- Email: [email protected]
Has Magnetic Resonance–Guided Biopsy of the Prostate Become the Standard of Care?
EUROPEAN UROLOGY 64 (2013) 720–721
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 713–719 of this issue
Has Magnetic Resonance–Guided Biopsy of the Prostate Become the Standard of Care? Mark Emberton Division of Surgery and Interventional Science, University College London, London, UK
The article by Siddiqui and colleagues published in this issue of European Urology forces us to consider a change in clinical practice [1]. Moments such as this do not come along that often, but when they do, we must seize the opportunity. This is the only mechanism we have for improving the care that we deliver. Before we embark on whole-scale change, it is important to consider the evidence driving the change and anticipate the consequences of the change, both intended and unintended. The issue relates to whether or not prostate biopsy should be informed by knowledge of tumour location. In other words, is it reasonable to carry on as we are and biopsy the prostate in a manner that is blind to location, or, instead, should we insist on an approach that seeks information on the whereabouts of the dominant tumour? This article adds to a growing body of evidence that points to the superiority of an image-guided approach over the traditional blind approach in terms of the probability of detecting clinically significant prostate cancer [2]. In summary, 582 men (many of whom had been biopsied before) who had lesions declared on multiparametric magnetic resonance imaging (MRI) of the prostate were eligible for the study [1]. These men underwent a standard 12-core transrectal ultrasound (TRUS)-guided biopsy that was conducted blind to the tumour location, that is, the person conducting the biopsy was not aware of the MRI result. Once the standard biopsy set was complete, unblinding of the MRI permitted the targeted biopsies to be performed. A maximum of two needles per target were permitted, one deployed in the axial plane, the other in the sagittal. The MRI-derived targets were registered onto the ultrasound using software that this group has developed in conjunction with Philips Healthcare through a cooperative research and development agreement.
Which approach was superior? The image-guided approach used fewer needles compared with systematic TRUS: 5.7 versus 12 [1]. The overall prostate cancer detection rate was very similar between the two methods— 253 cases for the image-guided approach and 255 for systematic TRUS—indicating that the detection efficiency of targeted sampling is twice that of systematic TRUS. The real interest comes from the number of cases of clinically significant prostate cancer detected by either approach. The image-guided approach detected more clinically significant cancers. Image-guided prostate biopsy was associated with 88 cases of clinically significant disease compared with the 57 cases identified by the traditional biopsy approach, despite fewer needle deployments. As might be imagined, neither approach was perfect because each approach managed to detect clinically significant cancers that the alternative approach had missed. Once again this ‘‘residual’’ detection favoured the targeted approach. Targeting added another 38 cases of clinically significant disease to those identified by systematic TRUS biopsy. Conversely, systematic TRUS added another 7 cases to the 88 already detected by the imageguided approach. So what messages can we derive from this large prospective study [1] that confirms what others have shown? I think we can say, quite emphatically, that an image-guided approach to prostate biopsy is superior for the purpose of detecting clinically significant prostate cancer. I think we can be less certain at the present time whether this can be done in isolation or whether it needs to be nested within a semi-random, non-targeted sampling regimen. The authors address this issue in their discussion and, I believe, share this uncertainty. Declaring a new gold standard is not something that should be undertaken lightly. More than 1 million prostate
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.05.059. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.06.050
EUROPEAN UROLOGY 64 (2013) 720–721
721
biopsies are performed each year in the European Union alone. If image-guided sampling is adopted, provision will have to be made for MRI image acquisition, training of reporters, training of urologists, metrics for quality control, and purchase of software applications and targeting systems (of which there are now many) to assist us in the intervention. Fortunately, the community has responded quickly to the challenge and has agreed, within a multidisciplinary framework, to some standards going forward [3]. I believe this important paper [1] is the first in the literature to report to those standards.
Biotech, PCUK, and the PELICAN Cancer Foundation. He is a medical
Conflicts of interest: Mark Emberton is a principal investigator for MRI
[3] Moore CM, Kasivisvanathan V, Eggener S, et al. START Consortium.
studies such as PROMIS (UK NIHR HTA funded) Smart Target (Wellcome
Standards of Reporting for MRI-targeted Biopsy Studies (START) of
Trust funded) and PICTURE (PELICAN and AMD). He has received
the prostate: recommendations from an international working
research support from Sanofi, GSK, Sonacare, Angiodynamics, STEBA
group. Eur Urol 2013;64:544–52.
director for Mediwatch PLC and NUADA Medical Ltd and does consultancy work for GSK, Sonacare, Angiodynamics, and Sophiris.
