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Erschienen in: memo - Magazine of European Medical Oncology 4/2018

Open Access 12.11.2018 | short review

Short review of biparametric prostate MRI

verfasst von: Dr. Fabian Steinkohl, PhD PD Dr. Renate Pichler, PD Dr. Daniel Junker

Erschienen in: memo - Magazine of European Medical Oncology | Ausgabe 4/2018

Summary

Magnetic resonance imaging (MRI) of the prostate has become the gold standard for visualization of prostate cancer. Prostate MRI is usually performed as multiparametric MRI (mpMRI). Since mpMRI has several drawbacks, a biparametric MRI (bpMRI) of the prostate has been proposed. Many studies have been published on mpMRI and bpMRI in recent years. This short review offers an overview of the latest developments in this rapidly evolving field of research.

Introduction

Prostate carcinoma (PCa) is the most common cancer in men [1]. PCa is suspected because of a positive digital rectal examination of the prostate or because of high values of prostate-specific antigen. This antigen is produced by normal but also by malignant prostatic epithelium [2] and is widely used as a screening tool for PCa. Usually, a systematic biopsy of the prostate is performed to clarify this suspicion. This approach has a sensitivity of only 50% [3]. If the systematic biopsy of the prostate is negative but PCa is still suspected, magnetic resonance imaging (MRI) of the prostate can be performed. MRI can identify suspicious lesions with a high diagnostic accuracy [4]. The first study on the diagnostic value of pelvic MRI was published in 1983 [5]. According to Hricak et al., it was unclear whether MRI can distinguish neoplastic nodules from benign prostatitis. The field of prostate MRI has been developing rapidly since then. A milestone was the introduction of the Prostate Imaging Reporting and Data System (PI-RADS) in 2012 [6]. PI-RADS standardized prostate MRI protocols and standardized image interpretation and reporting of prostate MRI. PI-RADS is also used to communicate imaging findings between radiologists and the referring physician. PI-RADS assigns scores for lesions in the prostate from 1 to 5. PI-RADS 1 means “clinically significant PCa is highly unlikely,” PI-RADS 5 means “clinically significant cancer is highly likely” (Table 1).
Table 1
PI-RADS scores and their definition according to the ESUR panel
PI-RADS score
Definition of the ESUR panel
1
Clinically significant cancer is highly unlikely
2
Clinically significant cancer is unlikely
3
Presence of clinically significant cancer is equivocal
4
Clinically significant cancer is likely
5
Clinically significant cancer is highly likely
PI-RADS Prostate Imaging Reporting and Data System, ESUR European Society of Urogenital Radiology
In recent years, prostate MRI is increasingly used to visualize PCa [7]. A new, simplified version, PI-RADS v2 was introduced in 2012 [8]. PI-RADS v2, too, is based on multiplanar T2-weighted sequences (T2w), diffusion-weighted sequences (DWI), and dynamic contrast-enhanced sequences (DCE). The prostatic anatomy is evaluated in the T2w sequences. The prostatic zones can be discriminated and important extraprostatic structures, such as the neurovascular bundles, can be seen. DWI is the key sequence in the PI-RADS system. PCa has a higher cell density than the surrounding normal prostatic tissue. Hence, the Brownian motion within the tumor is limited. This diffusion restriction can be visualized with DWI, but the spatial resolution of DWI is low. Intravenous contrast agent, usually gadolinium, has to be administered for the DCE sequences. DCE shows the contrast enhancement of the prostate over the time. PCa is believed to have an early gadolinium uptake and an early wash-out of the contrast agent. In the currently used PI-RADS v2, DCE plays a minor role. An early contrast enhancement in the DCE can lead to an upgrading from PI-RADS 3 to PI-RADS 4. Combining the aforementioned different sequences in one MRI examination has become known as multiparametric MRI (mpMRI; Fig. 1). MpMRI is well evaluated, but it has several drawbacks. To overcome some of them, a number of groups have proposed a “biparametric prostate MRI” (bpMRI).
This short review summarizes the latest findings on bpMRI for radiologists and referring physicians.

Benefits of omitting DCE

In contrast to multiparametric MRI protocols, biparametric MRI protocols do not include DCE. Therefore, it has three major advantages: examination times are shorter, costs are lower, and the risk of adverse events with contrast agents is eliminated.

