	3	0	3
2024 June	3	0	3
2024 May	6	0	6
2024 April	1	0	1
2024 March	2	0	2
2023 December	3	0	3
2023 November	1	1	2
2023 September	2	0	2
2023 August	3	2	5
2023 July	2	0	2
2023 June	3	2	5
2023 May	3	0	3
2023 April	2	0	2
2023 March	2	0	2
2023 February	4	0	4
2023 January	1	0	1
2018 November	0	2	2
2018 May	1	0	1
2018 April	12	2	14
2018 March	10	1	11
2018 February	2	1	3
2018 January	13	6	19
2017 September	1	0	1

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