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| Magnetic resonance imaging-guided prostate biopsy—A review of literature |
Kulthe Ramesh Seetharam Bhata,*( ),Srinivas Samavedib,Marcio Covas Moschovasa,Fikret Fatih Onola,Shannon Roofa,Travis Rogersa,Vipul R. Patela,Ananthakrishnan Sivaramanc
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a Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, USA
b The Hays Medical Centre, University of Kansas Health System, Hays, KS, USA
c Chennai Urology and Robotics Institute, Chennai, Tamilnadu, India |
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Abstract Objective: Multiparametric magnetic resonance imaging (MP-MRI) helps to identify lesion of prostate with reasonable accuracy. We aim to describe the various uses of MP-MRI for prostate biopsy comparing different techniques of MP-MRI guided biopsy. Materials and methods: A literature search was performed for “multiparametric MRI”, “MRI fusion biopsy”, “MRI guided biopsy”, “prostate biopsy”, “MRI cognitive biopsy”, “MRI fusion biopsy systems”, “prostate biopsy” and “cost analysis”. The search operation was performed using the operator “OR” and “AND” with the above key words. All relevant systematic reviews, original articles, case series, and case reports were selected for this review. Results: The sensitivity of MRI targeted biopsy (MRI-TB) is between 91%-93%, and the specificity is between 36%-41% in various studies. It also has a high negative predictive value (NPV) of 89%-92% and a positive predictive value (PPV) of 51%-52%. The yield of MRI fusion biopsy (MRI-FB) is similar, if not superior to MR cognitive biopsy. In-bore MRI-TB had better detection rates compared to MR cognitive biopsy, but were similar to MR fusion biopsy. Conclusion: The use of MRI guidance in prostate biopsy is inevitable, subject to availability, cost, and experience. Any one of the three modalities (i.e. MRI cognitive, MRI fusion and MRI in-bore approach) can be used. MRI-FB has a fine balance with regards to accuracy, practicality and affordability.
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Received: 24 December 2019
Available online: 20 January 2021
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Corresponding Authors:
Kulthe Ramesh Seetharam Bhat
E-mail: Seetharam_bhat2003@yahoo.co.in
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| Authors | Trial design | Number of patients | Conclusion | | Kasivisvanathan et al. [19] | - Multicenter, randomized, noninferiority trial at 25 centers in 11 countries (PRECISION STUDY) | 500
- PIRADS 3, 4, 5—Biopsied vs. standard 12 core biopsy.
- The primary outcome was the proportion of men with csPCa, defined as the presence of a single biopsy core indicating disease of Gleason score 3+4 or greater | - There was significantly higher rates of detection of PCa using MRI-TB vs. systematic biopsy (p=0.005). | | van der leest et al. [31] | - Multicentric prospective paired cohort—Patients underwent prebiopsy MRI
- MRI guided biopsy vs. standard biopsy | 626
- csPCa was defined as grade group ≥2 (Gleason score≥3+4) in any core. | - MRI-TB and systematic TRUS biopsy had similar rates of clinically significant PCa. MRI-TB detected a lower proportion of clinically insignificant disease. | | Rouvière et al. [27] | - Multicentric-prospective paired cohort—16 centre in France. | 275
- MRI with a Likert score of 3 or higher (three cores per lesion) targeted.
- Detection of ISUP grade group 2 or higher PCa | - 20% of clinically significant PCa was diagnosed by MRI-TB, 14% by TRUS biopsy. Combined biopsy had maximal detection rates (66%). | | Ahmed et al. [28] | - Multicentric-prospective paired cohort (PROMIS trial)—Patients underwent all three test. | 576 - Primary definition—Gleason ≥4+3 or more, or a MCCL involvement of 6 mm or more.
- The reference test (TPM-biopsy) was done with core biopsies | - MP-MRI guided biopsy leads to 18% more clinically significant cancer compared to standard pathway. MP-MRI when used to triage men can avoid unnecessary biopsy in 27%, but can miss 5% of clinically significant PCa.
Sensitivity-93%
Specificity-41%
NPV-89%
PPV-51% | | Thompson et al. [29] | - Single centre—prospective paired cohort
- Data were reported according to the START (standards of reporting for MRI targeted biopsy studies) criteria.
- All patients had MRI, transperineal template mapping biopsy. | 344
- Gleason score 7-10 with greater than 5% Gleason grade 4, 20% or more cores positive, or 7 mm or more.
- Radical prostatectomy specimen gold standard | - MP-MRI can avoid 23% of unnecessary biopsies and enhanced the detection of low risk PCa by 34%.
