Updates in mpMRI

Kirsten L. Greene, MD, MAS, FACS, the Paul Mellon Professor and Chair of Urology at the University of Virginia School of Medicine, gives an update on multiparametric (mp) MRI’s current role in prostate cancer detection, surveillance, staging, and recurrence. She defines mpMRI as featuring diffusion weighted images and being dynamic contrast enhanced (DCE), but also notes that biparametric MRI, which omits DCE, appears to be an effective option as well. Dr. Greene goes over the different MRI-targeted biopsy trials for prostate cancer detection, including PROMIS, PRECISION, MRI FIRST, 4M, TRIO, and PRECISE, and she explains that all of these show that mpMRI has superior sensitivity to transrectal ultrasound (TRUS) for high-grade disease, but that mpMRI alone does miss anywhere from 5 to 10% of clinically significant cancer. For this reason, Dr. Greene says, the recommendation is to use MRI prior to biopsy and use image-guided techniques, but also keep systemic biopsy. She then briefly discusses the NCCN 2021 guidelines for use of mpMRI for initial biopsy, confirmatory biopsy, prior to second biopsy, and for recurrence. Dr. Greene also looks at mpMRI for serial imaging during active surveillance, explaining that it is useful for identifying missed or anterior lesions and for delaying the next biopsy after confirmatory biopsy, but also that when to stop active surveillance based on MRI alone is controversial. She also considers the future of mpMRI in combination with PSMA PET. Dr. Greene concludes that there is a clear role for MRI (multi and biparametric) in detection, active surveillance, pre-treatment staging, and recurrence, and she reminds viewers that MRI accuracy depends upon the equipment and the experience of the radiologist.

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