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Urologic Oncology:
Prostate MRI 101
Jeffrey K. Mullins, MD
Director Urologic Oncology
CHI Memorial Chattanooga
Urology Associates
January 11, 2020
Disclosures
• No Financial Disclosures
Objective
• Provide a data driven approach to the use of
multi-parametric prostate MRI in the following
situations
• Elevated PSA
• Active Surveillance for Prostate Cancer
• Surgical Planning
MRI and PSA Screening
PSA Screening:
Understanding the Problem
Siegel et al. ACS Cancer Statistics 2019
PSA Screening
Understanding the Problem
False Negatives
Indolent Cancers
Morbidity of Treatment
USPTFS Decision Aid.
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFi
nal/prostate-cancer-screening1?ds=1&s=prostate
PSA Screening
Understanding the Problem
• USPTFS Issues “D” Recommendation for
ALL men (2012)
• Later updated to “C” in 2018
• Results
• Decreased Screening
• Decreased Incidence
• Increasing Mortality?
PSA Screening
Understanding the Problem
Bill-Axelson et al. NEJM 2018
PSA Screening
Solving the Problem
• Solutions to improve PSA screening
• Decrease # of biopsies
• Decrease detection of low risk prostate cancer
• Increase utilization of Active Surveillance
• Decrease Morbidity of Treatment
PSA Screening
MRI Solution Benefits of MRI
1. Reduces Biopsy
2. Decreases Detection of Indolent Prostate Cancer
3. Increases Detection of Significant Prostate Cancer
Kasivisvanathan et al. NEJM 2018
Ahmed et al. Lancet 2017
JAMA Netw Open 2019
MP-MRI for Elevated PSA
Important Caveat
FALSE NEGATIVE RATE
(1 – Sensitivity)
10 – 20% for Gleason ≥
3+4=7
Ahmed et al. Lancet 2017
MR-MRI
Important Caveat
Negative Predictive Value Of MRI1. PSA Density <0.07 = 86.52. PSA Density 0.07 – 0.15= 88.93. PSA Density > 0.15 = 66.9
Distler et al. Jurol 2017
MR-MRI for Elevated PSA
Take Home Points
Guideline Based Practice supported by 3 Trials
(Level 1 Evidence)
NCCN Guidelines on prostate cancer early detection. 2018
MR-MRI for Elevated PSA
Take Home Points
WE CANNOT COMPLETELY RELY ON MRI FOR EVALATION OF
ELEVATED PSA!!
However….
MP-MRI for Elevated PSA
What We Do
• MP-MRI First
• Prostate Biopsy if
• PIRADS 3-5 Lesion
• PSA Density >0.15 and negative MRI
• PSA continues to rise despite negative MRI
• Biopsy Technique
• Targeted (2- 4 cores) Fusion Biopsy
• Systematic Sampling (6 -12 cores)
• Transperineal Fusion Biopsy (First in TN)
MR-MRI for Elevated PSA
Take Home Points
Rosenkrantz et al. JUrol 2016
MRI and Active Surveillance
MP-MRI and Active Surveillance:
Safe to Enter?
Compared with men without an MRI lesion, a significant increase in biopsy reclassification was noted for men with
a MRI lesion (40 vs 12.5%, P = 0.04).
Mullins et al. BJU Int 2013
MP-MRI and Active Surveillance:
Safe to Continue?
MP-MRI and Active Surveillance:
Safe to Continue?
Significant # of upgrades were missed using either only Systematic or Targeted Biopsies
Jayadevan. JAMA Netw Open 2019
MR-MRI and Active Surveillance
Conclusions
• Important in choosing ideal AS candidates
(along with other factors)
• Important in detecting upgrading
• Not a stand-alone tool for surveillance. Biopsy
(systematic + targeted still needed)
MRI and Surgical Planning
MP-MRI and Surgical Planning:
My Preference:MRI for every surgical patient
Mehralivand et al. Radiology 2019
MRI and Surgical Planning
Conclusions and Recommendations
• MRI is a valuable tool in the evaluation of
elevated PSA and Prostate Cancer
• Urology Referral still recommended for
elevated PSA
• ALL Active Surveillance patients should be
followed by Urologist
THANK YOU!
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