Multiparametric MRI and MRI Fusion-Guided Biopsy for the Diagnosis of Prostate Cancer: current status

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INTRODUCTION

In Western countries, prostate cancer (PC) is the most frequent noncutaneous tumour in men [1]. According to the EAU recommendations, prostate biopsy is the gold standard for PC diagnosis.

The first diagnostic biopsy method is the random technique (rather than sextant), with 12 samples taken only in the peripheral zone [2]. This technique has limitations in undersampling (insufficient number of samples in relation to prostate volume); oversampling (excessive core number, with identification of non-significant microfoci); overstaging, with a diagnosis of non-significant tumours (low sensitivity); understaging, with failure to diagnose clinically significant cancers (low specificity); and operator experience-related errors [3].

The new therapeutic trend of active surveillance (for low-risk tumours) and minimally invasive targeted procedures necessitates more precision in prostate examination, necessitating advancements in bioptic approach.

Prostate biopsy is currently recommended for men aged 50–69 years with elevated serum prostate specific antigen (PSA) levels (> 3 ng/mL) or abnormal digital rectal examination findings (nodules, induration, and asymmetry) and after a first set of negative biopsy results, when suspicion of PC remains high, increasing the number of samples (i.e., saturation biopsy) and sampling of the transitional zone [4].

Since its initial application in 1983, MRI has been widely used for PC diagnosis due to increased availability and multiparametric imaging, which combines anatomic and functional data [5, 6].

The European Society of Urogenital Radiology (ESUR) published guidelines based on expert consensus in 2012 to standardise the evaluation and reporting of prostate MRI: the Prostate Imaging Reporting and Data System (PIRADS) [7]. Since then, the PIRADS Score has been externally evaluated and found to be reliable for more accurate detection of PC [8].

In 2019, the PI-RADS Steering Committee published updated reporting guidelines, describing assessment categories and technical parameters described in version 2 of the PI-RADS [9].

With these premises, the role of multiparametry MRI (mpMRI) has become central not only in the diagnosis of PC, but also in biopsy, as a tool for correct staging and assessment of tumor extension (Gleason Score).

The current goal is to make MR-guided biopsy increasingly available, minimizing inter-operator variability and depending on the available system.

METHODS OF MRI-GUIDED PROSTATE BIOPSY

For performing a targeted prostate biopsy, three types of MRI guidance are available:

-cognitive fusion, in which the operator visually directs the TRUS biopsy to the prostatic area of abnormalities on mpMRI.

-direct MRI-guided biopsy, performed within an MRI tube (in-bore biopsies): technique is quite precise for identifying areas of interest within the prostate, but it is time-consuming, expensive, and impractical because the entire process is performed within the MRI gantry [10].

- software coregistration of stored MRI with real-time ultrasound, using a fusion device. with mpMRI findings digitally overlaid on real-time TRUS images for targeted biopsy. This procedure can be performed with elastic fusion systems (e.g., Koelis Urostation; Eigen Artemis) or rigid fusion systems (e.g., Philips Uronav, Eindhoven, The Netherlands, Med-Com BiopSee, Darmstadt, Germany).

 

Each method has its advantages and disadvantages.

While there is substantial variation in the sensitivity of detecting clinically indolent disease across studies, most most researches show that the sensitivity of MR-US fusion (cognitive or device) ranges between 80 and 95% [11].

The main clinical indications for MR/US fusion biopsy are persistently elevated PSAs despite previous negative prostate biopsies and the follow-up of patients on active surveillance [12].

Cognitive fusion

Cognitive fusion is easy, rapid, and requires no additional equipment other than an MRI and a standard transrectal ultrasonography (TRUS) facility. The ultrasound operator does not need any additional training beyond the standard TRUS biopsy. Cognitive fusion is based on the sonographer's ability to localise the region of interest by picturing its location within the prostate after viewing the worrisome lesion on MRI [12].

MRI and TRUS pictures are superimposed by a cognitive overlay during biopsy, which can be done with a printed document or by presenting MR images on the screen of a workstation in the TRUS room, adjacent to the TRUS platform [13].

The physician aims the target lesion with knowledge of lesion localization on MRI.

The advantages of cognitive fusion are speed and simplicity; that is, it requires no additional equipment beyond what is ordinarily necessary for a TRUS biopsy [14].

