Use MRI for Prostate Biopsy, Consensus Statement Says

Diana Phillips

December 12, 2016

Men with suspected prostate cancer who have had a prior negative biopsy should undergo high-quality prostate magnetic resonance imaging (MRI) instead of or before repeat biopsy if the technology and interpretative skills are available, according to a consensus statement from the American Urological Association and Society of Abdominal Radiology published in the December issue of the Journal of Urology.

The recommendation is based on the results of a literature review by Andrew B. Rosenkrantz, MD, from the New York University Langone Medical Center, New York City, and colleagues, which showed that prostate MRI and subsequent MRI-targeted cores are more effective than standard repeat biopsies alone for detecting prostate cancer in this population.

This guideline is a departure from current clinical practice, Dr Rosenkrantz said in an interview with Medscape Medical News.

"Currently, if a patient has a systematic negative prostate biopsy and there is persistent concern for prostate cancer, another biopsy may again be done in a systematic, nontargeted, fashion," he explained. "This new joint statement encourages obtaining an MRI before the repeat biopsy to help find suspicious areas in the prostate missed by the first biopsy, so as to provide a target during the repeat session."

The available data indicate that "targeting the MRI-defined areas will increase the detection of significant cancer at the time of the repeat biopsy," Dr Rosenkrantz said.

Prostate MRI, when used, should done in accordance with Prostate Imaging Reporting and Data System, Version 2 (PI-RADS V2), guidelines, according to the consensus statement. The authors advise that patients receiving a PI-RADS assessment category of 3 to 5 undergo repeat biopsy with image-guided targeting.

Further, practices that integrate prostate MRI into their patient management protocols "are advised to implement quality assurance programs to monitor targeted biopsy results," the authors write. They note that the MRI techniques are relatively new and that the lack of standardization of image quality and variation in individual radiologists' interpretation abilities can influence outcomes.

The motivation for the consensus guidelines was the "common and challenging clinical problem" of patients with a prior negative biopsy who continue to have elevated or rising levels of prostate-specific antigen, the authors write. "Although general guidelines exist regarding the need for repeat biopsy, well-recognized consensus guidelines are lacking, and decisions are often driven by individual or local practice patterns."

For example, current American Urological Association guidelines provide indications for the performance of the initial prostate biopsy only. The National Comprehensive Cancer Network recommends repeat biopsy after a negative biopsy when certain criteria are met and advises the consideration of MRI with additional MRI-targeted cores after at least one negative biopsy, but does not recommend MRI use explicitly.

The most recent European Association of Urology guidelines similarly list indications for repeat biopsy and suggest MRI with MRI-targeted cores in the case of persistent clinical suspicion after negative biopsies to rule out an anteriorly located tumor. The most recent imaging recommendations for prostate cancer diagnosis and staging from the American College of Radiology indicate that prostate MRI is usually appropriate when there is continued clinical suspicion for cancer after negative biopsies.

On the basis of their literature review, the authors observed that the cancer detection rate for clinically significant cancer on MRI-targeted biopsy in the rebiopsy setting ranges from 11% to 54%, which is a greater yield than that achieved using standard systematic sampling alone.

"The decision whether to perform MRI in this setting must also take into account results of any other biomarkers, the cost of the examination, as well as availability of high quality prostate MRI interpretation," the authors stress.

"If MRI is done, it should be performed, interpreted, and reported in accordance with PI-RADS V2 guidelines."

Additional recommendations include:

  • the use of cognitive (visual) targeting by a skilled practitioner in the absence of advanced technologies, such as transrectal ultrasound–MRI fusion or in-bore MRI targeting;

  • obtaining at least two targeted cores from each MRI-defined target;

  • making case-specific decisions whether to also perform concurrent systematic sampling, because multiple studies have shown that MRI-targeted cores miss a proportion of clinically significant cancers;

  • performing solely targeted biopsy only when quality assurance efforts have validated the performance of prostate MRI interpretations with results consistent with the published literature;

  • the use of ancillary biomarkers in patients with a negative or low-suspicion MRI (PI-RADS assessment category of 1 or 2, respectively) to determine whether repeat systematic biopsy is warranted; and

  • continuing clinical and laboratory follow-up in low-suspicion MRI patients in whom repeat biopsy is deferred, and possibly incorporating repeat MRI into the surveillance regimen.

The consensus statement was developed collaboratively by a panel of urologists and radiologists "to generate as clinically relevant and practical a paradigm as possible," according to Dr Rosenkrantz. They hope it can help change how prostate cancer is diagnosed and monitored by providing more reliable biopsies, more accurate risk assessment, and potentially, improved treatment options.

Several of the authors have disclosed financial or other relationships with Thieme Medical Publishers, MDxHealth, and Hitachi-Aloka Medical.

J Urol. 2016;196:1613-1618. Full text

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