Sensitivity-96%
Specificity-36%
NPV-92%
PPV-52% | | Panebianco et al. [32] | - Single centre—RCT
- TRUS vs. TRUS + MRI targeted biopsy | 570 in each group
- Cut off for biopsy, PSA >4 ng/mL; PSA velocity >0.75 ng/mL/year; free/total PSA ratio <0.010 (PSA 4-10 ng/mL)
- PCa Gleason score of 6 or precancerous lesions were detected. | - Accuracy of MP-MRI was 97%. | | Baco et al. [33] | - Single centre—RCT
- MRI-targeted biopsy studies (START) criteria | 175 (86 MRI vs. 89 control)
- csPCa on biopsy was defined as MCCL ≥5 mm for Gleason score 6 disease or any MCCL for Gleason score ≥7. | - PCa detection rates were similar in both groups. | | Siddiqui et al. [34] | - Single centre—Paired cohort | 1 003
-The primary objective was to compare targeted and standard biopsy approaches for detection of high-risk PCa (Gleason score ≥4+3).
- Secondary-focused on detection of low-risk PCa (Gleason score 3+3 or low-volume 3+4)
- Biopsy—The ability of the biopsy to predict pathology at prostatectomy. | - MRI-TB diagnosed 30% more high risk PCa and 17% lesser low-risk PCa. Sensitivity for high risk PCa was 77% vs. 53% with similar specificity. | | Drost et al. [30] | - A Cochrane systematic review and meta-analysis | - 43 studies (6 871 men)
- This review used template biopsy as standard reference and compared the diagnostic accuracy of MRI index only lesions, MRI-targeted biopsy, MRI pathway (MRI +/ - MRI targeted biopsy) and systematic biopsy.
- The primary end point was ISUP 2 and above (csPCa), and secondary end point was ISUP 1. | - Pooled data
Sensitivity-0.91
Specificity-0.37
NPV-92%
PPV-52
- MRI-TB missed 9% of ISUP grade 2 or higher cancer. | | Elwenspoek et al. [35] | - Systematic review and meta-analysis
- Evaluated three biopsy
1)
Pathway systematic biopsy
2)
MRI-TB
3)
Both pathway | - 7 RCTs (2 582 men) csPCa definition varied in different series | - 57% improvement in detection of csPCa, 33% reduction in number of biopsy and 77% reduction in the number of cores. | | Woo et al. [36] | - Systematic reviews and meta-analysis
1)
MRI-TB
2)
MRI plus systematic biopsy as intervention
3)
Systemic TRUS as comparator | - 9 RCTs (2 908 men) csPCa definition varied in different series | - MRI stratified pathway detected more clinically significant PCa than TRUS biopsy (relative detection rate 1.45 for all men, 1.42 for biopsy na?ve and 1.6 for men with prior negative biopsy). | | Schoots et al. [37] | - Systematic review and meta-analysis
- MRI-TB vs. TB | - 16 studies (1 926 men)
varied definition | - MRI-TB had higher rate of detection of significant PCa (MRI-TB vs. TB sensitivity: 0.91 vs. 0.76) and lower rate of detection of insignificant PCa (0.44 vs. 0.83). | | Moore et al. [38] | - Systematic review | - 599 patients | - MRI-TB detects clinically significant PCa with less number of cores (MRI-TB [3.8 cores] vs. TB [12 cores]). | | Wegelin et al. [39] | - Systematic review and meta-analysis
- Three techniques of MRI-TB are available: 1) In-bore MRI target biopsy (MRI-TB), 2) MRI-transrectal ultrasound fusion (MRI-FB), and 3) cognitive registration (MRI-CB). | - 43 studies | - Overall detection rates are similar in different biopsy techniques.
- Increased rate of csPCa and decrease in clinically insignificant PCa. |
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Summary of studies comparing between MRI-targeted biopsy and systematic biopsy.
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| Device | Fusion mechanism | Tracking mechanism | Routes | Comments | | Uronav | - Elastic registration | - Electromagnetic tracking mechanism | - Transrectal
- Transperineal | - Can use prior biopsy plan to guide the current biopsy. | | Artemis | - Rigid and elastic registration | - Electromagnetic tracking by mechanical arm with no external trackers
- Rigid motion compensation | - Transrectal
- Transperineal | - Can use prior biopsy plan to guide the current biopsy. | | Urostation | - Rigid and elastic registration | - Organ based tracking using 3D TRUS | - Transrectal
- Transperineal | - Capability of PET/CT fusion
- Treatment guidance | | Biojet | - Rigid registration | - Trackers and angle sensors in the mechanical arm | - Transperineal
- Transrectal. | - Can use prior biopsy plan to guide the current biopsy. | | Real-time virtual sonography | - Rigid registration | - Electromagnetic tracking | - Transrectal
- Transperineal | - Compatible with B-mode, colour Doppler, dynamic
- Contrast harmonic imaging and real-time tissue elastography modes | | LOGIQ 9 | - Rigid registration | - Electromagnetic tracking | - Transrectal
- Transperineal | - Manual correction
- Capability of PET/CT fusion
- Automatic motion correction using CIVCO omniTRAX?, a plastic support brackets. | | Fusion Biopsy 2.0 | - Rigid and elastic registration | - Electromagnetic tracking by a robotic arm | - Transrectal
- Transperineal | - Automatic motion compensation | | Virtual navigator | - Rigid registration | - Electromagnetic with two sensors | - Transrectal
- Transperineal | - PET/CT/MRI/3D ultrasound fusion | | Biopsee | - Rigid registration | - Two built-in encoders tracking the TRUS probe
- A stepper for the transperineal biopsy. | - Transperineal | - Limited by only 2 degree-of-freedom motion. |
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Comparison of different MRI-fusion biopsy systems.