However, one of the downside of cognitive fusion biopsy approaches is the possibility of sampling error when attempting to conceptualise the region of interest, which is especially problematic for smaller tumours. Another disadvantage of cognitive fusion is the inability to track the position of each previous biopsy.

Despite this, the tumour detection rate of cognitive fusion is comparable to that of device-mediated fusion, and in most investigations, both cognitive and device-mediated fusion appear to be superior to random systematic sampling alone [15, 16].

The disadvantage of cognitive fusion is the possibility of human mistake in extrapolating from MRI to TRUS in the absence of a real overlay.

Several studies have been conducted to assess the value of cognitively performed TB. Lawrentschuk et al. found that cognitive TB performed better than random cores, especially in anterior lesions [17]. In a retrospective analysis, Haffner et al. compared TB results with those of 12 random biopsies in 555 patients [18]. A TB approach alone would have required just 3.8 cores per patient, avoiding unnecessary biopsies in 38% of patients with normal MRIs, and avoiding the detection of minor cancer discovered by random biopsies in 13% of instance [18].

In this study, 13 significant cancers were missed with TB alone whereas 12 significant cancers were missed with the standard approach [18].

In another study, Puech et al. discovered that MRI before to biopsy increased cancer detection rate (CDR), which increased from 59% by 12-core SB to 65% by cognitive TB [15].

In terms of significant cancer (cancer core length >3 mm on any core and GS >3+3) CDR was 67% for TB and 52% for conventional biopsies [15].

Labanaris et al. demonstrated that TB allows for a 90% match between biopsy and surgical GS and indicated that MRI should be performed prior to biopsy to decrease SB underestimate of GS [19].

In conclusion, current research suggest that MRI guided biopsy has higher accuracy and cancer detection than standard TRUS-biopsy.

Haffner et al. conducted an interesting study that found cognitive fusion to be no better than systematic biopsies in men with questionable MRIs, highlighting the major risk with cognitive fusion: inter-observer variability [18]. Despite the fact that the present literature on cognitive fusion shows potential in the hands of professional cognitive fusionists, most urologists are now shifting towards commercially accessible device-mediated platforms due to a lack of tracking and digital overlay.

Direct MRI-guided biopsy is performed ‘in-bore’

A radiologist performs direct MRI-guided biopsy 'in-bore,' that is, within the MRI tube, by fusing a prior MRI indicating a lesion with a contemporaneous MRI to confirm biopsy needle localization. The transrectal route is employed. After each biopsy sample, the patient is rescanned to ensure localization. Typically, only a few targeted cores are taken; systematic sampling is not conducted.

The in-bore biopsy method provides the benefits of precision needle placement, fewer sampled cores, and a low risk of missed targets if they are MRI-visible [20]. Its disadvantages include greater expense and time consumption, as well as the incapacity to sample the residual gland on a regular basis [20]. This is especially relevant because MRI misses approximately 10% of severe lesions when compared to final RP pathology [21, 22].

Quentin et al. show that in-bore TB has an excellent significant cancer detection rate of 92.2% [23]. Hoeks et al. reported that 265 patients with dubious lesions on mpMRI who had previously negative TRUS-biopsies had transrectalin-bore TB, resulting in a CDR of 41% with 87% of the identified tumours being clinically significant [24].

The Barentsz group at Radboud University in Nijmegen, the Netherlands, presented a vast experience with in-bore biopsy [25]. The benefits of this procedure include a reduced number of cores taken, precise localisation of the biopsy, and less detection of insignificant tumours. The downsides of this procedure include the time and cost involved, including the in-bore time and the two MRI sessions required to obtain the biopsy specimens.

Furthermore, because only suspicious lesions are sampled, tissues with a 'normal' MRI appearance are not collected, which is problematic because any false-negative characteristics of prostate MRI are unknown [25].

MRI–TRUS fusion

In this method, the operator images the prostate using ultrasound, as has been used for decades; while viewing the prostate, the MRI of that prostate, which is performed beforehand and stored in the device, is fused with real-time ultrasound using a digital overlay, allowing the target(s) previously delineated by a radiologist to be brought into the ultrasound machine's aiming mechanism. The fusion produces a three-dimensional reconstruction of the prostate, and the aiming and tracking of biopsy sites takes place on the reconstructed model [25] (Fig.1, fig.2). Several commercial platforms are now available, each with a different method of co-registration and a different hardware platform for lining up the biopsy with the co-registered picture [3]. In comparison to VE, MRI/TRUS-fusion-guided biopsy may have higher reproducibility due to less operator dependence and by delivering real-time feedback on actual biopsied areas [3]. The disadvantages include greater software/device costs, dependence on software for accuracy, and the associated learning curve and operator training [26] (Fig.3, fig.4).

