Prostate CancerA Prospective, Blinded Comparison of Magnetic Resonance (MR) Imaging–Ultrasound Fusion and Visual Estimation in the Performance of MR-targeted Prostate Biopsy: The PROFUS Trial
Introduction
Although increasing evidence supports use of multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy (MR-TB) in clinical practice, the optimal methodology for targeting magnetic resonance imaging (MRI)-suspicious regions (mSR) remains unknown [1], [2], [3], [4], [5], [6]. In-gantry prostate biopsy of mSR using real-time magnetic resonance (MR) guidance has been reported to have excellent outcomes, but the technique remains restricted to a few centers and is limited by multiple challenges, including a steep learning curve, time investment and the opportunity cost of magnet time [7], [8], [9], [10], [11]. Many investigators have used a visual, or cognitive, guidance technique in which the surgeon samples a visually estimated location on ultrasound that corresponds to the mSR location (VE-TB) [12], [13], [14]. The accuracy of MR-TB is influenced by multiple variables, including mSR size, alignment of prostate landmarks, and operator experience [15].
Software-based coregistration of MRI–ultrasound (MRI-US) targeted biopsy (MRF-TB) requires demarcation of mSR on prebiopsy MR images and software “fusion” of these images during real-time ultrasound imaging. Several MRF-TB platforms exist, but their accuracy compared with VE-TB remains unclear. Consequently, we undertook a prospective, blinded comparison of MRF-TB and VE-TB among men undergoing prostate biopsy.
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Study design and population
After receiving institutional review board approval, enrollment began on June 18, 2012, and closed on March 19, 2013. Consecutive men presenting for prostate biopsy underwent prebiopsy mpMRI and were offered inclusion on identification of any mSR. If included, all patients underwent informed consent. Over this period, 210 men presented for prostate biopsy, and 193 (91.9%) underwent mpMRI. Seventeen men (8.1%) were excluded because of MRI contraindications. Prebiopsy mpMRI demonstrated no
Study population
The clinical characteristics for these groups are detailed in Table 1. Among 125 men enrolled, 67 (54%) had had no prior prostate biopsy (group 1), 34 (27%) had had a prior negative prostate biopsy (group 2), and 24 (19%) had been previously diagnosed with low-risk cancer on active surveillance (group 3).
The study targeted 172 separate mSR, with an overall median suspicion score of 3 [2.0–4.0]. Single targets were present in 76 patients (60.8%), while 48 men (38.4%) had two separate mSR. A
Discussion
Much of the current dilemma regarding prostate cancer (PCa) screening, detection, and appropriate treatment can be attributed to the use of random sampling methods for prostate biopsy [20], [21], [22]. Standard biopsy relies on sampling efficiency for cancer detection, which intrinsically risks the consequences of sampling error: undersampling, oversampling, and inaccurate risk stratification [23]. Despite increasing evidence to support a benefit for MR-TB in PCa detection, the optimal method
Conclusions
In this study, MRF-TB was more often histologically informative than VE-TB, and although it did not provide a higher CDR, a trend toward an improved CDR with MRF-TB was noted in all subsets, suggesting a need for a larger sample size. Targeting was improved by MRF among smaller lesions. A software-based coregistration tool would likely assist the community adoption of MRI-TB, especially in centers that have limited experience with visual targeting. This study prompts additional work into the
References (26)
- et al.
Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves cancer detection following transrectal ultrasound biopsy and correlates with multiparametric magnetic resonance imaging
J Urol
(2011) - et al.
A novel stereotactic prostate biopsy system integrating pre-interventional magnetic resonance imaging and live ultrasound fusion
J Urol
(2011) - et al.
Magnetic resonance imaging for the detection, localisation, and characterisation of prostate cancer: recommendations from a European consensus meeting
Eur Urol
(2011) - et al.
How good is MRI at detecting and characterising cancer within the prostate?
Eur Urol
(2006) - et al.
Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review
Eur Urol
(2013) - et al.
Standards of reporting for MRI-targeted biopsy studies (START) of the prostate: recommendations from an international working group
Eur Urol
(2013) - et al.
Contemporary trends in low risk prostate cancer: risk assessment and treatment
J Urol
(2007) - et al.
Extended and saturation prostatic biopsy in the diagnosis and characterisation of prostate cancer: a critical analysis of the literature
Eur Urol
(2007) - et al.
Optimization of initial prostate biopsy in clinical practice: sampling, labeling and specimen processing
J Urol
(2013) - et al.
Systematic review of complications of prostate biopsy
Eur Urol
(2013)
Targeted prostate biopsy: opportunities and challenges in the era of multiparametric prostate magnetic resonance imaging
J Urol
Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen
J Urol
Magnetic resonance imaging targeted biopsy in men with previously negative prostate biopsy results
J Endourol
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