mpMRI-targeted biopsy had greater sensitivity than TRUS-guided biopsy ( 87 % versus 60 %) and a higher negative predictive value ( 72 % versus 65 %) for detecting Gleason score prostate cancer ≥3 + 4 , or cancer core length ≥4 mm . 8 Multiple studies have confirmed these findings with varying degrees of power , and increasingly there is consensus that mpMRI targeted biopsy should be included in the diagnostic pathway for men with elevated PSA possibly in the biopsy naive setting , and used definitively in the patient with a negative prior standard biopsy .
Currently there are two methods for sampling an MRI visualized lesion when performing a TRUS targeted biopsy : visual registration or software registration . While in bore biopsies ( within the MRI gantry ) are possible , the technical and radiologic expertise to perform these , as well as cost concerns , limit the use of this technique . Visual registration ( or Cognitive Fusion ) is limited by operator ability to interpret and overlay the MRI image on the TRUS image , and may be subject to a higher learning curve . Software registration ( Fusion with proprietary software ) overcomes the learning curve of visual registration and provide greater operator confidence in sampling the MRI targeted lesion . 9 At this time , no consensus statement is available to compare the two approaches . While some studies have demonstrated up to a 2.4 fold higher detection of clinically significant cancer , a randomized trial of 234 patients found no difference in the detection of clinically significant cancers between the two techniques . 10 Likely these investigations are limited , and while each technique has benefits and limitations , it ’ s ultimately at the operator ’ s discretion which technique is most feasible . The author prefers visual registration performed perineal due to the decreased risk of post biopsy sepsis and the ease of visual registration in this approach , though this is not universal . 11 One limitation to the perineal approach is that it ’ s performed typically in the OR with anesthesia and is more time and resource consuming than the traditional TRUS biopsy .
One concern with utilizing mpMRI in the triage of men with elevated PSA is the unknown effect on cost . While mpMRI is more expensive than traditional TRUS with standard 12 core biopsies , authors have argued that the cost mitigation of treatment related expenses may balance out this upfront increase in cost . Some studies evaluating cost effectiveness of this strategy have concluded that the most cost-effective strategy for detecting clinically significant prostate cancer is the use of mpMRI as the first test , followed by a transrectal mpMRI-targeted biopsy in men in whom the mpMRI suggests the presence of prostate cancer . Many authors conclude that not finding clinically indolent cancers is preferable to the over-detection and over-treatment associated with the traditional pathway , though as of yet no consensus statement exists with regards to this . 8
The utility of mpMRI does have limitations , much of which can be attributed to inter-observer variability in its interpretation . Much of this variability has been attributed to experiential discrepancies at centers with low volume versus high volume centers . Some series
UROLOGY : CLINICAL UPDATES FROM THE PRACTICE have indicated the inter-observer concordance can be as high as 80 % in centers with radiologists who have interpreted greater than 40 exams , and in those with prior training and feedback experience . The utility of mpMRI is unfortunately also limited by access , while most series utilize a 3 Tesla ( 3T ) MRI , these are not universally available . To overcome this , the PROMIS trial included centers with 1.5T MRI to improve the generalizability of these findings within the community at large . 8 In this trial , diagnostic performance was similar between the centers with 3T and 1.5T MRI indicating that widespread utility of mpMRI is feasible across health care systems .
Over the past decade , mpMRI has become an increasingly promising evaluation for patients with elevated PSA and those with prostate cancer . It ’ s possible , with ongoing study , that using this as a triage tool could improve the detection of clinically significant prostate cancers and improve the evaluation of an elevated PSA by providing a noninvasive screening examination which appropriately risk stratifies the patients for targeted biopsies .
References :
1
Andriole GL , Crawford ED , Grubb RL , 3rd , et al . Prostate cancer screening in the randomized Prostate , Lung , Colorectal , and Ovarian Cancer Screening Trial : mortality results after 13 years of follow-up . J Natl Cancer Inst . Jan 18 2012 ; 104 ( 2 ): 125-32 . doi : 10.1093 / jnci / djr500
2
Schroder FH , Hugosson J , Roobol MJ , et al . Screening and prostate-cancer mortality in a randomized European study . N Engl J Med . Mar 26 2009 ; 360 ( 13 ): 1320- 8 . doi : 10.1056 / NEJMoa0810084
3
Mottet N , Bellmunt J , Bolla M , et al . EAU-ESTRO-SIOG Guidelines on Prostate Cancer . Part 1 : Screening , Diagnosis , and Local Treatment with Curative Intent . Eur Urol . Apr 2017 ; 71 ( 4 ): 618-629 . doi : 10.1016 / j . eururo . 2016.08.003
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Serefoglu EC , Altinova S , Ugras NS , Akincioglu E , Asil E , Balbay MD . How reliable is 12-core prostate biopsy procedure in the detection of prostate cancer ? Can Urol Assoc J . May-Jun 2013 ; 7 ( 5-6 ): E293-8 . doi : 10.5489 / cuaj . 11224
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Schoots IG , Petrides N , Giganti F , et al . Magnetic resonance imaging in active surveillance of prostate cancer : a systematic review . Eur Urol . Apr 2015 ; 67 ( 4 ): 627- 36 . doi : 10.1016 / j . eururo . 2014.10.050
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Weinreb JC , Barentsz JO , Choyke PL , et al . PI-RADS Prostate Imaging - Reporting and Data System : 2015 , Version 2 . Eur Urol . Jan 2016 ; 69 ( 1 ): 16-40 . doi : 10.1016 / j . eururo . 2015.08.052
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Simmons LAM , Kanthabalan A , Arya M , et al . The PICTURE study : diagnostic accuracy of multiparametric MRI in men requiring a repeat prostate biopsy . Br J Cancer . Apr 25 2017 ; 116 ( 9 ): 1159-1165 . doi : 10.1038 / bjc . 2017.57
8
Ahmed HU , El-Shater Bosaily A , Brown LC , et al . Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer ( PROMIS ): a paired validating confirmatory study . Lancet . Feb 25 2017 ; 389 ( 10071 ): 815- 822 . doi : 10.1016 / S0140-6736 ( 16 ) 32401-1
9
Bjurlin MA , Meng X , Le Nobin J , et al . Optimization of prostate biopsy : the role of magnetic resonance imaging targeted biopsy in detection , localization and risk assessment . J Urol . Sep 2014 ; 192 ( 3 ): 648-58 . doi : 10.1016 / j . juro . 2014.03.117
10
Wegelin O , Exterkate L , van der Leest M , et al . The FUTURE Trial : A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies . Eur Urol . Apr 2019 ; 75 ( 4 ): 582-590 . doi : 10.1016 / j . eururo . 2018.11.040
11
Borghesi M , Ahmed H , Nam R , et al . Complications After Systematic , Random , and Image-guided Prostate Biopsy . Eur Urol . Mar 2017 ; 71 ( 3 ): 353-365 . doi : 10.1016 / j . eururo . 2016.08.004
Dr . Messer is an Associate Professor in the Department of Urology at the University of Louisville School of Medicine .
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