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Home » EU Health, Health, Prostate Cancer

The role of MRI in prostate cancer expands

Submitted by on 30 Mar 2016 – 15:25

The role of imaging techniques such as multiparametric MRI (mpMRI) in prostate cancer is set to expand in the coming years, particularly in cases where technology is more integrated with treatment. Prof Jelle Barentsz, Professor of Radiology, Radboud ProstateMR-Reference Center discusses the details

barentzThe main disadvantages of the current diagnostic pathway in men with an elevated risk of prostate cancer (PCa) are that: (a) systematic transrectal ultrasound (TRUS) prostate biopsy (PB) misses a substantial proportion (20%) of significant PCa because of inherent systematic sampling errors, especially in the anterior prostate [1,2]; (b) misclassifies pathologic status including Gleason score (GS) and tumour stage [3]; and (c) detects a high proportion of men with disease that is unlikely to be harmful (clinically insignificant), with subsequently overtreatments resulting in unintended harm [4]. The latter was the main reason for the U.S. Preventive Services Task Force recommendation against prostate-specific antigen- based screening for prostate cancer in 2012 [5].

Can multi-parametric MRI solve these problems?

There is increasing evidence, such as two Level 1a systematic reviews [6,7], a Level 1a prospective clinical randomised trial [8], and multiple Level 1b studies [9,10], that multi-parametric magnetic resonance imaging (mpMRI) is the best method of visualising primary significant PCa. It is, therefore, widely accepted that mpMRI has the performance characteristics to help manage men with suspected or proven PCa [11,12]. The clinical utility in terms of the ability to ‘‘rule in’’ and ‘‘rule out’’ the presence of significant disease depends on using the mpMRI approach, image quality, reading system, and reporter expertise [13–16]. The cancer detection ability of mpMRI is dependent on the anatomic location, tumour volume, and aggressiveness (GS) of the underlying cancer [3]. mpMRI detected lesions are not always significant malignant lesions [17]; false positive cancer/non-cancer cases do occur, thus adequate biopsy sampling is mandated for each lesion detected [18].

What type of cancers does mpMRI-TB detect?

Literature indicates an improved ability of mpMRI-PB is to detect clinically significant cancers. A recent systematic review showed that the detection rate of clinical significant cancer is higher (44–87%) than the rates reported for TRUS-PB [7], depending on the definition of clinical significance used for targeted biopsy; this ability applies equally to biopsy naıve and men with prior negative biopsies. Histologic grades on mpMRI-TB show high concordance (88%) with final pathology after prostatectomy, which is a sharp contrast to TRUS-PB (55% concordance rate) [3].

Does mpMRI-PB systematic miss clinically significant disease?

The key questions are: (1) what proportion of men with negative mpMRI harbour cancers that would require radical therapy if detected; and (2) what proportion of patients with significant disease would be detected by an additional backup TRUS-PB? The reported negative predictive value (NPV) of mpMRI-PB for significant disease has been reported to be high: 63-98% [7]. The central issue is the balance between benefits and limitations of mpMRI- targeted biopsy (TB) when used alone compared with the strategy of combined mpMRI-TB with backup TRUS-PB in men with positive mpMRI findings. This was recently addressed in a very large prospective trial [9]. In 1003 men, there were additional cancers detected when mpMRI-TB was combined with TRUS-PB. However, of the 103 additional cancers detected, the majority were low risk (83% low risk; 5% high risk). Importantly, 200 combined biopsies yielded only one additional high-risk cancer, but over-diagnosed 17 low risk cancers. Also, there was no change in risk stratification in the majority of patients (857 patients; 85%), with only 19 men (2%) converting from no-cancer or low risk disease to intermediate or high risk with the combined approach. Taken together, these and other data strongly argue against the strategy of combining mpMRI-PB with systematic TRUS-TB in order to improve biopsy yields.

Is there a performance difference of mpMRI-TB in biopsy naive patients compared with those with previous negative TRUS-PB?

In previous negative biopsy patients, mpMRI-PB greatly increased detection rates (+54%) of significant cancers and markedly reduced (-49% and -18% respectively) insignificant cancers detection, rendering the mpMRI-TB approach clinically effective. Thus both the European Association of Urology 2015 and the UK National Institute of Clinical and Care Excellence 2014 guidelines recommend mpMRI before repeat TRUS biopsy. UK National Institute of Clinical and Care Excellence 2014 additionally recommends against a second biopsy if mpMRI is negative, unless high-risk features are present [11].


To enhance interdisciplinary communications between radiologists and referring clinicians, it is essential that uniform, understandable terminology and content of radiology reports be used. Reports should include assessment categories of suspicion for clinically significant disease to facilitate the use of targeted biopsy. The Prostate Imaging Reporting and Data System (PI-RADS) of the European Society of Urogenital Radiology (ESUR) has been widely accepted and validated [19]. A new PI-RADS version 2 was recently adopted by the AmericanCollege of Radiology and ESUR, but has yet to be validated [20,21]. To incorporate mpMRI findings using the PI-RADS system with biopsy strategies new pathways should be developed [22].

Training and quality controls

Furthermore, to achieve and maintain good mpMRI diagnostic performance, adequate training, supervision, and quality-control of the acquisition of the images, the PI-RADS assessment, and the targeted biopsy procedure are needed. This is particularly true when complex image registration procedures are needed to enable small lesions to be sampled. Importantly, histology feedback is required with continuous audit checks within the multi disciplinary care teams. An important consideration for these teams is, what to do when a negative biopsy is obtained from a highly suspicious region on imaging.

Extensive training programs by Specialised Prostate MRI Centres must be developed in order to fulfil the rapidly increasing demand of mpMRI. These Specialised Centres will train and certify multiple Diagnostic Centres of Excellence throughout Europe, where diagnosis of prostate cancer is optimized. To ensure continuous high quality, the training and certification should be followed by a quality control program. In this way, a European prostate diagnostic network of Specialised Prostate MRI Centres (for training and QC) and Diagnostic Centres of Excellence (to provide best quality care) will be created. The potential advantages of such a prostate network are: a) better quality through double reading and inter-collegial consultation, b) faster implementation of newly validated techniques, c) will allow sharing knowledge, and d) create large scientific databases to speed up the validation process. For double reading of prostate mpMRI already tools are available and in some places implemented, being internet connected PI-RADS workstations.


The upfront cost per cancer diagnosed is greater using mpMRI-PB methods, in part because of the need for capacity building and tooling up. This may be counterbalanced by changes in the risk stratification of diagnosed patients towards those requiring radical treatments. Modelling studies in the Netherlands and the United Kingdom suggested that an mpMRI-PB strategy can be cost-effective while maintaining the benefits of reduced overdiagnosis and overtreatment together, with improvements in quality of life [23,24]. To get health service provider buy-in, the therapeutic consequences of mpMRI-PB also need to be considered [25].


mpMRI-PB changes the risk stratification of men diagnosed with prostate cancer towards improved detection of men with cancers requiring radical treatments. To realise the clinical benefits of mpMRI-PB without overwhelming current resources, appropriate patient selection and investments in diagnostic and communication tools are needed. Imaging interpretation should be aligned with clinical management plans. Effective communication of imaging findings and improved urologic understanding of imaging uncertainties will improve the outcomes for men with suspected prostate cancer.

To meet the increasing demand of mpMRI a prostate network of Specialised Prostate MR Centers for training and QC, and Diagnostic Centers of Excellence to provide optimal care should be established as soon as possible

* This paper is based on Barentsz et al [26] and Padhani et al [22].


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