Platinum Priority – Prostate CancerEditorial by Niccolò M. Passoni and Thomas J. Polascik on pp. 30–31 of this issueProspective Study of Diagnostic Accuracy Comparing Prostate Cancer Detection by Transrectal Ultrasound–Guided Biopsy Versus Magnetic Resonance (MR) Imaging with Subsequent MR-guided Biopsy in Men Without Previous Prostate Biopsies
Introduction
PCa is the most common male malignancy and the second most common cause of male cancer-related death [1]. Randomised trials have shown that early detection, through prostate-specific antigen (PSA) screening, can alter the natural history of the disease and reduce mortality [2]. However, this benefit is associated with the diagnosis of many indolent tumours, for which radical treatment leads to an adverse impact on quality of life without altering survival [3], [4], [5], [6], [7]. Population-based reports suggest little disconnect between diagnosis and treatment [8], [9], [10]. The overdiagnosis and overtreatment of PCa has caused various professional organisations to review their PSA screening guidelines [11], potentially reversing recent declines in disease-specific mortality [12].
Another approach to minimise overtreatment would be to reduce the overdiagnosis of low-risk PCa. Urologists use PSA followed by systematic transrectal ultrasound–guided biopsy (TRUSGB) rather than imaged-based diagnosis due to poor discrimination of PCa with transrectal ultrasound (TRUS). Due to the high prevalence of low-risk PCa, the TRUSGB diagnostic pathway finds many indolent tumours. TRUSGB also causes difficulties in managing patients with high PSA values but benign biopsies, and it also misclassifies the volume or risk of approximately a third of cases of biopsy-detected PCa when compared with whole-mount pathology [13], [14], [15].
Advances in 3-T multiparametric magnetic resonance imaging (mpMRI) have improved image-based diagnosis [16], [17], [18]. Also, targeted magnetic resonance (MR)–guided biopsy (MRGB) has become an alternative approach to TRUSGB. MRGB uses fewer cores than TRUSGB and can be applied only in men with lesions suspicious for intermediate/high-risk PCa [19], [20], [21], [22]. Although selective MRGB is an appealing pathway, few data support its reliability. It is unknown what proportion and what type of PCa would be missed by omitting biopsy from men with normal mpMRI scans. With this in mind, we designed a prospective diagnostic study to compare selective MRGB and unselected TRUSGB in men with an elevated PSA.
Section snippets
Recruitment, imaging, and biopsy
In this prospective single-centre diagnostic study, 226 biopsy-naive subjects with concerning PSA levels and/or an abnormal digital rectal examination (DRE) were consecutively enrolled by referral from urologists from July 2012 through January 2013. All subjects underwent mpMRI prostate performed at 3 T (Magnetom Skyra, Siemens) without endorectal coil. The mpMRI detection protocols and technique for MRGB have been reported [23]. Figure 1 lists the exclusion criteria; three subjects were
Patients and tumours
A total of 223 subjects were available for the final analysis (Fig. 1). These were typical for a white population at risk of PCa (Table 1) with a median age of 63 yr (interquartile range [IQR]: 57–68), median serum PSA of 5.3 ng/ml (IQR: 4.1–6.6), and median prostate volume of 41 ml (IQR: 30–59). DRE was suspicious for PCa in 40 men (17.9%). The mpMRI was suspicious for PCa (PI-RADS 4/5) in 109 (49%), equivocal (PI-RADS 3) in 33 (15%), and identified no abnormality (PI-RADS 1/2) in the remaining
Discussion
The results of this diagnostic study support apparent patient benefits. Most importantly, when using the mpMRI/MRGB pathway instead of TRUSGB, the number of men diagnosed with low-risk PCa will be reduced, and at the same time, the number of men diagnosed with intermediate/high-risk PCa will be increased. Secondly, because the data indicate minimal benefit from MRGB of PI-RADS 3 lesions, the number of men who need a biopsy (ie, in PI-RADS 4/5 only) can be halved, requiring only 2–3 needles
Conclusions
For asymptomatic men with elevated PSA, mpMRI followed by selective use of MR biopsy compared with TRUSGB reduces the detection of low-risk PCa, and it reduces the need for biopsy while improving the overall detection of intermediate/high-risk PCa.
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