Examination time

Omitting an MRI sequence shortens the examination time. There are wide differences in the literature on how much time can be saved by using a biparametric approach. Obmann et al. found 11.9 min scanning time (and 15.7 min table time) for bpMRI and ±45 min for mpMRI [9]. This was confirmed by Dong Hoon Lee et al., who found an in-bore time of 15 min for bpMRI and 45 min for mpMRI [10]. Other authors found considerably shorter time differences between mpMRI and bpMRI. Junker et al. reported a time reduction of 12 min using bpMRI [11] and another group found a time reduction of only 2.30 min [12]. A very fast biparametric MRI protocol that takes only 8.45 min has been published by Kuhl et al. [13].

Costs for mpMRI

Performing a DCE involves direct costs for contrast agents and peripheral venous catheters as well as indirect costs for personnel and longer scanning times. Data for costs diverge in the literature. Junker et al. reported additional costs of about € 56 for a 70-kg patient only for the contrast agent [11]. A Korean group calculated costs of about $ 600 for mpMRI and only $ 300 for bmMRI [10].

Risk associated with contrast medium

The contrast medium used for DCE in mpMRI is gadolinium-based. The risk of immediate hypersensitivity reactions to a gadolinium-based contrast medium is low [14]. Until recently, gadolinium was considered to be safe [15], but it has emerged recently that gadolinium can form depositions in the brain [16]. Therefore, caution is called for when gadolinium is administered [17]. In view of these findings, it seems to be advisable to reconsider the necessity of DCE.

Diagnostic performance of mpMRI and bpMRI

Although DCE is part of the PI-RADS v2 guidelines [8] and is considered a cornerstone of prostatic MRI by some authors [18], its role is controversial in the literature. Greer and colleagues found that DCE significantly improves PCa detection in the peripheral zone of the prostate [19]. Some older studies found an improvement of PCa detection due to the use of DCE [20, 21]. A limited incremental value of 3% was calculated for DCE [22]. Recent studies state that DCE has no or only a limited role in PCa detection [2327]. The suspicion was raised that DCE could potentially increase the number of false-positive examinations [13]. These findings resonate well in the scientific community. To date, 16 articles can be found on PubMed.gov using the search terms “biparametric prostate MRI” from January 2018.
Two large meta-analyses have been published this year. One analyzed 33 studies from the period 2007–2017 [28], another one analyzed 20 studies, all published before December 2017 [29]. Xiang-ke Niu and colleagues found a pooled sensitivity of 0.81 and a specificity of 0.77 for bpMRI for PCa detection [28]. Woo et al. reported a pooled sensitivity of 0.74 and a specificity of 0.90 for bpMRI and a pooled sensitivity of 0.76 and a specificity of 0.89 for mpMRI. Therefore, the authors conclude that bpMRI has the same diagnostic performance as mpMRI for the detection of PCa [29]. Recent single-center studies from 2018 published similar results [7, 9, 11, 12, 30].

Reasons for using DCE

Although there are many good reasons for omitting the use of gadolinium-based contrast agents for prostate MRI, there are still situations in which DCE can be useful. DCE can be used to detect certain small PCa [24]. It can be used to monitor response to therapy after radical prostatectomy [31]. Additionally, we find that DCE helps to avoid typical pitfalls (e. g., in the anterior fibromuscular stroma) and to diagnose seminal vesicle infiltration or extracapsular extension.

Future developments of prostate MRI

Current multiparametric MRI protocols are designed to answer a variety of clinical questions (see above; [13]). The demand for prostate MRI rises since prostate MRI is used as a PCa screening tool prior to biopsy. In view of the latest publications it seems feasible to use bpMRI in these cases. Scialpi and colleagues proposed a new and simpler version of PI-RADS [24] that is based on a bpMRI. In their simplified PI-RADS, DWI is the dominant sequence in the peripheral and transition zone. Furthermore, the maximal size of a category 3 lesion is 0.5 cm3. Another advantage is that bpMRI images are easier to read. While a large Norwegian study found a poor inter-reader agreement for mpMRI [32], an Italian group reported that there is excellent agreement between different readers with different levels of experience for bpMRI [7].
PI-RADS v2 will continue to evolve. We believe that the use of DCE is not necessary in every patient, but the indication for administering gadolinium-based contrast agents will have to be considered individually depending on the clinical question.

Conclusion

During the past months, several studies have been published on biparametric prostate MRI protocols. All of them underline the feasibility of shorter biparametric protocols for PCa detection. In light of these findings, we believe that the need for administering contrast agents for prostate MRI has to be considered individually for each patient depending on the clinical question.