This method has the disadvantage of being indirect, requiring the use of an additional device, and needing specialised operator training. The benefit is that it may be done in minutes in an outpatient clinic environment under local anaesthesia, using techniques that have been used for years. The results obtained with a fusion device are highly encouraging [25].

Device-mediated fusion allows for the targeting of biopsies into previously defined MRI regions of interest using a 3D rendering apparatus that superimposes saved MRI pictures on real-time US images, a technique known as co-registration. While there are several commercial MR-US fusion platforms available, they all use some type of image co-registration and needle/probe tracking (mechanical or electromagnetic). These technologies enable the acquisition, storage, and reconstruction of real-time ultrasound images, as well as the creation of 3D maps of lesion locations and prior biopsy sites for future reference [27]. Because any movement of the patient or the prostate impacts image co-registration, these fusion devices additionally employ dynamic repeat registration methods using motion-compensation algorithms to guarantee accurate and reproducible index lesion targeting [12].

Recent research compared the detection of PC and severe disease to the use of traditional SB or TPMB as a reference-test [22, 28, 29].

Siddiqui et al. recently demonstrated in a cohort of >1000 patients using the Uronav system and conventional 12-core TRUS-biopsy as reference-test that TB diagnosed 30% more high-risk cancers versus standard biopsy (P0.001) and 17% fewer low-risk cancers (P=0.002) using primary Gleason pattern 4 as significance level [22]. Rastinehad et al. GS 3+4 as clinically significant PC definition and reported that 14.3% to 20.9% of significant PC were discovered by TB alone but ignored by traditional TRUS technique [30]. Furthermore, 23.5% of patients were upgraded from insignificant to significant PC through MRI/TRUS-fusion guided biopsy [30]. In contrast, 4/105 significant PC were missed by MRI/TRUS-fusion guided biopsy [30].

Baco et al. demonstrated that 98% of index tumours, defined as the highest GS or biggest volume in case of multifocality with equal GS, were diagnosed by MRI and that 98% of the correct location was diagnosed by MRI/TRUS-fusion guided TB using the Koelis Urostation® [31].

In terms of public health, Cerantola et al. published a cost-effectiveness analysis comparing TRUS biopsy to MRI target biopsy (MRTB) in 2016. They assessed the cumulative effects after 5, 10, 15, and 20 years and determined that including MRI and MRTB in PC diagnosis and care is a cost-effective measure after 5, 10, 15, and 20 years [32].

Comparative studies of different targeted biopsy approaches

Only a few studies have examined the CDR of various targeting strategies, and the results are contradictory [26].

Delongchamps et al. reported that cognitive fusion-biopsy was not significantly better than SB in a study comparing VE with two MRI/TRUS-fusion devices, but both software co-registration devices tested (Esaote/MyLabTMTwice and Koelis/Urostation) significantly increased CDR compared to SB in a cohort of 391 patients using conditional logistic regression analysis [33]. 

In a prospective trial of 125 men with worrisome lesions, Wysock et al. compared MRI/TRUS-fusionguided biopsies using the Eigen/Artemis system versus VE targeting [34]. They found that MRI/TRUS-fusion-guided biopsies had a slightly improved CDR compared to VE for all cancers (32% vs. 26.7%,P=0.1374) and for GS ≥3+4 (20.3% vs. 15.1%,P=0.0523).

Puech et al. found no difference in PC CDR for rigid software co-registration utilising MedCom Navigator versus cognitive fusion TB (53% vs. 47%). Furthermore, no variations in cancer positive observed in the categories of posterior (46 of 79, 58%), anterior (33 of 79, 42%), or smallest (25 of 79, 32%) MR imaging targets [15]. In 2013, Bjurlin MA. et al. conducted a literature review. Their findings indicate that using MRI to target prostate biopsies has the potential to reduce sampling error associated with conventional biopsy by providing better disease localization and sampling. They discovered that increased cancer sampling allows more accurate risk classification, which may influence therapeutic decision making. However, the best clinical application of MRI targeted biopsy has not yet been determined [3].

