Tag Archive for: prostate imaging

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Article of the Week: With a previous negative prostate biopsy and a suspicious lesion on MRI, is a 12-core biopsy still necessary in addition to a targeted biopsy?

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Art R. Rastinehad , discussing his paper. 

If you only have time to read one article this week, it should be this one.

In patients with a previous negative prostate biopsy and a suspicious lesion on magnetic resonance imaging, is a 12-core biopsy still necessary in addition to a targeted biopsy?

Simpa S. Salami*, Eran Ben-Levi, Oksana Yaskiv, Laura Ryniker*, Baris Turkbey§, Louis R. Kavoussi*, Robert Villani† and Ardeshir R. Rastinehad*

 

*The Arthur Smith Institute for Urology, Department of Diagnostic and Interventional Radiology, and Department of Pathology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, and § Molecular Imaging Program, National Institutes of Health, Bethesda, MD, USA

 

OBJECTIVES

To evaluate the performance of multiparametric magnetic resonance imaging (mpMRI) in predicting prostate cancer on repeat biopsy; and to compare the cancer detection rates (CDRs) of MRI/transrectal ultrasonography (TRUS) fusion-guided biopsy with standard 12-core biopsy in men with at least one previous negative biopsy.

PATIENTS AND METHODS

We prospectively enrolled men with elevated or rising PSA levels and/or abnormal digital rectal examination into our MRI/TRUS fusion-guided prostate biopsy trial. Participants underwent a 3 T mpMRI with an endorectal coil. Three radiologists graded all suspicious lesions on a 5-point Likert scale. MRI/TRUS fusion-guided biopsies of suspicious prostate lesions and standard TRUS-guided 12-core biopsies were performed. Analysis of 140 eligible men with at least one previous negative biopsy was performed. We calculated CDRs and estimated area under the receiver operating characteristic curves (AUCs) of mpMRI in predicting any cancer and clinically significant prostate cancer.

RESULTS

The overall CDR was 65.0% (91/140). Higher level of suspicion on mpMRI was significantly associated with prostate cancer detection (P < 0.001) with an AUC of 0.744 compared with 0.653 and 0.680 for PSA level and PSA density, respectively. The CDRs of MRI/TRUS fusion-guided and standard 12-core biopsy were 52.1% (73/140) and 48.6% (68/140), respectively (P = 0.435). However, fusion biopsy was more likely to detect clinically significant prostate cancer when compared with the 12-core biopsy (47.9% vs 30.7%; P < 0.001). Of the cancers missed by 12-core biopsy, 20.9% (19/91) were clinically significant. Most cancers missed by 12-core biopsy (69.6%) were located in the anterior fibromuscular stroma and transition zone. Using a fusion-biopsy-only approach in men with an MRI suspicion score of ≥4 would have missed only 3.5% of clinically significant prostate cancers.

CONCLUSIONS

Using mpMRI and subsequent MRI/TRUS fusion-guided biopsy platform may improve detection of clinically significant prostate cancer in men with previous negative biopsies. Addition of a 12-core biopsy may be needed to avoid missing some clinically significant prostate cancers.

Editorial: A urologists’ guide to the multi-parametric magnetic resonance imaging (mpMRI)-galaxy

The rise of multi-parametric MRI (mpMRI) for the assessment of patients with suspicion of prostate cancer has led to an enormous shift in the practice of every urologist dealing with frontline diagnostics [1].

At the same time, researchers and industry have identified acres of fruitful soil to place the seeds of their respective interests, sometimes in collaboration with each other producing valuable contributions to this shift in practice, sometimes taking benefits by merely assimilating themselves or their product to this development.

Both, the speed of change and the extent of proliferation, make it almost impossible for by-standing clinicians to keep up and filter the evidence-based essence for their local practice.

There are three important issues that need to be considered:

1 The Quality of mpMRI

The development of mpMRI for prostate assessment occurred over the last decade with well-known leaders pushing the frontiers. Their research benefitted from their individual experience of interpreting and reporting MRIs. This is then reflected in their outcomes in form of cancer detection rates and accuracy. More recently we have identified that achieving these results must involve standardisation of MRI protocols and reading [2-4], systematic training in validated courses and a significant learning curve [5]. The latter is only possible to achieve if the practice is embedded in a collaborative team of radiologists, pathologists and urologists. But even then it may be impossible for local teams to deliver the published accuracy, and the urologists and radiologists need to be mindful of that when counselling patients using mpMRI in their local environment.

2 The Technical and Clinical Validity of MRI-Based Biopsies

Transperineal vs transrectal, targeted alone vs targeted with systematic, cognitive vs fusion biopsies – these are the key debates surrounding the application of mpMRI into the urologists’ armamentarium. For none of them there is or will be a unified answer.

