Platinum Priority – Review – Prostate CancerEditorial by Behfar Ehdaie and Shahrokh F. Shariat on pp. 141–142 of this issueImage-Guided Prostate Biopsy Using Magnetic Resonance Imaging–Derived Targets: A Systematic Review☆
Introduction
In a lecture delivered in 2008, Dr. Patrick Walsh made the following statement: “The discovery that would have the greatest impact on our field would be the development of accurate imaging of tumour within the prostate” [1].
The original six-core transrectal prostate biopsy, termed random systematic by Stamey in 1989 [2], has incorporated more cores over time, with 10–12 cores being an accepted practice standard. This has increased the negative predictive value of the transrectal biopsy but has led to an increase in the detection of low-volume, low-risk disease. Worldwide postmortem studies using 3-mm step section histology have demonstrated that such disease is present in >40% of men >50 yr of age [3].
In addition, the standard transrectal approach is poor at sampling cancers in the anterior, midline, and apex, leading to the underdiagnosis of clinically significant disease. Up to one in three biopsy diagnoses of low-volume, low-risk cancers are upgraded or upstaged at whole mount step section pathology [4].
The prostate is the only solid organ in which a standardised approach to sampling is taken. All other diagnostic pathways for solid or hollow organ cancers incorporate either direct (eg, cystoscopic) or radiologic imaging (ultrasound, computed tomography [CT], magnetic resonance imaging [MRI]) to identify areas of greater likelihood of cancer for subsequent assessment.
MRI has been shown to have a high degree of accuracy in the detection of clinically significant prostate cancer when compared with radical prostatectomy histology [5]. When functional parameters such as dynamic contrast enhancement (DCE), diffusion-weighted imaging (DWI), and spectroscopy are used, in addition to standard T1- and T2-weighted sequences, MRI may afford an opportunity for a similar image-guided approach to the prostate [6].
This systematic review addresses the following question: In men with a clinical suspicion of prostate cancer, based on a raised prostate-specific antigen (PSA) or an abnormal digital rectal examination (DRE), does an MRI-guided biopsy strategy result in a higher detection rate of clinically significant cancer and a lower detection rate of clinically insignificant cancer compared with standard transrectal ultrasound (TRUS)-guided biopsy?
Section snippets
Evidence acquisition
An initial search was carried out to identify articles for further review, using PubMed and Embase databases, Cochrane reviews, the Cochrane database of clinical trials, and the database of abstracts of reviews of effects. The search terms used were ‘prostate OR prostate cancer’ AND ‘magnetic resonance imaging OR MRI’ AND ‘biopsy OR target’. Abstracts were reviewed for relevance to the defined review question. If it was not clear from the abstract whether the paper might contain relevant data,
Evidence synthesis
Use of evidence synthesis has allowed us to address some clinically important questions in relation to the use of MRI to inform the conduct of the biopsy.
Conclusions
In men with a clinical suspicion of prostate cancer, a biopsy of the prostate that used MRI to inform the sampling was associated with a detection rate of clinically significant prostate cancer of 42%. This approach might permit a reduction in the number of men—possibly up to a third—who need to undergo biopsy if they are deemed to have a normal MRI. The efficiency (number of clinically significant prostate cancers/number of men biopsied) of the targeted sampling appeared superior to the
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