Conflict of interest

F. Steinkohl, R. Pichler, and D. Junker declare that they have no competing interests.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Literatur
1.
Zurück zum Zitat Global Burden of Disease Cancer C, Fitzmaurice C, Allen C, et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol. 2017;3:524–48. CrossRef Global Burden of Disease Cancer C, Fitzmaurice C, Allen C, et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol. 2017;3:524–48. CrossRef
2.
Zurück zum Zitat Stenman UH, Leinonen J, Zhang WM, et al. Prostate-specific antigen. Semin Cancer Biol. 1999;9:83–93. CrossRefPubMed Stenman UH, Leinonen J, Zhang WM, et al. Prostate-specific antigen. Semin Cancer Biol. 1999;9:83–93. CrossRefPubMed
3.
Zurück zum Zitat Brock M, Eggert T, Palisaar RJ, et al. Multiparametric ultrasound of the prostate: adding contrast enhanced ultrasound to real-time elastography to detect histopathologically confirmed cancer. J Urol. 2013;189:93–8. CrossRefPubMed Brock M, Eggert T, Palisaar RJ, et al. Multiparametric ultrasound of the prostate: adding contrast enhanced ultrasound to real-time elastography to detect histopathologically confirmed cancer. J Urol. 2013;189:93–8. CrossRefPubMed
4.
5.
Zurück zum Zitat Hricak H, Williams RD, Spring DB, et al. Anatomy and pathology of the male pelvis by magnetic resonance imaging. AJR Am J Roentgenol. 1983;141:1101–10. CrossRefPubMed Hricak H, Williams RD, Spring DB, et al. Anatomy and pathology of the male pelvis by magnetic resonance imaging. AJR Am J Roentgenol. 1983;141:1101–10. CrossRefPubMed
7.
Zurück zum Zitat Di Campli E, Delli Pizzi A, Seccia B, et al. Diagnostic accuracy of biparametric vs multiparametric MRI in clinically significant prostate cancer: comparison between readers with different experience. Eur J Radiol. 2018;101:17–23. CrossRefPubMed Di Campli E, Delli Pizzi A, Seccia B, et al. Diagnostic accuracy of biparametric vs multiparametric MRI in clinically significant prostate cancer: comparison between readers with different experience. Eur J Radiol. 2018;101:17–23. CrossRefPubMed
8.
Zurück zum Zitat Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS prostate imaging—reporting and data system: 2015, version 2. Eur Urol. 2016;69:16–40. CrossRefPubMed Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS prostate imaging—reporting and data system: 2015, version 2. Eur Urol. 2016;69:16–40. CrossRefPubMed
10.
Zurück zum Zitat Lee DH, Nam JK, Lee SS, et al. Comparison of multiparametric and biparametric MRI in first round cognitive targeted prostate biopsy in patients with PSA levels under 10 ng/mL. Yonsei Med J. 2017;58:994–9. CrossRefPubMedPubMedCentral Lee DH, Nam JK, Lee SS, et al. Comparison of multiparametric and biparametric MRI in first round cognitive targeted prostate biopsy in patients with PSA levels under 10 ng/mL. Yonsei Med J. 2017;58:994–9. CrossRefPubMedPubMedCentral
13.
Zurück zum Zitat Kuhl CK, Bruhn R, Kramer N, et al. Abbreviated biparametric prostate MR imaging in men with elevated prostate-specific antigen. Radiology. 2017;285:493–505. CrossRefPubMed Kuhl CK, Bruhn R, Kramer N, et al. Abbreviated biparametric prostate MR imaging in men with elevated prostate-specific antigen. Radiology. 2017;285:493–505. CrossRefPubMed
14.
Zurück zum Zitat Jung JW, Kang HR, Kim MH, et al. Immediate hypersensitivity reaction to gadolinium-based MR contrast media. Radiology. 2012;264:414–22. CrossRefPubMed Jung JW, Kang HR, Kim MH, et al. Immediate hypersensitivity reaction to gadolinium-based MR contrast media. Radiology. 2012;264:414–22. CrossRefPubMed
15.