Transrectal approaches suit office-based provision of primary diagnostics in many European and USA health economies; although purists can say that the increasing risk of sepsis from antibiotic-resistant bacteria is not acceptable. But, favouring the less infection-prone transperineal approaches will have impact on theatre capacities even in a hospital-based health system like the UK.

Considering the current real-time quality of mpMRI, systematic biopsies in addition to targeted ones are still necessary. Urologists as a group have to come to an agreement about what is acceptable as a remaining risk when reducing or omitting systematic cores.

Cognitive targeting has been shown to be highly accurate; yet, fusion may offer standardisation and reduce user dependency. Not all fusion software on the market has undergone a thorough validated technical development and clinical accuracy evaluation. Peer-reviewed publications can be found involving the systems Urostation-Koelis, Uronav-Philips, Artemis and BiopSee-Medcom.

3 Translation into Clinical Practice

The positioning of the mpMRI within the assessment algorithm is key to optimise the benefit. Use as a pre-biopsy assessment tool may allow omission of further biopsies in some patients or facilitate targeting [6]. However, an established skill in the use of mpMRI and mpMRI-based biopsy is essential. Many UK centres have started the use of mpMRI in their practice further downstream in patients with persistent suspicion after negative first biopsies with good results for patients. It is already part of guidance that active surveillance should involve the use of MRI [1]. Some leading centres advocate that the diagnosis should be confirmed by MRI-based targeted and systematic biopsies.

Knowing that mpMRI will improve the accuracy of our assessment, we need to re-consider follow-up protocols. Increased certainty should be reflected in an improved cancer-related outcome, better patient experience and reduction in costs for the health system.

Prostate mpMRI as part of the urologists’ armamentarium is here to stay. A standardised team- and evidence-based approach will allow us to remain in control of the destination it leads us to.

Christof Kastner
Cambridge University Hospitals, Cambridge, UK

Video: Is a 12-core biopsy still necessary in addition to a targeted biopsy?

In patients with a previous negative prostate biopsy and a suspicious lesion on magnetic resonance imaging, is a 12-core biopsy still necessary in addition to a targeted biopsy?

Simpa S. Salami*, Eran Ben-Levi, Oksana Yaskiv, Laura Ryniker*, Baris Turkbey§, Louis R. Kavoussi*, Robert Villani† and Ardeshir R. Rastinehad*

 

*The Arthur Smith Institute for Urology, Department of Diagnostic and Interventional Radiology, and Department of Pathology, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, and § Molecular Imaging Program, National Institutes of Health, Bethesda, MD, USA

 

OBJECTIVES

To evaluate the performance of multiparametric magnetic resonance imaging (mpMRI) in predicting prostate cancer on repeat biopsy; and to compare the cancer detection rates (CDRs) of MRI/transrectal ultrasonography (TRUS) fusion-guided biopsy with standard 12-core biopsy in men with at least one previous negative biopsy.

PATIENTS AND METHODS

We prospectively enrolled men with elevated or rising PSA levels and/or abnormal digital rectal examination into our MRI/TRUS fusion-guided prostate biopsy trial. Participants underwent a 3 T mpMRI with an endorectal coil. Three radiologists graded all suspicious lesions on a 5-point Likert scale. MRI/TRUS fusion-guided biopsies of suspicious prostate lesions and standard TRUS-guided 12-core biopsies were performed. Analysis of 140 eligible men with at least one previous negative biopsy was performed. We calculated CDRs and estimated area under the receiver operating characteristic curves (AUCs) of mpMRI in predicting any cancer and clinically significant prostate cancer.

RESULTS

The overall CDR was 65.0% (91/140). Higher level of suspicion on mpMRI was significantly associated with prostate cancer detection (P < 0.001) with an AUC of 0.744 compared with 0.653 and 0.680 for PSA level and PSA density, respectively. The CDRs of MRI/TRUS fusion-guided and standard 12-core biopsy were 52.1% (73/140) and 48.6% (68/140), respectively (P = 0.435). However, fusion biopsy was more likely to detect clinically significant prostate cancer when compared with the 12-core biopsy (47.9% vs 30.7%; P < 0.001). Of the cancers missed by 12-core biopsy, 20.9% (19/91) were clinically significant. Most cancers missed by 12-core biopsy (69.6%) were located in the anterior fibromuscular stroma and transition zone. Using a fusion-biopsy-only approach in men with an MRI suspicion score of ≥4 would have missed only 3.5% of clinically significant prostate cancers.

CONCLUSIONS

Using mpMRI and subsequent MRI/TRUS fusion-guided biopsy platform may improve detection of clinically significant prostate cancer in men with previous negative biopsies. Addition of a 12-core biopsy may be needed to avoid missing some clinically significant prostate cancers.

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