Technical improvements in prostate magnetic resonance imaging (MRI) have resulted in the use of MRI to target prostate biopsies.
Objective
To systematically review the literature to compare the accuracy of MRI-targeted biopsy with standard transrectal biopsy in the detection of clinically significant prostate cancer.
Evidence acquisition
The PubMed, Embase, and Cochrane databases were searched from inception until December 3, 2011, using the search criteria ‘prostate OR prostate cancer’ AND ‘magnetic resonance imaging OR MRI’ AND ‘biopsy OR target’. Four reviewers independently assessed 4222 records; 222 records required full review. Fifty unique records (corresponding to 16 discrete patient populations) directly compared an MRI-targeted with a standard transrectal approach.
Evidence synthesis
Evidence synthesis was used to address specific questions. Where MRI was applied to all biopsy-naive men, 62% (374 of 599) had MRI abnormalities. When subjected to a targeted biopsy, 66% (248 of 374) had prostate cancer detected. Both targeted and standard biopsy detected clinically significant cancer in 43% (236 or 237 of 555, respectively). Missed clinically significant cancers occurred in 13 men using targeted biopsy and 12 using a standard approach. Targeted biopsy was more efficient. A third fewer men were biopsied overall. Those who had biopsy required a mean of 3.8 targeted cores compared with 12 standard cores. A targeted approach avoided the diagnosis of clinically insignificant cancer in 53 of 555 (10%) of the presenting population.
Conclusions
MRI-guided biopsy detects clinically significant prostate cancer in an equivalent number of men versus standard biopsy. This is achieved using fewer biopsies in fewer men, with a reduction in the diagnosis of clinically insignificant cancer. Variability in study methodology limits the strength of recommendation that can be made. There is a need for a robust multicentre trial of targeted biopsies.
Introduction
In a lecture delivered in 2008, Dr. Patrick Walsh made the following statement: “The discovery that would have the greatest impact on our field would be the development of accurate imaging of tumour within the prostate” [1].
The original six-core transrectal prostate biopsy, termed random systematic by Stamey in 1989 [2], has incorporated more cores over time, with 10–12 cores being an accepted practice standard. This has increased the negative predictive value of the transrectal biopsy but has led to an increase in the detection of low-volume, low-risk disease. Worldwide postmortem studies using 3-mm step section histology have demonstrated that such disease is present in >40% of men >50 yr of age [3].
In addition, the standard transrectal approach is poor at sampling cancers in the anterior, midline, and apex, leading to the underdiagnosis of clinically significant disease. Up to one in three biopsy diagnoses of low-volume, low-risk cancers are upgraded or upstaged at whole mount step section pathology [4].
The prostate is the only solid organ in which a standardised approach to sampling is taken. All other diagnostic pathways for solid or hollow organ cancers incorporate either direct (eg, cystoscopic) or radiologic imaging (ultrasound, computed tomography [CT], magnetic resonance imaging [MRI]) to identify areas of greater likelihood of cancer for subsequent assessment.
MRI has been shown to have a high degree of accuracy in the detection of clinically significant prostate cancer when compared with radical prostatectomy histology [5]. When functional parameters such as dynamic contrast enhancement (DCE), diffusion-weighted imaging (DWI), and spectroscopy are used, in addition to standard T1- and T2-weighted sequences, MRI may afford an opportunity for a similar image-guided approach to the prostate [6].
This systematic review addresses the following question: In men with a clinical suspicion of prostate cancer, based on a raised prostate-specific antigen (PSA) or an abnormal digital rectal examination (DRE), does an MRI-guided biopsy strategy result in a higher detection rate of clinically significant cancer and a lower detection rate of clinically insignificant cancer compared with standard transrectal ultrasound (TRUS)-guided biopsy?
Section snippets
Evidence acquisition
An initial search was carried out to identify articles for further review, using PubMed and Embase databases, Cochrane reviews, the Cochrane database of clinical trials, and the database of abstracts of reviews of effects. The search terms used were ‘prostate OR prostate cancer’ AND ‘magnetic resonance imaging OR MRI’ AND ‘biopsy OR target’. Abstracts were reviewed for relevance to the defined review question. If it was not clear from the abstract whether the paper might contain relevant data,
Evidence synthesis
Use of evidence synthesis has allowed us to address some clinically important questions in relation to the use of MRI to inform the conduct of the biopsy.
