mpMRI/ultrasound fusion-guided prostate biopsy: can we forget random cores?
Objective
An extended Prostate Biopsy (10–12 cores) remains the standard for the initial diagnostic evaluation of a suspicious prostate 1 .The rate of prostate cancer (PCa) detection for a first systematic transrectal ultrasound-guided biopsy (TRUS-GB) is typically 30–50% 2 . Nevertheless, clinically significant PCa can be missed even after several repeat TRUS-GB. Multiparametric MRI (mpMRI) of the prostate is able to detect clinically relevant CaP 3-4 . The ability to visualize suspicious PCa on mpMRI allowed to use images as targets for needle biopsy by incorporating (i.e. fusing) mpMRI into a needle-aiming or targeting method 5 . The aim of the study was to evaluate the utility of still performing random cores during targeted magnetic resonance imaging/ultrasound fusion-guided biopsy (FUS-GB) in the diagnosis of
clinically significant prostate cancer (PCa).
Materials and Methods
Between November 2013 and May 2017, all men with previous history of negative prostate biopsy with PSA level of 4-20 ng/mL undergone mpMRI and FUS-GB + TRUS random biopsy, were consecutively included in the study. All men underwent a 12 extended-cores protocol plus 2-3 targeted cores on the mpMRI index lesion. The UroStation™ (Koelis, France) and a V10 ultrasound system with an end-fire 3D TRUS transducer were used for the fusion images procedure. We analysed the detection rate of clinically significant PCa with FUS-GB + TRUS random biopsy and the incident of positive biopsy in target cores and in random cores.
Results
Two hundred and twenty nine men were included in this multicenter study. The median time between mpMRI and biopsy was 30 days. MpMRI detected at least 1 suspicious area in 165 patients (72%), 2 or more suspicious areas in 64 patients (28%). Overall, 122/229 patients (53.2%) had positive biopsies. Gleason score 3+3 was found in 64 patients (52.4%), Gleason score 3+4 in 31 patients (25.4 %), Gleason score 4+3 in 12 patients (9.8%), Gleason score 4+4 in 15 patients (12.2%). The rate of cores positive for clinically significant cancer in target cores alone was 68 % versus 4 % for standard cores alone (p≤0.001).
Discussions
In naive patients, ultrasound (US)-guided random biopsy is the standard of care to diagnose a prostate cancer. A transrectal approach is used for most prostate biopsies, although some urologists prefer a perineal approach. Cancer detection rates are comparable with both approaches. Correlation between mpMRI imaging (associating T2-weighted imaging with diffusion-weighted imaging, dynamic contrast-enhanced imaging, and/or H1-spectroscopy) and radical prostatectomy (RP) shows good sensitivity for the detection and localisation of Gleason score > 7 cancers 6-7 . Three methods of MRI guidance are available for targeted prostate biopsy: cognitive fusion, direct MRI-guided biopsy, performed within an MRI tube and software coregistration of stored MRI with realtime ultrasound, using a fusion device 8 . Wegelin O. et al shows that magnetic resonance imaging-guided biopsy detects more clinically significant prostate cancer (PCa) and less insignificant PCa compared with systematic biopsy in men at risk for PCa. MRI-Guided Biopsies (MRI-GB) had similar overall PCa detection rates compared with TRUS-Guided Biopsies, increased rates of csPCa, and decreased rates of insignificant PCa. MRI-Target Biopsy (MRI TB) has a superior overall PCa detection compared with Cognitive-TB. Fusion-TB and MRI-TB appear to have similar detection rates. Head-to-head comparisons of MRI-GB techniques are limited 9 . In a recent systematic review, in patients with previous negative prostate biopsy MRI-GB detected more prostate cancer (46.3% vs 26.6%), more significant prostate cancer (32 % vs 16%) and less non significant prostate cancer (9.5% vs 14.5%) than TRUS, with less number of
biopsies 10 . In our study, target biopsy with fusion MRI-TRUS image registration significantly improved cancer detection over that of systematic transrectal ultrasound-guided biopsy. FUS-GB alone missed only 2% high grade cancers detected by TRUS-GB.
Conclusion
In our experience, MRI/TRUS-fusion targeted biopsies detected more men with clinically significant PCa than standard biopsies. Therefore, it's reasonable to avoid random cores and perform only target cores. Randomized extended and saturation prostate biopsies ruled in a “past prostate biopsy scenario “. They are still a gold standard, but we can assume that they are quickly going to be forgotten
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