Clinical implementation of pre‐biopsy magnetic resonance imaging pathways for the diagnosis of prostate cancer

Abstract

Objective To assess the outcomes of pre‐biopsy magnetic resonance imaging (MRI) pathways, as a tool in biopsy‐naïve men with suspicion of prostate cancer, in routine clinical practice. Secondary outcomes included a comparison of transrectal MRI‐directed biopsy (TR‐MRDB) and transperineal (TP)‐MRDB in men with suspicious MRI. Patients and Methods We retrospectively assessed a two‐centre cohort of consecutive biopsy‐naïve men with suspicion of prostate cancer who underwent a Prostate Imaging‐Reporting and Data System version 2 (PI‐RADS v2) compliant pre‐biopsy MRI in a single, high‐volume centre between 2015 and 2019 (Centre 1). Men with suspicious MRI scans underwent TR‐MRDB in Centre 1 and TP‐MRDB with additional random biopsies (RB) in Centre 2. The MRI and histopathology were assessed in the same institution (Centre 1). Outcomes included: (i) overall detection rates of Grade Group (GG) 1, GG ≥2, and GG ≥3 cancer in men with suspicious MRI; (ii) Biopsy‐avoidance due to non‐suspicious MRI; and (iii) Cancer detection rates and biopsy‐related complications between TR‐ and TP‐MRDB. To reduce confounding bias for MRDB comparisons, inverse probability weighting (IPW) was performed for age, digital rectal examination, prostate‐specific antigen (PSA), prostate volume, PSA density, and PI‐RADS category. Results Of the 2597 men included, the overall GG 1, GG ≥2, and GG ≥3 prevalence was 8% (210/2597), 27% (697/2597), and 15% (396/2597), respectively. Biopsy was avoided in 57% (1488/2597) of men. After IPW, the GG 1, GG ≥2 and GG ≥3 detection rates after TR‐ and TP‐MRDB were comparable at 24%, 57%, and 32%; and 18%, 64%, and 38%, respectively; with mean differences of −5.7% (95% confidence interval [CI] −13% to 1.4%), 6.1% (95% CI −2.1% to 14%), and 5.7% (95% CI −1.7% to 13%). Complications were similar in TR‐MRDB (0.50%) and TP‐MRDB with RB (0.62%; mean difference 0.11%, 95% CI −0.87% to 1.1%). Conclusion This high‐volume, two‐centre study shows pre‐biopsy MRI as a decision tool is implementable in daily clinical practice. Compared to recent trials, a substantially higher biopsy avoidance rate was achieved without compromising GG ≥2/GG ≥3 detection and coinciding with lower over detection rates of GG 1 cancer. Prostate cancer detection and complication rates were comparable for TR‐ and TP‐MRDB.

Implications of the European Association of Urology Recommended Risk Assessment Algorithm for Early Prostate Cancer Detection

“…According to the EAU recommendation, 54% of men with intermediate or high risk will have Prostate Imaging-Reporting and Data System (PI-RADS) scores of 1–2 [1] , [14] . Similar rates (49–59%) have been reported by expert centers, but it should be noted that these percentages were from (screening) populations not yet stratified using pre-MRI risk assessment tools [13] , [15] , [16] . A recent Cochrane systematic review that also included centers with less prostate MRI expertise showed that the group of biopsy-naïve men with a clinical suspicion of PCa had a markedly lower PI-RADS 1–2 assessment rate (33%) [17] ; the prevalence of csPCa among studies included in the systematic review was 30%.…”

Up-to-Date Imaging and Diagnostic Techniques for Prostate Cancer: A Literature Review

“…Wide variations in sensitivity and specificity can be explained by different acquisition protocols, different thresholds being applied, different reference criteria used, biopsy inaccuracies, and the varied experience levels of the radiologists with PI-RADS v2. Multiple guidelines have recommended the routine application of mpMRI in biopsy-naïve patients with suspected PCa, and there is an ongoing implementation process in clinical practice [ 32 ].…”

Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway

“…With regards to the biopsy route, the transperineal route benefits from reduced or no antibiotic prophylaxis and, therefore, has gained popularity owing to concerns on the transrectal route regarding sepsis [126][127][128] . Transperineal biopsy favours an improved sampling of the anterior part of the prostate 129 , and can also be implemented in an outpatient setting under local anaesthesia 130 . Thus, transperineal biopsy is gaining momentum, considering that the transperineal and the transrectal approaches offer equal cancer detection rates 131 .…”