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MRI-targeted prostate biopsy: a review of technique and results

Nature Reviews Urology volume 10, pages 589–597 (2013)Cite this article

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Abstract

Multiparametric magnetic resonance imaging (mpMRI) is of interest for the diagnosis of clinically significant prostate cancer and mpMRI-targeted biopsies are being used increasingly in clinical practice. Target acquisition is performed using a range of magnet strengths and varying combinations of anatomical and functional sequences. Target identification at the time of biopsy can be carried out in the MRI scanner (in-bore biopsy) or, more commonly, the MRI-target is biopsied under ultrasonographic guidance. Many groups use cognitive or visual registration, whereby the biopsy target is identified on MRI and ultrasonography is subsequently used to direct the needle to the same location. Other groups use registration software to show prebiopsy MRI data on real-time ultrasonography. The reporting of histological results in MRI-targeted biopsy studies varies greatly. The most useful reports compare the detection of clinically significant disease in standard cores versus mpMRI-targeted cores in the same cohort of men, as recommended by the STAndards of Reporting for MRI-Targeted biopsy studies (START) consensus panel. Further evidence is needed before an mpMRI-targeted strategy can be recommended as the standard intervention for men at risk of prostate cancer.

Key Points

  • Multiparametric magnetic resonance imaging (mpMRI)-targeted biopsies are being used increasingly in clinical practice for the detection of clinically significant prostate cancer

  • MpMRI-targeted biopsies have demonstrated superiority over systematic biopsies for the detection of clinically significant disease and representation of disease burden, while deploying fewer cores

  • MRI-targeted biopsy studies demonstrate significant variability in terms of design and reporting of histological results

  • The European Consensus Meeting and the European Society of Urogenital Radiology guidelines have initiated the standardization process for reporting of prostate MRI

  • The STAndards of Reporting for MRI-Targeted biopsy studies (START) consensus group has published recommendations for the reporting of MRI-targeted prostate biopsies

  • Studies that adhere closely to the START criteria provide results that contribute to the robust comparison of mpMRI-targeted prostate biopsy with standard prostate biopsy

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Figure 1: MpMRI performed before transperineal template biopsy for a 69-year-old male with an elevated PSA.

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References

  1. Hodge, K. K. et al. Random systematic versus directed ultrasound-guided transrectal core biopsies of the prostate. J. Urol. 142, 71–74 (1989).

    Article  CAS  Google Scholar 

  2. King, C. R., McNeal, J. E., Gill, H. & Presti, J. Extended prostate biopsy scheme improves reliability of Gleason grading for radiotherapy patients. Int. J. Radiat. Oncol. Biol. Phys. 59, 386–393 (2004).

    Article  Google Scholar 

  3. Ismail, M. & Gomella, L. G. Ultrasound for prostate imaging and biopsy. Curr. Opin. Urol. 11, 471–477 (2001).

    Article  CAS  Google Scholar 

  4. Klotz, L. Active surveillance for low-risk prostate cancer. F1000 Med. Rep. 4, 16 (2012).

    Article  Google Scholar 

  5. Shariat, S. & Roehrborn, C. Using biopsy to detect prostate cancer. Nat. Rev. Urol. 10, 262–280 (2008).

    Google Scholar 

  6. Peuch, P. et al. Dynamic contrast-enhanced-magnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens. Urology 74, 1094–1099 (2009).

    Article  Google Scholar 

  7. Hambrock, T. et al. Prospective assessment of prostate cancer aggressiveness using 3-T diffusion weighted magnetic resonance imaging-guided biopsies versus a systematic 10-core transrectal ultrasound prostate biopsy cohort. Eur. Urol. 61, 177–184 (2012).

    Article  Google Scholar 

  8. Hambrock, T. et al. Relationship between apparent diffusion coefficients at 3.0-T MR imaging and gleason grade in peripheral zone prostate cancer. Radiology 259, 453–461 (2011).

    Article  Google Scholar 

  9. Robertson, N., Hu, Y. & Ahmed, H. Prostate cancer risk inflation as a consequence of image-targeted biopsy of the prostate: a computer simulation study. Eur. Urol. http://dx.doi.org/10.1016/j.eururo.2012.12.057

  10. Labanaris, A. P. et al. Guided e-MRI prostate biopsy can solve the discordance between Gleason score biopsy and radical prostatectomy pathology. Magn. Reson. Imaging 28, 943–946 (2010).