EARLY DETECTION OF PROSTATE CANCER

The US Preventive Services Task Force (USPSTF) updated its recommendations in 2018, largely based on the publication of longer follow-up data from large screening trials and emerging evidence that the use of active surveillance in low-risk prostate cancer reduces the harms associated with screening overtreatment. The USPSTF now recommends that men aged 55-69 years undergo PSA testing based on a discussion with their clinician about the relative benefits and harms, though it still advises against PSA screening in younger men (40-55 years) or those over 70 years [35].

In the absence of widespread, organised PSA testing, opportunistic testing has become routine practise in a number of EU member countries. However, new research reveals that while this strategy has minimal influence on prostate cancer-specific mortality, it is associated with more overdiagnosis than organised risk-adapted PSA testing [36]. This lack of effect is largely due to testing individuals who will not benefit (eg, those with a 10-year life expectancy) without sufficient informed decision-making [37], as well as repeated testing in men who are not at risk of developing severe prostate cancer [38].

Overdiagnosis can be reduced by employing a risk-adapted detection strategy based on PSA values in conjunction with risk calculators and multiparametric magnetic resonance imaging (mpMRI), which can distinguish between significant and insignificant prostate cancer and modify treatment accordingly. As a result, many early prostate cancer diagnoses can be handled with active surveillance, avoiding overtreatment [39]. Those with a lower risk profile may benefit from local treatment, which has fewer adverse effects and produces better results than if the condition was discovered and treated later, thereby enhancing or maintaining the patient's quality of life [40].

The EAU has created an algorithm to explain a risk-adapted strategy to prostate cancer detection. This algorithm is intended for usage in well-informed men over the age of 50 with a life expectancy of more than 10-15 years. This algorithm clearly demonstrates how to accomplish an early detection of serious prostate cancer while avoiding overdiagnosis and overtreatment. Following a clinical risk assessment and appropriate counselling, the PSA test represents the first step in identifying a large proportion of men with a low PSA value who do not require any further immediate investigations for 2-4 years (for those with a PSA value of 1-3 ng/ml) or 5 years (for those with a PSA value of 1 ng/ml and 60 years old) [39].

A risk stratification nomogram (which considers factors such as age, family history, digital rectal examination, and prostate volume [PSA density] in a risk calculator) will identify a subgroup of men (approximately 35% of all men with an initial PSA test of >3 ng/ml [41]) as those with a low risk who require clinical follow-up only, avoiding the need for further testing, including MRI and biopsy. Men with a PSA value of more than 3 ng/ml who were classed as intermediate or high risk would then have mpMRI, leading in the identification of a further subgroup (about 54% of all men undergoing MRI [41]) with a Prostate Imaging Reporting and Data System (PIRADS) score of 1-2 considered to be at a low risk of having significant prostate cancer and requiring clinical follow-up only.

Further risk categorization of males with a PIRADS score of 3 using PSA density and other clinical characteristics would reveal an additional category requiring just clinical follow-up (a PIRADS score of 1, 2 or 'low-risk' 3 accounts for around 57% of men tested by PIRADS [41]). As a result, the remaining subset of the original population could be regarded actually intermediate or high risk and should undergo targeted and/or systematic biopsy. It is also worth noting that, within this subgroup, those with a positive diagnosis and a favourable grading group (approximately 25% of all confirmed diagnoses [41]) may be eligible for active surveillance rather than active treatment.

However, as part of a collaborative decision-making process, all final treatment decisions should take the patient's values and preferences into account [40]. This algorithm demonstrates how PSA testing can be used more intelligently by incorporating risk calculators such as those developed by the ERSPC and the Prostate Cancer Prevention Trial (PCPT) [42], as well as mpMRI and the PIRADS score [43, 44], to reduce the number of men undergoing biopsy. The proposed time intervals for repeat PSA testing depending on age and initial PSA test result reflect the risk of a future clinically significant cancer diagnosis [45] and thus help to reduce false positive biopsies.

The risk calculator to be utilised must also be carefully selected. Although the ERSPC risk calculator has been well verified and may thus be regarded superior, a recalibration step may be required to account for regional variations in prevalence and the link between PSA and prostate cancer risk [46].

