Is MRI Fusion Biopsy the New Gold Standard of Diagnosis? Con Argument

Posted by E. David Crawford, MD | Jan 2020

E. David Crawford, MD, presented “Is MRI Fusion Biopsy the New Gold Standard of Diagnosis? Con Argument” during the 28th Annual Perspectives in Urology: Point Counterpoint on November 15, 2019 in Scottsdale, Arizona.

How to cite: Crawford, E. David. “Is MRI Fusion Biopsy the New Gold Standard of Diagnosis? Con Argument” November 15, 2019. Accessed Apr 2024. https://grandroundsinurology.com/is-mri-fusion-biopsy-the-new-gold-standard-of-diagnosis-con-argument/

Is MRI Fusion Biopsy the New Gold Standard of Diagnosis? Con Argument – Summary:

E. David Crawford, MD, argues that MRI fusion-guided biopsy should not be the gold standard of prostate cancer diagnosis. He cites MRI’s limitations in detecting clinically significant cancers and predicting extracapsular extension and tumor volume, as well as the existence of new technologies such as micro-ultrasound, in this point-counterpoint debate.

The “pro” rebuttal to this presentation is “Is MRI Fusion Biopsy the New Gold Standard of Diagnosis? Pro Argument” by A. Karim Kader, MD, PhD.

Abstract:

Though MRI is a valuable imaging tool for screening and targeting, this modality has significant limitations. In a retrospective analysis of the correlation between MRI results and whole-mount prostatectomy pathology, MRI did not perform well in predicting the number and volume of tumors and missed 25% of cancers with Gleason scores higher than 4+3. Furthermore, MRI missed 17% percent of clinically significant solitary lesions and has a false positive rate of 19%. MRI performs poorly in predicting extracapsular extension, even when conducted at excellent imaging centers with world-class technology and radiologists. Also, MRI typically underestimates tumor volume.

Because of these limitations, even after the well-known outcomes from the PROMIS and PRECISION trials, which were favorable to MRI, guidelines still acknowledge that false negatives can occur when using MRI to guide biopsy decisions, and therefore standard transrectal ultrasound biopsy should still be considered. MRI alone is also not adequate for planning and conducting focal therapy.

A technology that could perform better in this stage of the diagnostic pathway is a novel 29 MHz micro-ultrasound system, which allows for real-time visualization and targeting while conducting a biopsy. Compared to MRI/ultrasound fusion biopsy, micro-ultrasound has significant advantages, such as cost, inter-reader variability, and workflow complexity.

While MRI is a useful tool, due to its disadvantages relating to visualization and detection and the existence of better technologies, it should not be the gold standard in prostate cancer diagnosis.

About Perspectives in Urology: Point Counterpoint

Perspectives in Urology: Point Counterpoint (PCP) is an annual, multi-day, CME-accredited conference devoted to discussing and debating the latest topics in men’s health and general urology, as well as management of bladder, renal, and both localized and advanced prostate cancer. More than didactic lectures, the conference’s format includes debates, point-counterpoint discussion panels, and unique case-based presentations. Dr. Crawford presented this lecture during the 28th PCP in 2019. Please visit this page in order to register for future PCP meetings.

About The Author

E. David Crawford, MD

Researcher-physician E. David Crawford, MD, has devoted his career in medicine to educating the public about men's health issues and finding effective techniques and procedures to address prostate cancer, the most common malignancy affecting men in the United States. He is currently a Professor of Urology and Jack A. Vickers Director of Prostate Research at the University of California, San Diego. Dr. Crawford received his medical degree from the University of Cincinnati and his postgraduate training included an internship and residency in urology at the Good Samaritan Hospital in Cincinnati. He subsequently completed a genitourinary cancer fellowship at the University of California Medical Center in Los Angeles. Dr. Crawford is an internationally recognized expert in benign prostate hypertrophy, urologic cancers, and in particular, prostate cancer. He has conducted research in the treatment of advanced bladder cancer, metastatic adenocarcinoma of the prostate, hormone-refractory prostate cancer, and other areas of urological infections and malignancies. He has authored or coauthored over 810 scientific articles, has published seven textbooks, authored over 60 book chapters, and provided more than 2,200 educational talks for patients and physicians. In an effort to raise public awareness about prostate health, Crawford in 1989 founded the Prostate Conditions Education Council (PCEC). The non-profit organization is comprised of a consortium of leading physicians, health educators, scientists, and men's health advocates. PCEC's advocacy for free or low-cost prostate screening has affected the lives of millions of American men. He currently chairs the PCEC. Crawford is an active member of many national and international organizations, including the American Society of Clinical Oncology, the American Urological Association (AUA), and the American Association for the Advancement of Science. Within the AUA, he has been a member of the Committee to Study Urologic Research Funding and the prostate cancer clinical trials subcommittee. Crawford served on the board of governors, the scientific advisory board of the Southwest Oncology Group, and was chairman of the Genitourinary Cancer Committee for 27 years. This group is the largest clinical trials group in the world. Crawford's involvement in the national prostate cancer arena has been widely recognized. He has received many honors and awards, including the CAP Cure Annual Award for Scientific Presentation in 1999 In 1997, he was presented with a 'Freddie Award" at the AMA International Health and Medical Film Competition for the program, ITV: The Cutting Edge Medical Report (Prostate Cancer: Understanding, Diagnosing, and Defeating), which Crawford hosted with special guest, retired General Norman Schwarzkopf. Crawford again won a prestigious 'Freddie Award" 5 years ago... He is a member of Best Doctors of America and was named Healthcare Provider of the Year in the Denver Metro area by the Denver Business Journal. He has been recognized as one of the Best Doctors of America for the past two decades and is recognized as one of the top 20 urologists in the country, for men, by Men’s Health Magazine. In 2018 he received the honor of being named the Distinguished Alumnus of the Year from the University of Cincinnati School of Medicine. In May of 2019, he received the Presidential citation from the American Urological Association recognizing for his “tireless role in genitourinary cancer research that has benefited countless urologic cancer patients.” He accepted the position of Editor in Chief of Grand Rounds in Urology in June of 2019. In 2021, he was the recipient of the Merle Stringer, M.D. annual award for excellence in medicine by the Florida State Medical Association.

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