    Article  Google Scholar 

  11. Herman, S. D., Friedman, A. C., Radecki, P. D. & Caroline, D. F. Incidental prostatic carcinoma detected by MRI and diagnosed by MRI/CTguided biopsy. AJR Am. J. Roentgenol. 146, 351–352 (1986).

    Article  CAS  Google Scholar 

  12. Yakar, D. et al. Feasibility of 3T dynamic contrast-enhanced magnetic resonance-guided biopsy in localizing local recurrence of prostate cancer after external beam radiation therapy. Invest. Radiol. 45, 121–125 (2010).

    Article  Google Scholar 

  13. Sciarra, A. et al. Value of magnetic resonance spectroscopy imaging and dynamic contrast-enhanced imaging for detecting prostate cancer foci in men with prior negative biopsy. Clin. Cancer Res. 16, 1875–1883 (2010).

    Article  CAS  Google Scholar 

  14. Lichy, M. P. et al. Morphologic, functional, and metabolic magnetic resonance imaging-guided prostate biopsy in a patient with prior negative transrectal ultrasoundguided biopsies and persistently elevated prostate-specific antigen levels. Urology 69, 1208 (2007).

    Article  Google Scholar 

  15. Haffner, J. et al. Role of magnetic resonance imaging before initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer detection. BJU Int. 108, E171–E178 (2011).

    Article  Google Scholar 

  16. Miyagawa, T. et al. Real-time virtual sonography for navigation during targeted prostate biopsy using magnetic resonance imaging data. Int. J. Urol. 17, 855–860 (2010).

    Article  Google Scholar 

  17. Prando, A., Kurhanewicz, J., Borges, A. P., Oliveira, E. M. & Figueiredo, E. Prostatic biopsy directed with endorectal MR spectroscopic imaging findings in patients with elevated prostate specific antigen levels and prior negative biopsy findings: early experience. Radiology 236, 903–910 (2005).

    Article  Google Scholar 

  18. Park, B. K. et al. Prospective evaluation of 3-T MRI performed before initial transrectal ultrasound-guided prostate biopsy in patients with high prostate-specific antigen and no previous biopsy. AJR Am. J. Roentgenol. 197, W876–W881 (2011).

    Article  Google Scholar 

  19. Pinto, P. A. et al. Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves cancer detection following transrectal ultrasound biopsy and correlates with multiparametric magnetic resonance imaging. J. Urol. 186, 1281–1285 (2011).

    Article  Google Scholar 

  20. Hambrock, T. et al. Magnetic resonance imaging guided prostate biopsy in men with repeat negative biopsies and increased prostate specific antigen. J. Urol. 183, 520–527 (2010).

    Article  CAS  Google Scholar 

  21. Bourne, R. et al. Detection of prostate cancer by magnetic resonance imaging and spectroscopy in vivo. ANZ J. Surg. 73, 666–668 (2003).

    Article  Google Scholar 

  22. Amsellem-Ouazana, D. et al. Negative prostatic biopsies in patients with a high risk of prostate cancer. Is the combination of endorectal MRI and magnetic resonance spectroscopy imaging (MRSI) a useful tool? A preliminary study. Eur. Urol. 47, 582–586 (2005).

    Article  Google Scholar 

  23. Testa, C. et al. Accuracy of MRI/MRSI-based transrectal ultrasound biopsy in peripheral and transition zones of the prostate gland in patients with prior negative biopsy. NMR Biomed. 23, 1017–1026 (2010).

    Article  CAS  Google Scholar 

  24. Choi, M. S. et al. The clinical value of performing an MRI before prostate biopsy. Korean J. Urol. 52, 572–577 (2011).

    Article  Google Scholar 

  25. Cirillo, S. et al. Value of endorectal MRI and MRS in patients with elevated prostate-specific antigen levels and previous negative biopsies to localize peripheral zone tumours. Clin. Radiol. 63, 871–879 (2008).

    Article  CAS  Google Scholar 

  26. Kumar, R. et al. Potential of magnetic resonance spectroscopic imaging in predicting absence of prostate cancer in men with serum prostate-specific antigen between 4 and 10 ng/ml: a follow-up study. Urology 72, 859–863 (2008).

    Article  Google Scholar 

  27. Kumar, V. et al. Potential of (1)H MR spectroscopic imaging to segregate patients who are likely to show malignancy of the peripheral zone of the prostate on biopsy. J. Magn. Reson. Imaging 30, 842–848 (2009).

