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Prostate MRI Update 2016: MR-TRUS Fusion Biopsy

SCBT•MR 2016

Katarzyna J. Macura, MD, PhD, FACR, FSCBTMR

The Russell H. Morgan Department of Radiology and Radiological Science,

Johns Hopkins University, Baltimore, MD

Background

• 1 mln prostate biopsies are performed annually in the USA during the

PSA era

• Blind biopsies are misleading

– Underdetection of significant cancer (anterior prostate or apex)

– 35% falsely negative

– Overdetection of small indolent cancer of little clinical significance (up to 50% of

detected cancers)

• > 26,000 deaths projected in 2016

• MRI-ultrasound fusion for guidance of targeted prostate biopsy emerged

as an important tool for diagnosis of clinically significant prostate cancer,

while minimizing detection of indolent cancer

Prostate Cancer at a Glance

NCI - http://seer.cancer.gov/statfacts/html/prost.html

Lifetime Risk: 14.0% of men will be diagnosed with prostate cancer during their lifetime

Prevalence: In 2013, estimated 2,850,139 men living with prostate cancer in the US

Indications for MR-TRUS fusion biopsy

• Elevated PSA and suspected cancer, previous negative TRUS biopsy

• Known cancer considered for active surveillance

• Known cancer to determine disease status during active surveillance

• Candidates for focal therapy

59M, Gleason 3+4=7 (80% of 1 core), G3+3=6 tumor (2

cores, 50% each), and HGPIN

De-novo diagnosis of prostate cancer:

biopsy naïve patient

TRUS

Nodule 20 mm

PI-RADS 5

De-novo diagnosis of prostate cancer:

multiple negative TRUS biopsies

71M, Gleason 4+4=8 involving 2 cores (30%, 40%)

Nodule 10 mm

PI-RADS 4

Extruded BPH nodule or PZ nodule?

75M, benign prostatic tissue

Nodule 8 mm

circumscribed

PI-RADS 2-3

Cancer vs. Extruded BPH

Elevated PSA, negative prior TRUS x 2:

typically missed on TRUS anterior nodule

Nodule 16mm PI-RADS 5

65M, Gleason 3+3=6 involving 3 cores

(100%, 40%, 5%).

Patient in active surveillance:

establish the risk, monitor stability

F-U 2-years later

Nodule 10mm PI-RADS 4 75M, Gleason score 3+3=6 60% of core

Comparison standard vs. targeted BX

Systematic BX:

1) RIGHT APEX: BENIGN.

2) RIGHT MID: BENIGN.

3) RIGHT BASE: HGPIN.

4) LEFT APEX: BENIGN.

5) LEFT MID: BENIGN WITH

CHRONIC INFLAMMATION.

6) LEFT BASE: BENIGN WITH

CHRONIC INFLAMMATION.

Radical prostatectomy:

Adenocarcinoma (conventional, NOS)

GLEASON SCORE - DOMINANT

NODULE: 4 + 5 = 9

GLEASON SCORE - SECONDARY

NODULE: 3 + 3 = 6

LOCATION - DOMINANT NODULE:

Right; Posterolateral/Posterior;

Apex/Mid/Base

LOCATION - SECONDARY NODULE:

Left; Posterolateral; Mid

LOCAL EXTENT: Organ confined;

MARGINS: Negative

61M, PSA from 5.7 to 18 ng/mL over 8 years

negative prior TRUS biopsies x2

Nodule 16 mm, capsule bulge

PI-RADS 5

Targeted BX:

PROSTATE, Target 1 RIGHT BASE

MID: PROSTATIC

ADENOCARCINOMA,

GLEASON SCORE 4 + 3 = 7

INVOLVING 80% OF ONE (1) OF

TWO (2) CORES.

(70% GLEASON PATTERN 4) .

Comparison of MR/Ultrasound Fusion–Guided

Biopsy With Ultrasound-Guided Biopsy for the

Diagnosis of Prostate CancerJAMA. 2015;313(4):390-397

Targeted biopsy diagnosed 30% more high-risk cancers vs. standard biopsy

and 17% fewer low-risk cancers.

A Randomized Controlled Trial To Assess and Compare the

Outcomes of Two-core Prostate Biopsy Guided by Fused

Magnetic Resonance and Transrectal Ultrasound Images and

Traditional 12-core Systematic Biopsy

Clinically significant cancer two-core MRI/TRUS-TB 38% vs. 12-core RB in control 49%

Prospective Evaluation of the Prostate Imaging

Reporting and Data System Version 2 for Prostate

Cancer Detection

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THE JOURNAL OF UROLOGY, Vol.

196, 690-696, September 2016

Cancer detection rate:

PI-RADS 5 - 78%

PI-RADS 4 - 30%

PI-RADS 3 - 16%

PI-RADS 2 – 22%

Conclusion: The current criteria result in a high false-positive rate and stricter criteria

may be needed to increase the cancer detection rate for PI-RADS scores of 3, 4, and 5.

Correlation of PI-RADS score of regions of interest (ROIs) on mpMRI with

targeted biopsy (bx) findings (benign, Gleason score or GS 6, GS >7) in the

AS cohort (A), confirmatory biopsy cohort (B) and targeted biopsy cohort (C).

The Role of Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion Biopsy in Active

Surveillance. Eur Urol. 2016

Augmenting MRI with clinical variables

Prostate Health Index

Tosoian JJ et al. JHU, in pressScatter plot of PHI by PI-RADS score and biopsy results (n=121)

No men with PHI<27 and PI-RADS≤3

had grade group ≥2 cancer.

Several men with low PI-RADS scores

and PHI>27 had clinically significant PCa.

Gleason Score

1 GS 3+3=6

2 GS 3+4=7

3 GS 4+3=7

4 GS 4+4=8

5 GS9 or GS10

Pathologic Grade Group:

AUA – SAR Consensus Statement

• “When high-quality prostate MRI is available, it should be strongly

considered in any patient with a prior negative biopsy who has persistent

clinical suspicion for prostate cancer and who is undergoing a repeat

biopsy.”

• “If MRI is done, it should be performed, interpreted, and reported in

accordance with PI-RADS V2 guidelines.“

• “Patients receiving a PI-RADS assessment category of 3-5 warrant

repeat biopsy with image guided targeting.”

• “At least two targeted cores should be obtained from each MRI-defined

target.”

AUA – SAR Consensus Statement

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THANK YOU! SCBT•MR 2016