Zurück zum Zitat Deray G, Rouviere O, Bacigalupo L, et al. Safety of meglumine gadoterate (Gd-DOTA)-enhanced MRI compared to unenhanced MRI in patients with chronic kidney disease (RESCUE study). Eur Radiol. 2013;23:1250–9. CrossRefPubMed Deray G, Rouviere O, Bacigalupo L, et al. Safety of meglumine gadoterate (Gd-DOTA)-enhanced MRI compared to unenhanced MRI in patients with chronic kidney disease (RESCUE study). Eur Radiol. 2013;23:1250–9. CrossRefPubMed
16.
Zurück zum Zitat McDonald RJ, McDonald JS, Kallmes DF, et al. Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology. 2015;275:772–82. CrossRefPubMed McDonald RJ, McDonald JS, Kallmes DF, et al. Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology. 2015;275:772–82. CrossRefPubMed
17.
Zurück zum Zitat Gulani V, Calamante F, Shellock FG, et al. Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol. 2017;16:564–70. CrossRefPubMed Gulani V, Calamante F, Shellock FG, et al. Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol. 2017;16:564–70. CrossRefPubMed
18.
Zurück zum Zitat Puech P, Sufana-Iancu A, Renard B, et al. Prostate MRI: can we do without DCE sequences in. Diagn Interv Imaging. 2013;94:1299–311. CrossRefPubMed Puech P, Sufana-Iancu A, Renard B, et al. Prostate MRI: can we do without DCE sequences in. Diagn Interv Imaging. 2013;94:1299–311. CrossRefPubMed
19.
Zurück zum Zitat Greer MD, Shih JH, Lay N, et al. Validation of the dominant sequence paradigm and role of dynamic contrast-enhanced imaging in PI-RADS version 2. Radiology. 2017;285:859–69. CrossRefPubMedPubMedCentral Greer MD, Shih JH, Lay N, et al. Validation of the dominant sequence paradigm and role of dynamic contrast-enhanced imaging in PI-RADS version 2. Radiology. 2017;285:859–69. CrossRefPubMedPubMedCentral
20.
Zurück zum Zitat Delongchamps NB, Beuvon F, Eiss D, et al. Multiparametric MRI is helpful to predict tumor focality, stage, and size in patients diagnosed with unilateral low-risk prostate cancer. Prostate Cancer Prostatic Dis. 2011;14:232–7. CrossRefPubMed Delongchamps NB, Beuvon F, Eiss D, et al. Multiparametric MRI is helpful to predict tumor focality, stage, and size in patients diagnosed with unilateral low-risk prostate cancer. Prostate Cancer Prostatic Dis. 2011;14:232–7. CrossRefPubMed
21.
Zurück zum Zitat Tamada T, Sone T, Higashi H, et al. Prostate cancer detection in patients with total serum prostate-specific antigen levels of 4–10 ng/mL: diagnostic efficacy of diffusion-weighted imaging, dynamic contrast-enhanced MRI, and T2-weighted imaging. AJR Am J Roentgenol. 2011;197:664–70. CrossRefPubMed Tamada T, Sone T, Higashi H, et al. Prostate cancer detection in patients with total serum prostate-specific antigen levels of 4–10 ng/mL: diagnostic efficacy of diffusion-weighted imaging, dynamic contrast-enhanced MRI, and T2-weighted imaging. AJR Am J Roentgenol. 2011;197:664–70. CrossRefPubMed
22.
Zurück zum Zitat Vargas HA, Hotker AM, Goldman DA, et al. Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference. Eur Radiol. 2016;26:1606–12. CrossRefPubMed Vargas HA, Hotker AM, Goldman DA, et al. Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference. Eur Radiol. 2016;26:1606–12. CrossRefPubMed
23.
Zurück zum Zitat Stanzione A, Imbriaco M, Cocozza S, et al. Biparametric 3T magnetic resonance imaging for prostatic cancer detection in a biopsy-naive patient population: a further improvement of PI-RADS v2? Eur J Radiol. 2016;85:2269–74. CrossRefPubMed Stanzione A, Imbriaco M, Cocozza S, et al. Biparametric 3T magnetic resonance imaging for prostatic cancer detection in a biopsy-naive patient population: a further improvement of PI-RADS v2? Eur J Radiol. 2016;85:2269–74. CrossRefPubMed
24.
