Minimally invasive magnetic resonance image-guided prostate interventions.

Whole gland prostate cancer treatment, i.e. radical prostatectomy or radiation therapy, is highly effective but also comes with a significant impact on quality of life and possible overtreatment in males with low to intermediate risk disease. Minimal-invasive treatment strategies are emerging techniques. Different sources of energy are used to aim for targeted treatment in order to reduce treatment-related complications and morbidity. Imaging plays an important role in targeting and monitoring of treatment approaches preserving parts of the prostatic tissue. Multiparametric magnetic resonance imaging (mpMRI) is widely used during image-guided interventions due to the multiplanar and real-time anatomical imaging while providing an improved treatment accuracy. This review evaluates the available image-guided prostate cancer treatment options using MRI or magnetic resonance imaging/transrectal ultrasound (MRI/TRUS)-fusion guided imaging. The discussed minimal invasive image-guided prostate interventions may be considered as safe and feasible partial gland ablation in patients with (recurrent) prostate cancer. However, most studies focusing on minimally invasive prostate cancer treatments only report early stages of research and subsequent high-level evidence is still needed. Ensuring a safe and appropriate utilization in patients that will benefit the most, and applied by physicians with relevant training, has become the main challenge in minimally invasive prostate cancer treatments.

A comparison of magnetic resonance imaging techniques used to secure biopsies in prostate cancer patients.

Introduction: Prostate cancer (PCa) is the most common diagnosed malignancy among the male population in the United States. The incidence is increasing with an estimated amount of 175.000 cases in 2019. Areas covered: Primarily, PCa is generally detected by an elevated or rising serum prostate-specific antigen (PSA) and digital rectal examination (DRE) followed by pathological examination. Histopathology ultimately confirms the presence of PCa and determines a Gleason score. However, PSA and DRE have low specificity and sensitivity, respectively. Subsequently, accurate assessment of the aggressiveness of PCa is essential to prevent overdiagnosis and thus overtreatment of low-risk or indolent cancers. By visualizing PCa suspicious lesions and sampling them during the targeted biopsy, it is likely that the diagnostic accuracy of significant PCa improves. This article reviews the current imaging techniques used to secure biopsies in patients with a suspicion of PCa. The advantages and limitations of each technique are described. Expert opinion: Multiparametric magnetic resonance imaging (mpMRI) and subsequent-targeted biopsy have improved the diagnostic accuracy of PCa detection in men with an elevated or rising serum PSA. Prostate lesions visible on mpMRI are easily targeted during either in-bore MRI-guided biopsy, cognitive fusion biopsy or MRI-TRUS fusion biopsy.

Multiparametric magnetic resonance imaging and follow-up to avoid prostate biopsy in 4259 men.

OBJECTIVE: To determine the proportion of men avoiding biopsy because of negative multiparametric magnetic resonance imaging (mpMRI) findings in a prostate MRI expert centre, and to assess the number of clinically significant prostate cancers (csPCa) detected during follow-up. PATIENTS AND METHODS: Retrospective study of 4259 consecutive men having mpMRI of the prostate between January 2012 and December 2017, with either a history of previous negative transrectal ultrasonography-guided biopsy or biopsy naïve. Patients underwent mpMRI in a referral centre. Lesions were classified according to Prostate Imaging Reporting And Data System (PI-RADS) versions 1 and 2. Negative mpMRI was defined as an index lesion PI-RADS ≤2. Follow-up until 13 October 2018 was collected by searching the Dutch Pathology Registry (PALGA). Gleason score ≥3 + 4 was considered csPCa. Kaplan-Meier analysis and univariable logistic regression models were used in the cohort of patients with negative mpMRI and follow-up. RESULTS: Overall, in 53.6% (2281/4259) of patients had a lesion classified as PI-RADS ≤2. In 320 patients with PI-RADS 1 or 2, follow-up mpMRI was obtained after a median (interquartile range) of 57 (41-63) months. In those patients, csPCa diagnosis-free survival (DFS) was 99.6% after 3 years. Univariable logistic regression analysis revealed age as a predictor for csPCa during follow-up (P < 0.05). In biopsied patients, csPCa was detected in 15.8% (19/120), 43.2% (228/528) and 74.5% (483/648) with PI-RADS 3, 4 and 5, respectively. CONCLUSION: More than half of patients having mpMRI of the prostate avoided biopsy. In those patients, csPCa DFS was 99.6% after 3 years.

