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Is it time to consider a role for MRI before prostate biopsy?

Nature Reviews Clinical Oncology volume 6, pages 197–206 (2009)Cite this article

Abstract

The use of MRI in prostate cancer management is controversial and current guidelines underplay its role. Technological advances over the past 5 years, however, demand a re-evaluation of this position. In this article, we propose an increased use of MRI, not only in those with a diagnosis of prostate cancer but also for men before a prostate biopsy. The use of MRI before a biopsy can serve as a triage test in men with raised serum prostate-specific antigen levels, in order to select those for biopsy with significant cancer that requires treatment. This strategy could avoid biopsy, and hence unnecessary treatment, in those with no disease or insignificant cancer. In addition, avoidance of postbiopsy artifact caused by hemorrhage will lead to better local staging accuracy, while determining more accurately the disease burden. This approach could improve risk stratification by selecting those who require adjuvant therapy or dose escalation. Furthermore, MRI evaluation of cancer burden could be important in active surveillance regimens to select those needing intervention.

Key Points

  • The role of MRI in prostate cancer management is controversial; most guidelines recommend its use only in high-risk patients on the basis of evidence that used early-generation machines rather than up-to-date data

  • The use of spectroscopy, dynamic contrast enhancement and diffusion weighting in combination with traditional T2-weighted scans increases the accuracy of MRI to detect and stage prostate cancer

  • If multisequence MRI was applied in the prebiopsy setting to overcome biopsy artifact, it could potentially increase the detection of significant prostate cancer, and decrease the diagnosis of indolent disease

  • Such scans could guide traditional therapy such as surgery and radiotherapy and select those men with high-risk disease that require dose escalation, and those with a low burden of disease

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Figure 1: Chronological sequence of T2-weighted MR axial images (1.5 Tesla) showing sequence of changes in prostate after needle insertion.
Figure 2: The added value of diffusion weighted scans could aid in the detection of anterior tumors that are not visible with other MRI modalities.
Figure 3: Combining different MRI modalities (multisequence MRI) might confer greater accuracy and confidence of diagnosis in cancer detection.
Figure 4: Extracapsular extension.

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Authors and Affiliations

  1. Division of Surgical and Interventional Sciences, University College London, UK

    Hashim U. Ahmed, Manit Arya & Mark Emberton

  2. University College London Hospitals NHS Foundation Trust, London, UK

    Alex Kirkham, Rowland Illing, Alex Freeman & Clare Allen

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  1. Hashim U. Ahmed
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Correspondence to Hashim U. Ahmed.

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Competing interests

HU Ahmed declared he receives research support and is a consultant/speakers bureau for Misonix/Focus Surgery, Steba Biotech and UKHIFU. He also receives research support from Advanced Medical Diagnostics, and is a consultant for Misonix/Focus Surgery and Steba Biotech. HU Ahmed is a stock holder for Prostate Mapping. M Emberton is a consultant for Misonix/Focus Surgery and is on the speakers bureau and receives research support from Advanced Medical Diagnostics, Misonix/Focus Surgery, Steba Biotech and UKHIFU. M Emberton is a stock holder for Prostate Mapping. RO Illing is a consultant for Misonix/Focus Surgery and receives research support/is on the speakers bureau for Misonix/Focus Surgery and UKHIFU. RO Illing is a stock holder for Prostate Mapping. C Allen is a stock holder for Prostate Mapping. The other authors declared no competing interests.

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Ahmed, H., Kirkham, A., Arya, M. et al. Is it time to consider a role for MRI before prostate biopsy?. Nat Rev Clin Oncol 6, 197–206 (2009). https://doi.org/10.1038/nrclinonc.2009.18

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