CANCER RISK ASSESSMENT USING TARGETED BIOPSY

The change from systematic biopsy to image-targeted biopsy raises significant concerns for prostate cancer clinical care. More men should choose active surveillance if new biopsy techniques give them with more confidence.

However, it is probable that the use of targeted biopsies will be exploited to justify additional overtreatment. Currently, risk classification systems based on biopsy results greatly impact therapy decisions [47].These systems evolved from traditional systematic biopsies. When tumours are sampled more thoroughly with targeted biopsy, the proportion of positive cores and the maximum CCL are higher than with traditional biopsy [48, 18].

As a result, when compared to systematic biopsy, targeted biopsy resulted in an increase in risk attribution. In a computer simulation study including 107 reconstructed 3D models of whole-mount prostatectomy specimens, Robertson et al. [49] revealed this critical issue. They discovered that a 12-core TRUS biopsy properly categorised just 24% of clinically significant cancer-containing prostates as high risk, compared to 74% of cases using a transperineal targeted biopsy with 4 cores. Furthermore, targeted biopsies had a higher proportion of positive cores and higher maximum CCLs. They concluded that when risk models derived from conventional TRUS biopsy are used to image-directed biopsy, there is a systematic rise in risk attribution.

194 males on active surveillance received MR-US fusion targeted biopsy at UCLA, which included both systematic and targeted sampling. Using only systematic biopsy and the Epstein histologic criteria (Gleason 6, 2 cores cancer, and 50% of any core), 28% of men were categorised as poor candidates for surveillance on confirmatory biopsy.

Incorporating targeted biopsy increases the number of reclassified patients to 41%. In some circumstances, this is due to the discovery of additional dangerous malignancies, while in others (i.e., numerous malignant cores from a single MRI target), it is the result of using a classification system that does not take targeted biopsy into account.

Given the inflation in risk attribution, it is probable that targeted biopsy may be used to justify aggressive treatment of more men, exacerbating the overtreatment problem. To avoid this unwanted effect, new risk stratification criteria based on image-targeted biopsy must be developed and verified. Consider a man who had a conventional biopsy with a low-volume Gleason score of 3 + 3 and a targeted biopsy with a low-volume Gleason score of 3 + 4. Targeted biopsy combined with device-based tracking of malignant detects could be utilised to safely follow tumours that are now thought to require treatment [47].

 

INCORPORATION OF MULTIPARAMETRIC MRI FUSION-GUIDED BIOPSY INTO RISK MODELING FOR PROSTATE CANCER

When compared to RP-specimens, mpMRI detects 85-95% of index-lesions and significant PCa (sPCa) [50]. The use of targeted biopsy (TB) of dubious mpMRI-lesions in a fusion biopsy context increases the identification of sPCa by 30% [22].

Multivariable risk-based techniques have been established to identify men with sPCa while avoiding needless biopsies [51, 52]. A risk calculator based on data from the European Randomised Study of Screening for PC (ERSPC) was created to quantify the risk of sPCa. Roobol et al. revealed that in men with a PCa risk of less than 12.5%, 33% of routine biopsies might be avoided [52]. Recent RC, on the other hand, do not incorporate MRI data.

Although TB of mpMRI-suspicious lesions alone is a potential technique for reducing overdetection of minor illness, MRI-invisible sPCa can be missed [22, 53, 54].

Unlike Alberts et al., Radtke et al. and van Leeuwen et al. developed risk calculators and added pre-biopsy mpMRI to clinical parameters to determine an individual sPCa-risk using a validated biopsy approach combining fusion guided TB and transperineal systematic saturation biopsies (SB) as reference on the one hand and transperineal mapping and TB plus 12-core TRUS on the other [55, 56].

In the Area under the curve of Receiver operating characteristics (ROC) curve analysis, Van Leeuwen et al. demonstrated that a model combining age, PSA, DRE, prostate volume, a previous biopsy result, and mpMRI PI-RADS Likert score outperforms the model of clinical parameters alone with a discrimination of 0.90 [56]. In addition to the model for biopsy-naive men, Radtke et al. internally validated a risk model for men with a previous negative biopsy that combined PSA, prostate volume, DRE, age, and mpMRI PI-RADS Likert scoring [55]. When compared to a validated clinical parameter risk calculator and PI-RADS, the model beat both instruments [55]. When risk models that include mpMRI and clinical parameters are compared to risk models that just use clinical parameters or PIRADS, the accuracy of the decision to do a biopsy in a patient with sPCa suspicion can be increased. In conclusion, risk models that contain mpMRI are superior than risk models that do not include mpMRI not just for men before to initial biopsy but also for patients who have had previous negative biopsy results. [55, 56].