    Article  Google Scholar 

  28. Kumar, V. et al. Transrectal ultrasound guided biopsy of prostate voxels identified as suspicious of malignancy on three-dimensional 1H MR spectroscopic imaging in patients with abnormal digital rectal examination or raised prostate specific antigen level of 4–10 ng/ml. NMR Biomed. 20, 11–20 (2007).

    Article  Google Scholar 

  29. Lattouf, J.-B. et al. Magnetic resonance imaging directed transrectal ultrasonography-guided biopsies in patients at risk of prostate cancer. BJU Int. 99, 1041–1046 (2007).

    Article  Google Scholar 

  30. Perrotti, M. et al. Prospective evaluation of endorectal magnetic resonance imaging to detect tumour foci in men with prior negative prostatic biopsy: a pilot study. J. Urol. 162, 1314–1317 (1999).

    Article  CAS  Google Scholar 

  31. Portalez, D. et al. Prospective comparison of T2w-MRI and dynamic-contrast-enhanced MRI, 3D-MR spectro- scopic imaging or diffusion-weighted MRI in repeat TRUS-guided biopsies. Eur. Radiol. 20, 2781–2790 (2010).

    Article  Google Scholar 

  32. Vilanova, J. C. et al. The value of endorectal MR imaging to predict positive biopsies in clinically intermediate-risk prostate cancer patients. Eur. Radiol. 11, 229–235 (2001).

    Article  CAS  Google Scholar 

  33. Yuen, J. S. P. et al. Endorectal magnetic resonance imaging and spectroscopy for the detection of tumour foci in men with prior negative transrectal ultrasound prostate biopsy. J. Urol. 171, 1482–1486 (2004).

    Article  CAS  Google Scholar 

  34. Engelhard, K., Hollenbach H.-P., Deimling, M., Kreckel, M. & Riedl, C. Combination of signal intensity measurements of lesions in the peripheral zone of prostate with MRI and serum PSA level for differentiating benign disease from prostate cancer. Eur. Radiol. 10, 1947–1953 (2000).

    Article  CAS  Google Scholar 

  35. Labanaris, A. P., Engelhard, K., Zugor, V., Nutzel, R. & Kuhn, R. Prostate cancer detection using an extended prostate biopsy schema in combination with additional targeted cores from suspicious images in conventional and functional endorectal magnetic resonance imaging of the prostate. Prostate Cancer Prostatic Dis. 13, 65–70 (2010).

    Article  CAS  Google Scholar 

  36. Beyersdorff, D. et al. MR imaging-guided prostate biopsy with a closed MR unit at 1.5 T: initial results. Radiology 234, 576–581 (2005).

    Article  Google Scholar 

  37. Roethke, M. et al. MRI-guided prostate biopsy detects clinically significant cancer: analysis of a cohort of 100 patients after previous negative TRUS biopsy. World J. Urol. 30, 213–218 (2012).

    Article  CAS  Google Scholar 

  38. Franiel, T. et al. Areas suspicious for prostate cancer: MR-guided biopsy in patients with at least one transrectal US-guided biopsy with a negative finding—multiparametric MR imaging for detection and biopsy planning. Radiology 259, 162–172 (2001).

    Article  Google Scholar 

  39. Zangos, S. et al. MR-compatible assistance system for biopsy in a high-field-strength system: initial results in patients with suspicious prostate lesions. Radiology 259, 903–910 (2011).

    Article  Google Scholar 

  40. Zangos, S. et al. MR-guided transgluteal biopsies with an open low-field system in patients with clinically suspected prostate cancer: technique and preliminary results. Eur. Radiol. 15, 174–182 (2005).

    Article  Google Scholar 

  41. Hambrock, T. et al. Thirty-two-channel coil 3 T magnetic resonance-guided biopsies of prostate tumour suspicious regions identified on multimodality 3 T magnetic resonance imaging: technique and feasibility. Invest. Radiol. 43, 686–694 (2008).

    Article  Google Scholar 

  42. Engelhard, K. et al. Prostate biopsy in the supine position in a standard 1.5 T scanner under real time MR-imaging control using a MR-compatible endorectal biopsy device. Eur. Radiol. 16, 1237–1243 (2006).