Results of Targeted Biopsy in Men with Magnetic Resonance Imaging Lesions Classified Equivocal, Likely or Highly Likely to Be Clinically Significant Prostate Cancer.

BACKGROUND: The Prostate Imaging Reporting and Data System (PI-RADS) is the most commonly used scoring system in prostate magnetic resonance imaging (MRI). One of the available techniques to target suspicious lesions is direct in-bore MRI-guided biopsy (MRGB). OBJECTIVE: To report on the experience and results of MRGB in a large cohort of patients with lesions classified as equivocal (PI-RADS 3), likely (PI-RADS 4), or highly likely (PI-RADS 5) to be clinically significant (cs) prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: We retrospectively included 1057 patients having MRGB, between January 2012 and September 2016, of lesions classified as PI-RADS≥3 on multiparametric MRI. Biopsy-naïve patients, patients with prior negative systematic transrectal ultrasound-guided biopsy, and patients in active surveillance were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome measurement is the detection rate of csPCa. Descriptive statistics and chi-square tests were used to calculate the differences in proportions. We considered a Gleason score of ≥3+4 as csPCa. RESULTS AND LIMITATIONS: PCa was diagnosed in 35% (55/156), 60% (223/373), and 91% (479/528), and csPCa in 17% (26/156), 34% (128/373), and 67% (352/528) of patients with PI-RADS 3, 4, and 5 lesions, respectively. Follow-up of patients with negative biopsy findings resulted in csPCa in 1.7% (5/300) after a median period of 41 (interquartile range 25-50) mo. The evaluation of prostate-specific antigen density (PSAD) to predict csPCa resulted in 42% of patients with a PI-RADS 3 lesion who could avoid biopsy in case a PSAD of ≥ 0.15ng/ml/ml would be used. In 6% (95% confidence interval, 2-15), csPCa would then be missed. The study is limited because of its retrospective character. CONCLUSIONS: MRGB in lesions scored PI-RADS≥3 yields high detection rates of csPCa in daily clinical practice in cases with previous negative biopsy. PATIENT SUMMARY: In daily clinical practice, direct in-bore magnetic resonance imaging-guided biopsy of suspicious lesions reported according to the Prostate Imaging Reporting and Data System yields high detection rates of clinically significant prostate cancer.

Retrospective comparison of direct in-bore magnetic resonance imaging (MRI)-guided biopsy and fusion-guided biopsy in patients with MRI lesions which are likely or highly likely to be clinically significant prostate cancer.

PURPOSE: To compare clinically significant prostate cancer (csPCa) detection rates between magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion-guided prostate biopsy (FGB) and direct in-bore MRI-guided biopsy (MRGB). METHODS: We performed a comparison of csPCa detection rates between FGB and MRGB. Included patients had (1) at least one prior negative TRUS biopsy; (2) a Prostate Imaging Reporting and Data System (PI-RADS) 4 or 5 lesion and (3) a lesion size of ≥8 mm measured in at least one direction. We considered a Gleason score ≥7 being csPCa. Descriptive statistics with 95% confidence intervals (CI) were used to determine any differences. RESULTS: We included 51 patients with FGB (59 PI-RADS 4 and 41% PI-RADS 5) and 227 patients with MRGB (34 PI-RADS 4 and 66% PI-RADS 5). Included patients had a median age of 69 years (IQR, 65-72) and a median PSA level of 11.0 ng/ml (IQR, 7.4-15.1) and a median age of 67 years (IQR, 61-70), the median PSA 12.8 ng/ml (IQR, 9.1-19.0) within the FGB and the MRGB group, respectively. Detection rates of csPCA did not differ significantly between FGB and MRGB, 49 vs. 61%, respectively. CONCLUSION: We did not detect significant differences between FGB and MRGB in the detection of csPCa. The differences in detection ratios between both biopsy techniques are narrow with an increasing lesion size. This study warrants further studies to optimize selection of best biopsy modality.