One point that must be emphasised is that, while detection of significant prostate cancer can be improved, an unsuspicious mpMRI or a low PIRADS-Score cannot be used to justify not proceeding with a biopsy in the case of prostate cancer suspicion. It is claimed that MRI fusion biopsy can help diagnose indolent prostate cancer. On the other hand, finding low-risk prostate cancer can improve patient safety by avoiding unnecessary treatment and improving disease monitoring accuracy and reliability when selecting individuals for active surveillance.

Avoiding mpMRI Fusion Biopsy Failure

Despite the fact that mpMRI has been found to offer helpful details to the diagnostic route for sPCa, mpMRI fusion biopsy can potentially fail. So far, four potential mechanisms for mpMRI fusion biopsy failure have been identified: mpMRI invisible cancer, improper sampling, mpMRI reader oversight, and intralesion Gleason Score (GS) heterogeneity [57]. Muthigi and colleagues demonstrated that in 71% of cases when SB discovered sPCa but TB did not, the malignant finding was within the sextant of the target lesion, correlating with the findings of Cash et al., who identified inaccurate sampling as one of the primary causes for fusion biopsy failure [58].

Similarly, Bryk and colleagues identified a combination of TB and ipsilateral SB as the best strategy to detect sPCa and avoid detection of low risk PCa in patients with unilateral mpMRI lesion using TB and both sided SB as reference [59]. The findings of those two studies imply that increasing the number of samples taken from the target area can help to minimise erroneous sampling and intralesion Gleason Score (GS) heterogeneity. Porpiglia et al., on the other hand, discovered that two targeted cores inserted in the centre of the lesion are sufficient to precisely portray the index lesion [60].

More research on this topic is required. The mpMRI fusion biopsy failure caused by mpMRI invisible cancer, which has a consistently found negative predictive value for mpMRI of 63-98%, can only be solved with further SB [61, 62]. However, most groups that combined TB with 12 core SB found no substantial benefit for detecting sPCa by combining both approaches over TB alone [22, 63].

In contrast, Filson et al. discovered that the combination biopsy approach detected much more sPCa than TB or SB alone [64].

These controversial results lead to the conclusion that the superiority of sPCa detection in a combined biopsy approach

compared to a TB only approach increases with the amount of SB, but with the risk of also finding significantly more low risk diseases.

The question of whether to omit SB or not might never get entirely solved and decisions should be made individually

to biopsy indications and patient’s needs.

One further point regarding the quality and possible reasons for failure of mpMRI fusion biopsy is the technique used to carry out the biopsy.

MULTIPARAMETRIC MRI FUSION-GUIDED BIOPSY IN MEN REQUIRING A REPEAT BIOPSY

Men with a previous negative biopsy and an ongoing suspicion of PCa are a patient category that needs to be continuously watched. Prior sampling reduces overall disease incidence relative to a biopsy-naive group, however individuals with continuous suspicion for PCa suffer due to the inadequate NPV of 12 core TRUS biopsy. MpMRI has been proven in many studies to be effective in monitoring this patient group and should thus be suggested in a repeat biopsy setting [65, 1].

Most recent studies examine these patients as a subset of a larger cohort, but some studies pay special attention to this patient group: Simmons et al. evaluated the diagnostic accuracy of mpMRI in men requiring a repeat prostate biopsy (PICTURE study), despite the fact that only 31% of men had a previous negative biopsy [66]. When used as a positive test result, an mpMRI score of 3 has a sensitivity of 97%, a specificity of 22%, an NPV of 91%, and a positive predictive value of 47% [66].

The authors conclude that a repeat biopsy can potentially be avoided in 14% of men at the cost of missing 9% of sPCa [66]. Hansen et al. reported a significantly improved area under the curve when combining PI-RADS and PSA density (0.82 vs. 0.85), implying that repeat biopsy should be avoided only in cases of worrying mpMRI and low PSA density [67]. Again, there is no clear data on when it is safe to exclude SB. Arsov et al., on the other hand, compared in-bore TB to fusion guided TB plus 12-core TRUS-SB in a prospective randomised experiment. They discovered that adding SB had no further benefit in detecting sPCa [10].