Conclusions
In men with a clinical suspicion of prostate cancer, a biopsy of the prostate that used MRI to inform the sampling was associated with a detection rate of clinically significant prostate cancer of 42%. This approach might permit a reduction in the number of men—possibly up to a third—who need to undergo biopsy if they are deemed to have a normal MRI. The efficiency (number of clinically significant prostate cancers/number of men biopsied) of the targeted sampling appeared superior to the
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Role of magnetic resonance imaging before initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer detection
Prostate cancer in the anterior region may be missed on a transrectal systematic biopsy (SBx). Therefore, this study aimed to evaluate the performance of magnetic resonance imaging-transrectal ultrasound (MRI-TRUS) fusion targeted biopsy (TBx) in detecting anterior region cancer in patients with a history of SBxs.
Prostate biopsies were performed in 224 patients after multiparametric MRI, among whom 119 patients with prostate imaging reporting and data system (PI-RADS version 2) scores of 3 to 5 underwent MRI-TRUS fusion TBxs. Afterward, cancer detection rates (CDRs) and TBx-positive core regions were compared by categorizing patients into those with or without a history of SBxs.
Total CDR was 68.8% (44/64 cases) in the initial biopsy group (Initial-Bx group) and 47.3% (26/55 cases) in the previous-negative-systematic biopsy group (Pre-Neg-SBx group) (P = 0.018). Interestingly, both TBx- and SBx-core positive cases were more common in the Initial-Bx group than in the Pre-Neg-SBx group (Initial-Bx group: 75% [33/44 cases] vs. Pre-Neg-SBx group: 42.3% [11/26 cases], P = 0.006). However, only TBx-core positive cases were more common in the Pre-Neg-SBx group than in the Initial-Bx group (Initial-Bx group: 11.4% [5/44 cases] vs. Pre-Neg-SBx group: 30.8% [8/26 cases], P = 0.043). In addition, the proportion of anterior lesions detected by TBx cores was higher in the Pre-Neg-SBx group than in the Initial-Bx group (Initial-Bx group: 26.3% [10/38 cases] vs. Pre-Neg-SBx group: 52.6% [10/19 cases], P = 0.049).
Using MRI-TRUS fusion TBx in the evaluation of previously negative SBx cases improved the detection rate of anterior lesions, which might have been missed in previous SBxs. Especially in patients with a history of SBxs mpMRI should be performed to screen for anterior lesions.
The number of core biopsies required per region of interest (ROI) is controversial, as is the localization of the core to be taken from a lesion. This study aimed to determine the ideal biopsy core number and location in a multiparametric magnetic resonance imaging guided targeted prostate biopsy (TPB), without reducing the clinically significant prostate cancer (csPC) detection rate.
Data of patients who had PI-RADS ≥3 lesions on multiparametric magnetic resonance imaging and underwent a TPB in our clinic between October 2020 and January 2022 were reviewed, retrospectively. The first and second cores were taken from the central part of the ROI, whereas the third and fourth cores were taken from the right and left peripheries of the ROI. We compared the csPC detection success of single-, 2-, 3-, and 4-core samplings.
Software-based transrectal TPB was performed on 251 ROIs in a total of 167 patients. Internal Society of Urological Pathology Grade Group ≥2 cancer was detected in at least one core in 64 (25.4%) lesions. Moreover, csPC was detected in 42 (65.6%) ROIs in first-core biopsies; in 59 (92.2%) ROIs in first- and second-core biopsies; in 62 (96.9%) ROIs in first-, second-, and third-core biopsies; and in 64 (100%) ROIs in first-, second-, third-, and fourth-core biopsies. Using McNemar's test for comparison, a significant difference was found in terms of csPC detection success between performing first-core and second-core biopsies (65.6 – 92.2%, p < 0.001); by contrast, no significant difference was observed in csPC detection success between 2-core and 3-core biopsies (92.2% - 96.9%, p = 0.24). Furthermore, no significant difference existed between performing second-core and fourth-core biopsies in terms of csPC detection success (92.2%–100%, p = 0.07).
We concluded that taking 2-core biopsies from the center of each ROIs during a transrectal TPB is sufficient for diagnosing csPC.
2023, Journal of the American College of Radiology
Prostate cancer is second leading cause of death from malignancy after lung cancer in American men. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, establishing disease extent (both local and distant), and evaluating aggressiveness, which are the driving factors of patient outcomes such as recurrence and survival. Prostate cancer is typically diagnosed after the recognizing elevated serum prostate-specific antigen level or abnormal digital rectal examination. Tissue diagnosis is obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy, commonly with multiparametric MRI without or with intravenous contrast, which has recently been established as standard of care for detecting, localizing, and assessing local extent of prostate cancer. Although bone scintigraphy and CT are still typically used to detect bone and nodal metastases in patients with intermediate- or high-risk prostate cancer, novel advanced imaging modalities including prostatespecific membrane antigen PET/CT and whole-body MRI are being more frequently utilized for this purpose with improved detection rates. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
MRI-guided biopsy (MGB) contributes to the diagnosis of clinically significant Prostate Cancer (csPCa). However, there are no clear recommendations for the management of men after a negative MGB. The aim of this study was to assess the risk of csPCa after a first negative MGB.