Zurück zum Zitat Scialpi M, Prosperi E, D’Andrea A, et al. Biparametric versus multiparametric MRI with non-endorectal coil at 3T in the detection and localization of prostate cancer. Anticancer Res. 2017;37:1263–71. CrossRefPubMed Scialpi M, Prosperi E, D’Andrea A, et al. Biparametric versus multiparametric MRI with non-endorectal coil at 3T in the detection and localization of prostate cancer. Anticancer Res. 2017;37:1263–71. CrossRefPubMed
25.
Zurück zum Zitat Mussi TC, Martins T, Garcia RG, et al. Are dynamic contrast-enhanced images necessary for prostate cancer detection on multiparametric magnetic resonance imaging? Clin Genitourin Cancer. 2017;15:e447–e54. CrossRefPubMed Mussi TC, Martins T, Garcia RG, et al. Are dynamic contrast-enhanced images necessary for prostate cancer detection on multiparametric magnetic resonance imaging? Clin Genitourin Cancer. 2017;15:e447–e54. CrossRefPubMed
26.
Zurück zum Zitat Sanz-Requena R, Marti-Bonmati L, Perez-Martinez R, et al. Dynamic contrast-enhanced case-control analysis in 3T MRI of prostate cancer can help to characterize tumor aggressiveness. Eur J Radiol. 2016;85:2119–26. CrossRefPubMed Sanz-Requena R, Marti-Bonmati L, Perez-Martinez R, et al. Dynamic contrast-enhanced case-control analysis in 3T MRI of prostate cancer can help to characterize tumor aggressiveness. Eur J Radiol. 2016;85:2119–26. CrossRefPubMed
27.
Zurück zum Zitat Hansford BG, Peng Y, Jiang Y, et al. Dynamic contrast-enhanced MR imaging curve-type analysis: is it helpful in the differentiation of prostate cancer from healthy peripheral zone? Radiology. 2015;275:448–57. CrossRefPubMed Hansford BG, Peng Y, Jiang Y, et al. Dynamic contrast-enhanced MR imaging curve-type analysis: is it helpful in the differentiation of prostate cancer from healthy peripheral zone? Radiology. 2015;275:448–57. CrossRefPubMed
28.
Zurück zum Zitat Niu XK, Chen XH, Chen ZF, et al. Diagnostic performance of biparametric MRI for detection of prostate cancer: a systematic review and meta-analysis. AJR Am J Roentgenol. 2018;211:369–78. CrossRefPubMed Niu XK, Chen XH, Chen ZF, et al. Diagnostic performance of biparametric MRI for detection of prostate cancer: a systematic review and meta-analysis. AJR Am J Roentgenol. 2018;211:369–78. CrossRefPubMed
30.
Zurück zum Zitat Choi MH, Lee YJ, Jung SE, et al. Prebiopsy biparametric MRI: differences of PI-RADS version 2 in patients with different PSA levels. Clin Radiol. 2018;73:810–7. CrossRefPubMed Choi MH, Lee YJ, Jung SE, et al. Prebiopsy biparametric MRI: differences of PI-RADS version 2 in patients with different PSA levels. Clin Radiol. 2018;73:810–7. CrossRefPubMed
31.
Zurück zum Zitat Verma S, Turkbey B, Muradyan N, et al. Overview of dynamic contrast-enhanced MRI in prostate cancer diagnosis and management. AJR Am J Roentgenol. 2012;198:1277–88. CrossRefPubMed Verma S, Turkbey B, Muradyan N, et al. Overview of dynamic contrast-enhanced MRI in prostate cancer diagnosis and management. AJR Am J Roentgenol. 2012;198:1277–88. CrossRefPubMed
32.
Zurück zum Zitat Muller S, Lilleaasen G, Sand TE, et al. Poor reproducibility of PIRADS score in two multiparametric MRIs before biopsy in men with elevated PSA. World J Urol. 2018;36:687–91. CrossRefPubMedPubMedCentral Muller S, Lilleaasen G, Sand TE, et al. Poor reproducibility of PIRADS score in two multiparametric MRIs before biopsy in men with elevated PSA. World J Urol. 2018;36:687–91. CrossRefPubMedPubMedCentral
Metadaten
Titel
Short review of biparametric prostate MRI
verfasst von
Dr. Fabian Steinkohl
PhD PD Dr. Renate Pichler
PD Dr. Daniel Junker
Publikationsdatum
12.11.2018
Verlag
Springer Vienna
Erschienen in
memo - Magazine of European Medical Oncology / Ausgabe 4/2018
Print ISSN: 1865-5041
Elektronische ISSN: 1865-5076
DOI
https://doi.org/10.1007/s12254-018-0458-1