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| Study | Methods | Conclusion | Significant findings | | Puech et al. [50] | - Intraindividual comparison of systematic vs. MRI-CB vs. MRI-FB | - Cognitive and software fusion biopsy were significantly superior to systematic biopsy.
- The yield was similar between the cognitive and the fusion biopsy. | ? Prostate carcinoma positivity rates for SB (59%) vs. MRI-TB (both) (69%).
? MRI-CB vs. MRI-FB positivity rate (47% vs. 53%; no significant difference). | | Wysock et al. [51] | - Intra individual comparison between MRI-CB and MRI-FB by two different urologist | - MR-FB had higher detection rate of Gleason score 7 or above.
- MRI-FB also better characterised nonbenign histology. | ? MRI-FB 20% vs. MRI-CB 15%; p=0.052.
? MRI-FB 77 vs. MRI-CB 60; p=0.0104.
? Multivariable analysis reveals size of the lesion as an independent factor predicting cancer in MRI-FB. | | Cool et al. [52] | - Comparison between 2D vs. 3D vs. MRI-FB using simulation models form 100 patients | - MRI-CB was inferior to MRI-TRUS fusion biopsy, irrespective of operator level of experience. | ? MRI-FB had 100% sampling rate but does not translate to 100% cancer detection rates as the prostate MP-MRI specificity ranges between 44% and 67%. | | Venderink et al. [53] | - Retrospective comparison between in bore MRI-guided biopsy vs. MRI-FB | - No significant differences in detecting csPSA between in bore MR biopsy and MR fusion guided biopsy. | ? Detection rates of csPSA did not differ between MRI-FB and MR-in bore guided biopsy (49% vs. 61% respectively).
? Overall detection rates for MRI-FB vs. MRI in-bore biopsy were 66.7% vs. 85% (p<0.05). | | Kwak et al. [54] | - Two operators of different experience performed visual registration (MR-CB) and MRI-FB biopsy | - The amount of mistargeting in MRI-CB was high regardless of site the lesion.
- Different levels of experience led to substantial difference in visual registration leading to missed diagnosis. | ? The mean distance of cognitive targets was 10.6 mm from the MRI fusion targets with 15.3% patients having less than 5 mm discrepancy.
? The difference between spatial difference between the experience and inexperienced were 9.7±5.1 mm vs. 13.4±7.4 mm; p=0.042. | | Arsov et al. [55] | - Randomized patient to in-bore MR imaging targeted biopsy vs. systematic biopsy/MRI-FB | - No significant difference
? Pathological diagnosis
? Grade
? Volume of tumour
- Significant fewer cores in the in-bore approach.
- Study stopped as the interim analysis did not show any difference. | ? 267 patients (106 in MRI-guided in-bore group vs. 104 in other approaches)
? In-bore approach vs. other approaches (mean cores: 5.6 cores vs. 17 cores, p<0.001). | | Wegelin et al. [39] | - Systematic review and meta-analysis compared MRI-FB vs. MRI-CB and in-bore TB | - In-bore MRI-TB had better detection rates compared to MR cognitive biopsy.
- MRI-FB and MRI-in-bore have similar detection rates. | ? In-bore MRI-TB vs. MR-CB (p=0.02).
? In-bore MRI-TB vs. MRI-FB (p=0.13)
? MRI-FB vs. MRI-CB (p=0.11). | | Wegelin et al. [56] | - FUTURE Trial: Multicenter randomised controlled trial comparing biopsy techniques based on MP-MRI | - No significant differences in the detection rates of clinically significant PCa among three biopsy techniques—MRI-FB vs. MRI-CB vs. MRI-guided in-bore biopsy. | ? No significant differences in the detection rates of overall PCa (p=0.4).
? No significant differences in the detection rates of csPCa (Gleason score ≥3+4) (p>0.9). |
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