Between 2014 and 2020, we selected men with a PI-RADS score ≥ 3 on MRI and a negative MGB (showing benign findings) performed for suspected prostate cancer. MGB (targeted and systematic biopsies) was performed using fully integrated mobile fusion imaging (KOELIS). The primary endpoint was the rate of csPCa (defined as an ISUP grade ≥ 2) diagnosed after a first negative MGB.
A total of 381 men with a negative MGB and a median age of 65 (IQR: 59–69, range: 46–85) years were included. During the median follow-up of 31 months, 124 men (32.5%) had a new MRI, and 76 (19.9%) were referred for a new MGB, which revealed csPCa in 16 (4.2%) of them. We found no statistical difference in the characteristics of men diagnosed with csPCa compared with men with no csPCa after the second MGB.
We observed a risk of significant prostate cancer in 4% of men two years after a negative MRI-guided biopsy. Performing a repeat MRI could improve the selection of men who will benefit from a repeat MRI-guided biopsy, but a clear protocol is needed to follow these patients.
4
La biopsie guidée par IRM (BGI) contribue au diagnostic de cancer de prostate cliniquement significatif (CaPcs). Cependant, peu de données ont été rapportées sur la prise en charge des hommes après une BGI négative. L’objectif de cette étude était d’évaluer le risque de CaPcs après une première BGI négative.
Entre 2014 et 2020, nous avons sélectionné des hommes avec un score PI-RADS ≥ 3 à l’IRM et une BGI négative (montrant des lésions bénignes) réalisée pour suspicion de cancer de la prostate. La BGI (biopsie ciblée et systématique) a été réalisée à l’aide d’une imagerie de fusion entièrement intégrée (KOELIS). Le critère d’évaluation principal était le taux de CaPcs (défini par un grade ISUP ≥ 2) diagnostiqué après une première BGI négative.
Un total de 381 hommes avec une BGI négative et un âge médian de 65 ans (écart interquartile : 59–69, tranche d’âge : 46–85) ont été inclus. Au cours du suivi médian de 31 mois, 124 hommes (32,5 %) ont eu une nouvelle IRM, et 76 (19,9 %) ont été adressés pour une nouvelle BGI, qui a révélé un CaPcs chez 16 (4,2 %) d’entre eux. Nous n’avons pas trouvé de différence statistique dans les caractéristiques des hommes diagnostiqués avec un CaPcs comparés aux hommes sans CaPcs après la seconde BGI.
Nous avons observé un risque de cancer de la prostate significatif chez 4 % des hommes deux ans après une biopsie guidée par IRM négative. La réalisation d’une nouvelle IRM pourrait améliorer la sélection des hommes qui bénéficieront d’une nouvelle biopsie guidée par IRM, mais un protocole clair est nécessaire pour suivre ces patients.
In our previous studies, we demonstrated the ability of an interstitial all-optical needle photoacoustic (PA) sensing probe and PA spectral analysis (PASA) to assess the aggressiveness of prostate cancer. In this clinical translation investigation, we integrated the optical components of the needle PA sensing probe into a 18G steel needle. The translational needle PA sensing probe was evaluated using intact human prostates in a simulated ultrasound-guided transperineal prostate biopsy. PA signals were acquired at 1220 nm, 1370 nm, 800 nm and 266 nm at each interstitial measurement location and quantified by PASA within the frequency range of 8–28 MHz. The measurement locations were stained for establishing spatial correlations between the quantitative measurements and the histological diagnosing. Most of the quantitative PA assessments reveal statistically significant differences between the benign and cancerous regions. Multivariate analysis combining the PASA quantifications shows an accuracy close to 90% in differentiating the benign and cancerous regions in the prostates.
Pathology is currently the gold standard for grading prostate cancer (PCa). However, pathology takes considerable time to provide a final result and is significantly dependent on subjective judgment. In this study, wavelet transform-based photoacoustic power spectrum analysis (WT-PASA) was used for grading PCa with different Gleason scores (GSs). The tumor region was accurately identified via wavelet transform time-frequency analysis. Then, a linear fitting was conducted on the photoacoustic power spectrum curve of the tumor region to obtain the quantified spectral parameter slope. The results showed that high GSs have small glandular cavity structures and higher heterogeneity, and consequently, the slopes at both 1210 nm and 1310 nm were high (p < 0.01). The classification accuracy of the PA time frequency spectrum (PA-TFS) of tumor region using ResNet-18 was 89% at 1210 nm and 92.7% at 1310 nm. Further, the testing time was less than 7 mins. The results demonstrated that identification of PCa can be rapidly and objectively realized using WT-PASA.