    Article  CAS  Google Scholar 

  43. Fütterer, J. J. et al. Prostate cancer: comparison of local staging accuracy of pelvic phased-array coil alone versus integrated endorectal-pelvic phased-array coils. Local staging accuracy of prostate cancer using endorectal coil MR imaging. Eur. Radiol. 17, 1055–1065 (2007).

    Article  Google Scholar 

  44. Hricak, H. et al. Carcinoma of the prostate gland: MR imaging with pelvic phased-array coils versus integrated endorectal-pelvic phased-array coils. Radiology 193, 703–709 (1994).

    Article  CAS  Google Scholar 

  45. Bloch, B. N. et al. 3 Tesla magnetic resonance imaging of the prostate with combined pelvic phased-array and endorectal coils; Initial experience. Acad. Radiol. 11, 863–867 (2004).

    PubMed  Google Scholar 

  46. Kirkham, A. P. S., Emberton, M. & Allen, C. How good is MRI at detecting and characterising cancer within the prostate? Eur. Urol. 50, 1163–1175 (2006).

    Article  Google Scholar 

  47. Kim, B. S., Kim, T.-H., Kwon, T. G. & Yoo, E. S. Comparison of pelvic phased-array versus endorectal coil magnetic resonance imaging at 3 Tesla for local staging of prostate cancer. Yonsei Med. J. 53, 550–556 (2012).

    Article  Google Scholar 

  48. Dickinson, L. et al. Magnetic resonance imaging for the detection, localization and characterisation of prostate cancer: recommendations from a European consensus meeting. Eur. Urol. 59, 477–494 (2011).

    Article  Google Scholar 

  49. Barentsz, J. O. et al. ESUR prostate MR guidelines. Eur. Radiol. 22, 746–757 (2012).

    Article  Google Scholar 

  50. Kirkham, A. P. S. et al. Prostate MRI: Who, when, and how? Report from a UK consensus meeting. Clin. Radiol. http://dx.doi.org/10.1016/j.crad.2013.03.030.

  51. Nagarajan, R. et al. Correlation of Gleason scores with diffusion-weighted imaging findings of prostate cancer. Adv. Urol. 2012, 374805 (2012).

    Article  Google Scholar 

  52. De Visschere, P., De Meerleer, G., Lumen, N. & Villeirs, G. in Prostate Cancer: A Comprehensive Perspective (ed. Tewari, A.) 499–510 (Springer, 2013).

    Book  Google Scholar 

  53. Quentin, M. et al. Inter-reader agreement of multi-parametric MR imaging for the detection of prostate cancer: evaluation of a scoring system. Rofo 184, 925–929 (2012).

    Article  CAS  Google Scholar 

  54. Portalez, D. et al. Validation of the European Society of Urogenital Radiology scoring system for prostate cancer diagnosis on multiparametric magnetic resonance imaging in a cohort of repeat biopsy patients. Eur. Urol. 62, 986–996 (2012).

    Article  Google Scholar 

  55. Rouvière, O. et al. Is it possible to model the risk of malignancy of focal abnormalities found at prostate multiparametric MRI?. Eur. Radiol. 22, 1149–1157 (2012).

    Article  Google Scholar 

  56. Lee, S. H., Chung, M. S. & Chung, B. H. Magnetic resonance imaging targeted biopsy in men with previously negative prostate biopsy results. J. Endourol. 26, 787–791 (2012).

    Article  Google Scholar 

  57. Watanabe, Y. et al. Detection and localization of prostate cancer with the targeted biopsy strategy based on ADC map: a prospective large-scale cohort study. J. Magn. Reson. Imaging 35, 1414–1421 (2012).

    Article  Google Scholar 

  58. Park, B. K., Lee, H. M., Kim, C. K., Choi, H. Y. & Park, J. W. Lesion localization in patients with a previous negative transrectal ultrasound biopsy and persistently elevated prostate specific antigen level using diffusion-weighted imaging at three tesla before rebiopsy. Invest. Radiol. 43, 789–793 (2008).

    Article  Google Scholar 

  59. Bhatia, C., Phongkitkarun, S., Booranapitaksonti, D., Kochakarn, W. & Chaleumsanyakorn, P. Diagnostic accuracy of MRI/MRSI for patients with persistently high PSA levels and negative TRUS guided biopsy results. J. Med. Assoc. Thai. 90, 1391–1399 (2007).

