MRI and prostate biopsy news

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PROSTATE BIOPSIES: WHY QUESTIONING THE TARGETED BIOPSY STRATEGY ONLY ?

Merely saturating the MRI target and its vicinity to diagnose significant prostate cancer (PCa) in virtually 100% of cases is not yet a consensus. This is understandable since cancers with a Gleason 4 grade component are diagnosed in areas outside the lesion, but "outside" the lesion may correspond to a tumor distinct from the lesion visible on MRI and one increasingly questions the significance of an MRI-undetected Gleason 3+4 PCa.

Prostate biopsies: improving the quality of targeted biopsies to avoid systematic biopsies

F. Cornud, M.D., A. Lefèvre, M.D., Clinique de l'Alma, Paris France (August 2020)

Two German studies (1, 2) have recently demonstrated that modifications of the technique of targeted biopsies may make it possible to discard systematic biopsies.

Micro-US guidance for Percutaneous Transperineal Focal Laser Ablation of Prostate Cancer (PCa) : the first two cases in France at Clinique de l’Alma, Paris, France.

F. Cornud F, M. Galiano, A. Lefèvre A, S. Regusci (July 2020)

The concept of focal treatment of PCa comes from the increasing detection of indolent, small-volume, low-grade, low-risk PCa that do not require an immediate radical treatment, which aims at treating the whole gland and not the tumor itself. Radical treatments (total gland surgical ablation or radiation therapy) can have side effects (urinary incontinence, sexual impotence, rectal and/or bladder toxicity, radiation urethritis) resulting in a significant impact on quality of life (https://uroweb.org/guideline/prostate-cancer/).

Prostate MRI in the early diagnosis of prostate cancer : bi- or multiparametric ?

F. Cornud, M.D., A. Lefèvre, M.D., Clinique de l'Alma, Paris France (April 2020)

Zawaieh et al (1), from the University of Cambridge reports a series of 264 patients who underwent prostate multiparametric MRI (mpMRI), with T2 and DWI (biparametric MRI, bpMRI), at 1.5 and 3T, interpreted first, prior to full mpMRI using a Likert 1-5 scale. Readers were asked to give a prospective opinion on likely benefit of contrast prior reviewing the contrast enhanced (DCE) sequence, and a retrospective opinion following full mpMRI review.

Is it time to consider biparametric MRI in the diagnosis of significant prostate cancer ?

F. Cornud, Arnaud Lefèvre, Clinique de l'Alma, Paris, France

Han et al. report the results of a retrospective single center series of 123 patients with suspicion of prostate cancer, a prostate specific antigen (PSA) serum level of 4-10 ng/ml, who underwent mpMRI, subsequent cognitive fusion TRUS guided biopsies and post-biopsy follow-up of more than one year (1). The authors compared the diagnostic performances of mpMRI to that of bpMRI in the diagnosis of significant cancer (any Gleason grade 4 component on biopsy cores) and evaluated the added value of PSA density, in particular in PI-RADS 3 lesions.

MRI-targeted prostate biopsies guided by micro-ultrasound and a transperineal approach

F. Cornud, A. Lefèvre, Clinique de l'Alma, Mai 2020

MRI-targeted prostate biopsies: should systematic biopsies be maintained and should the transrectal route be abandoned in favor of the safer transperineal approach?

The very recent meta-analysis by Tu et al¹, from the Chinese Sichuan University ¹ evaluates the respective roles of targeted and systematic biopsies (TB and SB) in the diagnosis of significant prostate cancer (sCa) in an analysis of 39 studies including 4000 patients, with data collection up the end of December 2018. In patients with an abnormal MRI (PI-RADS score>2), the combination of TB + SB resulted in a detection rate of sCa of 45%, higher than that of TB and SB alone. With TB only, the detection rate of sCa dropped by 13%, but by 25% with SB only. The logical conclusion of the meta-analysis is therefore that the TB+SB scheme should be maintained.

MRI-targeted prostate biopsy : the limitations of MRI-TRUS image fusion

F. Cornud, M.D., A. Lefevre, M.D., Clinique de l'Alma, Paris France (April 2019)

Hamid et al, from the well-known UCL (University College London) (1), present the results of their own image fusion software (SmartTarget) used to perform MRI-targeted prostate biopsies. The software is a deformable (or elastic) fusion system, therefore not using real-time navigation. Three samples were taken from 129 patients with a Likert score 3, 4 or 5 lesion, involving the posterior sectors of the peripheral zone in 75% of cases. During the same biopsy session, a second operator performed three samples with cognitive fusion, consisting in mentally overlaying the area of the MRI target onto the corresponding area during TRUS, without specifying whether the lesion is visible on TRUS.

To what extent can the existence of significant prostate cancer be ruled out in case of a non-suspicious MRI ?

F. Cornud, M.D., A. Lefevre, M.D., Clinique de l'Alma, Paris France (May 2019)

To answer this question, Panebianco et al (1) followed-up 1255 patients with a non-suspicious MRI (PI-RADS Score <3) for 4 years. Follow-up included PSA assay, multiparametric MRI (T2W, DWI and DCE) and systematic biopsies whenever deemed necessary, mainly when PSA level increased and/or PSA density (PSA level/prostatic volume) >0.15.

Positive pre-biopsy MRI : are systematic biopsies still useful in addition to targeted biopsies ?

F. Cornud, A. Lefèvre, Clinique de l'Alma, Paris, France, May 2019

Ploussard et al (1) answered positively in a recent review with the argument that systematic biopsies (SB), in addition to targeted biopsies (TB), improved the detection rate of significant cancers (defined by the presence of Gleason 4 grade) by about 10%.

The assumed reasons to explain this 10% gain are 1-the far lateral location of some cancers missed by targeted biopsies, 2-the prognostic value of systematic biopsies 3-the pitfalls of prostate MRI reporting. 4-the pitfalls of image fusion systems 5-the safety of systematic biopsies.

Prostatic MRI before biopsy : a point of no way back

Union pour le Développement de la Radiologie Interventionnelle (UDRI).
Non-profit organization (law 1901). Teaching Courses on Prostate MRI cancer detection : Workshops & Seminars.

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