Download Prostate MRI Update 2016 - SCBT-MR

Prostate MRI Update 2016: MR-TRUS Fusion Biopsy
Katarzyna J. Macura, MD, PhD, FACR, FSCBTMR
The Russell H. Morgan Department of Radiology and Radiological Science,
Johns Hopkins University, Baltimore, MD
SCBT•MR 2016
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Background
• 1 mln prostate biopsies are performed annually in the USA during the
PSA era
• Blind biopsies are misleading
– Underdetection of significant cancer (anterior prostate or apex)
– 35% falsely negative
– Overdetection of small indolent cancer of little clinical significance (up to 50% of
detected cancers)
• > 26,000 deaths projected in 2016
• MRI-ultrasound fusion for guidance of targeted prostate biopsy emerged
as an important tool for diagnosis of clinically significant prostate cancer,
while minimizing detection of indolent cancer
Prostate Cancer at a Glance
Lifetime Risk: 14.0% of men will be diagnosed with prostate cancer during their lifetime
Prevalence: In 2013, estimated 2,850,139 men living with prostate cancer in the US
NCI - http://seer.cancer.gov/statfacts/html/prost.html
Indications for MR-TRUS fusion biopsy
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Elevated PSA and suspected cancer, previous negative TRUS biopsy
Known cancer considered for active surveillance
Known cancer to determine disease status during active surveillance
Candidates for focal therapy
De-novo diagnosis of prostate cancer:
biopsy naïve patient
TRUS
Nodule 20 mm
PI-RADS 5
59M, Gleason 3+4=7 (80% of 1 core), G3+3=6 tumor (2
cores, 50% each), and HGPIN
De-novo diagnosis of prostate cancer:
multiple negative TRUS biopsies
Nodule 10 mm
71M, Gleason 4+4=8 involving 2 cores (30%, 40%)
PI-RADS 4
Extruded BPH nodule or PZ nodule?
Nodule 8 mm
circumscribed
75M, benign prostatic tissue
PI-RADS 2-3
Cancer vs. Extruded BPH
Elevated PSA, negative prior TRUS x 2:
typically missed on TRUS anterior nodule
Nodule 16mm
PI-RADS 5
65M, Gleason 3+3=6 involving 3 cores
(100%, 40%, 5%).
Patient in active surveillance:
establish the risk, monitor stability
Nodule 10mm
PI-RADS 4
75M, Gleason score 3+3=6 60% of core
F-U 2-years later
Comparison standard vs. targeted BX
61M, PSA from 5.7 to 18 ng/mL over 8 years
negative prior TRUS biopsies x2
Nodule 16 mm, capsule bulge
PI-RADS 5
Systematic BX:
1) RIGHT APEX: BENIGN.
2) RIGHT MID: BENIGN.
3) RIGHT BASE: HGPIN.
4) LEFT APEX: BENIGN.
5) LEFT MID: BENIGN WITH
CHRONIC INFLAMMATION.
6) LEFT BASE: BENIGN WITH
CHRONIC INFLAMMATION.
Targeted BX:
PROSTATE, Target 1 RIGHT BASE
MID: PROSTATIC
ADENOCARCINOMA,
GLEASON SCORE 4 + 3 = 7
INVOLVING 80% OF ONE (1) OF
TWO (2) CORES.
(70% GLEASON PATTERN 4) .
Radical prostatectomy:
Adenocarcinoma (conventional, NOS)
GLEASON SCORE - DOMINANT
NODULE: 4 + 5 = 9
GLEASON SCORE - SECONDARY
NODULE: 3 + 3 = 6
LOCATION - DOMINANT NODULE:
Right; Posterolateral/Posterior;
Apex/Mid/Base
LOCATION - SECONDARY NODULE:
Left; Posterolateral; Mid
LOCAL EXTENT: Organ confined;
MARGINS: Negative
Comparison of MR/Ultrasound Fusion–Guided
Biopsy With Ultrasound-Guided Biopsy for the
Diagnosis of Prostate Cancer
JAMA. 2015;313(4):390-397
Targeted biopsy diagnosed 30% more high-risk cancers vs. standard biopsy
and 17% fewer low-risk cancers.
A Randomized Controlled Trial To Assess and Compare the
Outcomes of Two-core Prostate Biopsy Guided by Fused
Magnetic Resonance and Transrectal Ultrasound Images and
Traditional 12-core Systematic Biopsy
Clinically significant cancer two-core MRI/TRUS-TB 38% vs. 12-core RB in control 49%
Prospective Evaluation of the Prostate Imaging
Reporting and Data System Version 2 for Prostate
Cancer Detection
Cancer detection rate:
PI-RADS 5 - 78%
PI-RADS 4 - 30%
PI-RADS 3 - 16%
PI-RADS 2 – 22%
THE JOURNAL OF UROLOGY, Vol.
196, 690-696, September 2016
Conclusion: The current criteria result in a high false-positive rate and stricter criteria
may be needed to increase the cancer detection rate for PI-RADS scores of 3, 4, and 5.
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Correlation of PI-RADS score of regions of interest (ROIs) on mpMRI with
targeted biopsy (bx) findings (benign, Gleason score or GS 6, GS >7) in the
AS cohort (A), confirmatory biopsy cohort (B) and targeted biopsy cohort (C).
The Role of Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion Biopsy in Active
Surveillance. Eur Urol. 2016
Augmenting MRI with clinical variables
Prostate Health Index
No men with PHI<27 and PI-RADS≤3
had grade group ≥2 cancer.
Several men with low PI-RADS scores
and PHI>27 had clinically significant PCa.
Gleason Score
1 GS 3+3=6
Pathologic Grade Group:
2 GS 3+4=7
3 GS 4+3=7
4 GS 4+4=8
5 GS9 or GS10
Scatter plot of PHI by PI-RADS score and biopsy results (n=121)
Tosoian JJ et al. JHU, in press
AUA – SAR Consensus Statement
AUA – SAR Consensus Statement
• “When high-quality prostate MRI is available, it should be strongly
considered in any patient with a prior negative biopsy who has persistent
clinical suspicion for prostate cancer and who is undergoing a repeat
biopsy.”
• “If MRI is done, it should be performed, interpreted, and reported in
accordance with PI-RADS V2 guidelines.“
• “Patients receiving a PI-RADS assessment category of 3-5 warrant
repeat biopsy with image guided targeting.”
• “At least two targeted cores should be obtained from each MRI-defined
target.”
THANK YOU!
SCBT•MR 2016
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