References [1] Siddiqui MM, Rais-Bahrami S, Truong H, et al. Magnetic resonance imaging/ultrasound–fusion biopsy significantly upgrades prostate cancer versus systematic 12-core transrectal ultrasound biopsy. Eur Urol 2013;64:713–9. [2] Moore CM, Robertson NL, Arsanious N, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur Urol 2013;63:125–40.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 713–719 of this issue
Has Magnetic Resonance–Guided Biopsy of the Prostate Become the Standard of Care? Mark Emberton Division of Surgery and Interventional Science, University College London, London, UK
The article by Siddiqui and colleagues published in this issue of European Urology forces us to consider a change in clinical practice [1]. Moments such as this do not come along that often, but when they do, we must seize the opportunity. This is the only mechanism we have for improving the care that we deliver. Before we embark on whole-scale change, it is important to consider the evidence driving the change and anticipate the consequences of the change, both intended and unintended. The issue relates to whether or not prostate biopsy should be informed by knowledge of tumour location. In other words, is it reasonable to carry on as we are and biopsy the prostate in a manner that is blind to location, or, instead, should we insist on an approach that seeks information on the whereabouts of the dominant tumour? This article adds to a growing body of evidence that points to the superiority of an image-guided approach over the traditional blind approach in terms of the probability of detecting clinically significant prostate cancer [2]. In summary, 582 men (many of whom had been biopsied before) who had lesions declared on multiparametric magnetic resonance imaging (MRI) of the prostate were eligible for the study [1]. These men underwent a standard 12-core transrectal ultrasound (TRUS)-guided biopsy that was conducted blind to the tumour location, that is, the person conducting the biopsy was not aware of the MRI result. Once the standard biopsy set was complete, unblinding of the MRI permitted the targeted biopsies to be performed. A maximum of two needles per target were permitted, one deployed in the axial plane, the other in the sagittal. The MRI-derived targets were registered onto the ultrasound using software that this group has developed in conjunction with Philips Healthcare through a cooperative research and development agreement.
Which approach was superior? The image-guided approach used fewer needles compared with systematic TRUS: 5.7 versus 12 [1]. The overall prostate cancer detection rate was very similar between the two methods— 253 cases for the image-guided approach and 255 for systematic TRUS—indicating that the detection efficiency of targeted sampling is twice that of systematic TRUS. The real interest comes from the number of cases of clinically significant prostate cancer detected by either approach. The image-guided approach detected more clinically significant cancers. Image-guided prostate biopsy was associated with 88 cases of clinically significant disease compared with the 57 cases identified by the traditional biopsy approach, despite fewer needle deployments. As might be imagined, neither approach was perfect because each approach managed to detect clinically significant cancers that the alternative approach had missed. Once again this ‘‘residual’’ detection favoured the targeted approach. Targeting added another 38 cases of clinically significant disease to those identified by systematic TRUS biopsy. Conversely, systematic TRUS added another 7 cases to the 88 already detected by the imageguided approach. So what messages can we derive from this large prospective study [1] that confirms what others have shown? I think we can say, quite emphatically, that an image-guided approach to prostate biopsy is superior for the purpose of detecting clinically significant prostate cancer. I think we can be less certain at the present time whether this can be done in isolation or whether it needs to be nested within a semi-random, non-targeted sampling regimen. The authors address this issue in their discussion and, I believe, share this uncertainty. Declaring a new gold standard is not something that should be undertaken lightly. More than 1 million prostate
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.05.059. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.06.050
EUROPEAN UROLOGY 64 (2013) 720–721
721
biopsies are performed each year in the European Union alone. If image-guided sampling is adopted, provision will have to be made for MRI image acquisition, training of reporters, training of urologists, metrics for quality control, and purchase of software applications and targeting systems (of which there are now many) to assist us in the intervention. Fortunately, the community has responded quickly to the challenge and has agreed, within a multidisciplinary framework, to some standards going forward [3]. I believe this important paper [1] is the first in the literature to report to those standards.
Biotech, PCUK, and the PELICAN Cancer Foundation. He is a medical
Conflicts of interest: Mark Emberton is a principal investigator for MRI
[3] Moore CM, Kasivisvanathan V, Eggener S, et al. START Consortium.
studies such as PROMIS (UK NIHR HTA funded) Smart Target (Wellcome
Standards of Reporting for MRI-targeted Biopsy Studies (START) of
Trust funded) and PICTURE (PELICAN and AMD). He has received
the prostate: recommendations from an international working
research support from Sanofi, GSK, Sonacare, Angiodynamics, STEBA
group. Eur Urol 2013;64:544–52.
director for Mediwatch PLC and NUADA Medical Ltd and does consultancy work for GSK, Sonacare, Angiodynamics, and Sophiris.
References [1] Siddiqui MM, Rais-Bahrami S, Truong H, et al. Magnetic resonance imaging/ultrasound–fusion biopsy significantly upgrades prostate cancer versus systematic 12-core transrectal ultrasound biopsy. Eur Urol 2013;64:713–9. [2] Moore CM, Robertson NL, Arsanious N, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur Urol 2013;63:125–40.