    PubMed  Google Scholar 

  60. Rouse, P. et al. Multi-parametric magnetic resonance imaging to rule-in and rule-out clinically important prostate cancer in men at risk: a cohort study. Urol. Int. 87, 49–53 (2011).

    Article  Google Scholar 

  61. Tamada, T. et al. T2-weighted MR imaging of prostate cancer: multishot echo-planar imaging vs fast spin-echo imaging. Eur. Radiol. 14, 318–325 (2004).

    Article  Google Scholar 

  62. Quentin, M. et al. Evaluation of a structured report of functional prostate magnetic resonance imaging in patients with suspicion for prostate cancer or under active surveillance. Urol. Int. 89, 25–29 (2012).

    Article  CAS  Google Scholar 

  63. Shigemura, K., Motoyama, S. & Yamashita, M. Do additional cores from MRI cancer-suspicious lesions to systematic 12-core transrectal prostate biopsy give better cancer detection? Urol. Int. 88, 145–149 (2012).

    Article  Google Scholar 

  64. Hadaschik, B. A. et al. A novel stereotactic prostate biopsy system integrating pre-interventional magnetic resonance imaging and live ultrasound fusion. J. Urol. 186, 2214–2220 (2011).

    Article  Google Scholar 

  65. Natarajan, S. et al. Clinical application of a 3D ultrasound-guided prostate biopsy system. Urol. Oncol. 29, 334–342 (2011).

    Article  Google Scholar 

  66. Kuru, T. et al. Critical evaluation of magnetic resonance imaging targeted, transrectal ultrasound guided transperineal fusion biopsy for detection of prostate cancer. J. Urol. 190, 1–7 (2013).

    Article  Google Scholar 

  67. Siddiqui, M. M. et al. Magnetic resonance imaging/ultrasound–fusion biopsy significantly upgrades prostate cancer versus systematic 12-core transrectal ultrasound biopsy. Eur. Urol. http://dx.doi.org/10.1016/j.eururo.2013.05.059

  68. Puech, P. et al. Prostate cancer diagnosis: multiparametric MR-targeted biopsy with cognitive and transrectal US-MR fusion guidance versus systematic biopsy prospective multicentre study. Radiology 268, 461–469 (2013).

    Article  Google Scholar 

  69. Singh, A. K. et al. Patient selection determines the prostate cancer yield of dynamic contrast-enhanced magnetic resonance imaging-guided transrectal biopsies in a closed 3-tesla scanner. BJU Int. 101, 181–185 (2008).

    Article  Google Scholar 

  70. Engehausen, D. G. et al. Magnetic resonance image-guided biopsies with a high detection rate of prostate cancer. Scientific World Journal 2012, 975971 (2012).

    Article  Google Scholar 

  71. Hoeks, C. A. et al. Three-Tesla magnetic resonance-guided prostate biopsy in men with increased prostate-specific antigen and repeated, negative, random, systematic, transrectal ultrasound biopsies: detection of clinically significant prostate cancers. Eur. Urol. 62, 902–905 (2012).

    Article  Google Scholar 

  72. Moore, C. M. et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur. Urol. 63, 125–140 (2013).

    Article  Google Scholar 

  73. Moore, C. M. et al. Standards of Reporting for MRI-targeted Biopsy Studies (START) of the prostate: recommendations from an International Working Group. Eur. Urol. http://dx.doi.org/10.1016/j.eururo.2013.03.030.

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Acknowledgements

M. Emberton receives financial support from the National Institutes of Health Research University College of London Comprehensive Biomedical Research Centre, UK. C. M. Moore receives funding from the Wellcome Trust, UK, the University College of London Hospital Trustees and the National Institutes of Health Research University College of London Comprehensive Biomedical Research Centre.

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  1. Department of Radiology, Royal Free Hospital, Pond Street, London, NW3 2QC, UK

    Nicola L. Robertson

  2. Division of Surgical & Interventional Science, University College London, 74 Huntley Street, London, WC1E 6AU, UK

    Mark Emberton & Caroline M. Moore

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N. L. Robertson and C. M. Moore researched, wrote, discussed, and edited the Review. M. Emberton made substantial contributions towards writing, editing, and discussing the article with colleagues.

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Correspondence to Nicola L. Robertson.

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Robertson, N., Emberton, M. & Moore, C. MRI-targeted prostate biopsy: a review of technique and results. Nat Rev Urol 10, 589–597 (2013). https://doi.org/10.1038/nrurol.2013.196

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