Current and Emerging Imaging Tools for Improving Risk Assessment and Selection of Patients for Biopsy

Clare Tempany, MD, the Ferenc A. Jolesz Professor of Radiology at Harvard Medical School in Boston, Massachusetts, summarizes evidence for multiparametric magnetic resonance imaging’s (mpMRI) utility in prostate cancer diagnosis, and goes over recent developments in its use. She first looks at selection criteria for biopsy and biopsy type, including history, digital rectal examination (DRE), prostate specific antigen (PSA), and imaging, arguing that mpMRI is particularly helpful in allowing patients to avoid unnecessary biopsies. Dr. Tempany then defines state-of-the art mpMRI as featuring diffusion/apparent diffusion coefficient, being T2-weighted, being IV contrast/dynamic contrast enhanced, and as being reported using the PI-RADS v2.1 assessment. She goes over the PI-RADS assessment categories, considers the findings of multiple publications backing up the value of mpMRI as compared to transurethral ultrasound (TRUS), and looks at evidence supporting guidance indicating patients with PI-RADS 3 lesions should get a biopsy. Dr. Tempany follows this up by summarizing a paper from the PI-RADS steering committee on how PI-RADS and mpMRI should be used. Suggestions include performing mpMRI in most men suspected of having clinically-significant disease, providing a safety net of monitoring for patients who decline immediate biopsy after low-likelihood MRI findings, and using a combination of systematic and targeted biopsies in biopsy-naive patients while only using targeted biopsies for patients with prior negative findings on TRUS. Dr. Tempany then notes that the AUA, EAU, and NICE guidelines all now recommend MRI before biopsy, and also observes that MRI is cost-effective if it leads to the avoidance of biopsy. She concludes by listing areas for future development, including multi-omics, molecular pathology, germline mutations, CTC/blood biomarkers, and mass spectrometry.

Read More