In contrast, recent papers comparing TB alone methods with 24 or 12 core SB reveal that TB alone misses a significant amount of sPCa [67].

 

 

MULTIPARAMETRIC MRI FUSION-GUIDED BIOPSY FOR MEN UNDER ACTIVE SURVEILLANCE

Men with PCa who are eligible for active surveillance (AS) are another important patient category because proper risk assessment of potentially less serious conditions is essential. To achieve this purpose, mpMRI in conjunction with fusion biopsy can aid in initial candidate screening and may aid in disease progression monitoring. Radtke et al. shown in a sample of 149 males that initial mpMRI and fusion biopsy prior to AS resulted in significantly reduced rates of later AS qualifying (20% vs. 48%) during a two-year follow-up compared to those selected for AS based on 12-core TRUS biopsy [68].

These findings are supported by Henderson et al. revealed in a prospective study that the apparent diffusion coefficient (ADC) is a good marker for choosing patients for AS since a low ADC value is associated with a shorter time to unfavourable histology [69]. Several recent research looked at mpMRI and fusion biopsy in the context of disease progression detection. Most of them reveal that mpMRI accurately predicts the likelihood of clinical progression and that patients with stable mpMRI findings have a low probability of developing the disease [70-72].

Including clinical criteria in the decision-making process appears to be advantageous when selecting patients for AS. Alberts et al. discovered in a cohort of 210 males no upgrade at baseline, confirmatory, or surveillance biopsy in instances of unsuspicious mpMRI and PSA density less than 0.15 ng/mL, implying that follow-up biopsy should be avoided in these individuals [10]. However, there is still debate about whether or not following up with fusion biopsy confined to mpMRI-visible targets is sufficient. Both Meng et al. and Frey et al. show that on combined SB and TB follow-up mpMRI fusion biopsy, TB detects significantly more upgrades than SB, supporting the rationale of removing SB [70, 53].

Tran et al., Ma et al., and Recabal et al., on the other hand, discovered that a significant fraction of higher grade malignancy could only be diagnosed by SB, suggesting the necessity for additional SB [71, 72]. These contradictory results can be explained in part by differences in study parameters such as median TB and SB cores, but they also highlight the need for additional research on long-term results, serial mpMRI for replacing repeat biopsies, and sufficiency of follow-up biopsies limited to mpMRI targets.

CONCLUSIONS

MRI targeted biopsy improves the quality of histological results, compared to other approaches, with a correct detection of approximately 90% of significant index lesions.

The systematic 12-core TRUS-guided biopsy is still widely used technique despite having limited sensitivity for the detection of clinically significant prostate cancer.

MRI-guided biopsies provide a higher detection rate for clinically significant prostate cancer and increase the percentage of positive cores.

Although currently used in patients who remain at high clinical suspicion of prostate cancer despite a negative TRUS-guided systematic biopsy, with the increasing use of upfront diagnostic MRI, these biopsies are foreseen to replace standard systematic biopsies.

The correct staging allows to choose the best treatment options, including focal treatments, and adequately evaluate the prognosis. It also reduces the incidence of re-biopsy, costs and complications.

It is crucial to standardize the bioptic technique and improve the fusion technique in order to reduce understaging caused by mistakes in tumor volume estimates. The role of mpMRI in the presurgical phase of RP is emerging, as mpMRI can help planning the initial surgical strategy, referring to clinical decision making.

Авторлар туралы

Valentina Testini

Email: testinivalentina@gmail.com
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Laura Eusebi

Email: lauraeu@virgilio.it
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Francesco Saverio Guerra

Email: francesco.rino@gmail.com
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Willy Giannubilo

Email: willygiannubilo@virgilio.it
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Manuel Di Biase

Email: manuel.dibiase@ospedale.perugia.it
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Annunziata Russo

Email: tittyrusso-23@libero.it
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Giuseppe Guglielmi

University of Foggia

Хат алмасуға жауапты Автор.
Email: giuseppe.guglielmi@unifg.it
ORCID iD: 0000-0002-4325-8330

Medical Doctor, Full Professor of Radiology.

Department of Clinical and Experimental Medicine.

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