- Email: [email protected]
Re: Diagnostic Accuracy of Multi-parametric MRI and TRUS Biopsy in Prostate Cancer (PROMIS): A Paired Validating Confirmatory Study
EURURO-7258; No. of Pages 1 EUROPEAN UROLOGY XXX (2017) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Diagnostic Accuracy of Multi-parametric MRI and TRUS Biopsy in Prostate Cancer (PROMIS): A Paired Validating Confirmatory Study Ahmed HU, El-Shater Bosaily A, Brown LC, et al Lancet. In press. http://dx.doi.org/10.1016/S0140-6736(16) 32401-1 Experts’ summary: This much-anticipated study reports the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI)– and transrectal ultrasound (TRUS)–guided biopsy of the prostate compared to a reference standard of transperineal mapping (TPM) biopsy of the prostate in men with a suspicion of prostate cancer. In a prospective multicenter study, the authors enrolled 740 men, 576 of whom underwent 1.5-T mpMRI followed by both TRUS biopsy and TPM biopsy. On TPM biopsy, 408/576 men (71%) had cancer, with 230/576 patients (40%) deemed to have ‘‘clinically significant’’ disease (Gleason grade group 3 or above, or maximum core length >5 mm). For clinically significant cancer, mpMRI was more sensitive (93%, 95% confidence interval [CI] 88–96%) than TRUS biopsy (48%, 95% CI 42–55%; p < 0.0001) and less specific (41%, 95% CI 36–46% for MP-MRI vs 96%, 95% CI 94–98% for TRUS biopsy; p < 0.0001). The authors conclude that 27% of patients might avoid a biopsy if mpMRI was embraced in the diagnostic protocol for detection of clinically significant prostate cancer. Experts’ comments: This is one of the most important papers yet published in the area of mpMRI prostate cancer and prostate biopsy. The authors are to be congratulated for designing and completing this study, which now defines a number of areas of interest in the diagnosis of early prostate cancer. So, what have we learned? First, that high-quality mpMRI performs very well in predicting the presence of clinically significant prostate cancer, with sensitivity of 93%. Second, that TRUS biopsy of the prostate performs particularly poorly in detection of significant cancer, with sensitivity of less than 50%. Third, that one-quarter of patients could avoid biopsy if the results of mpMRI were embraced in clinical practice. This latter point is contentious. While we do not agree with the definition of clinically significant prostate cancer as described in this study (Gleason grade group 3 or above, or maximum core length
>5 mm), it is most reassuring to see that more strict definitions as detailed within the paper lead to mpMRI sensitivity of 87% when significance is defined as any amount of Gleason pattern 4. This paper helps to clarify the high value of mpMRI as part of a multivariable approach to early detection of prostate cancer [1–3] and provides compelling evidence to funders that mpMRI should be supported as part of the diagnostic paradigm. It also highlights the extraordinarily poor performance characteristics of TRUS biopsy, especially in light of concerns about infectious complications [4,5]. A new paradigm of mpMRI and transperineal prostate biopsy is emerging for early detection of prostate cancer. Conflicts of interest: The authors have nothing to disclose.
References [1] Murphy DG, Ahlering T, Catalona WJ, et al. The Melbourne Consensus Statement on the early detection of prostate cancer. BJU Int 2014;113:2. [2] Futterer JJ, Briganti A, De Visschere P, et al. Can clinically significant prostate cancer be detected with multiparametric magnetic resonance imaging? A systematic review of the literature. Eur Urol 2015;68:1045–53. [3] Moore CM, Kasivisvanathan V, Eggener S, et al. Standards of reporting for MRI-targeted biopsy studies (START) of the prostate: recommendations from an international working group. Eur Urol 2013;64:544–52. [4] Murphy DG, Grummet JP. Planning for the post-antibiotic era—why we must avoid TRUS-guided biopsy sampling. Nat Rev Urol 2016;13:559–60. [5] Bennett HY, Roberts MJ, Doi SA, Gardiner RA. The global burden of major infectious complications following prostate biopsy. Epidemiol Infect 2016;144:1784–91. Jada Kapoora,b,c, Alastair D. Lamba,b,c, Declan G. Murphya,b,c,* a
Division of Cancer Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia b
Australian Prostate Cancer Research Centre, Epworth Healthcare, Richmond, Australia
c
The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia *Corresponding author. Division of Cancer Surgery, Peter MacCallum
Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3002, Australia. E-mail address: [email protected] (D.G. Murphy).
http://dx.doi.org/10.1016/j.eururo.2017.02.014 0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Diagnostic Accuracy of Multi-parametric MRI and TRUS Biopsy in Prostate Cancer (PROMIS): A Paired Validating Confirmatory Study Ahmed HU, El-Shater Bosaily A, Brown LC, et al Lancet. In press. http://dx.doi.org/10.1016/S0140-6736(16) 32401-1 Experts’ summary: This much-anticipated study reports the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI)– and transrectal ultrasound (TRUS)–guided biopsy of the prostate compared to a reference standard of transperineal mapping (TPM) biopsy of the prostate in men with a suspicion of prostate cancer. In a prospective multicenter study, the authors enrolled 740 men, 576 of whom underwent 1.5-T mpMRI followed by both TRUS biopsy and TPM biopsy. On TPM biopsy, 408/576 men (71%) had cancer, with 230/576 patients (40%) deemed to have ‘‘clinically significant’’ disease (Gleason grade group 3 or above, or maximum core length >5 mm). For clinically significant cancer, mpMRI was more sensitive (93%, 95% confidence interval [CI] 88–96%) than TRUS biopsy (48%, 95% CI 42–55%; p < 0.0001) and less specific (41%, 95% CI 36–46% for MP-MRI vs 96%, 95% CI 94–98% for TRUS biopsy; p < 0.0001). The authors conclude that 27% of patients might avoid a biopsy if mpMRI was embraced in the diagnostic protocol for detection of clinically significant prostate cancer. Experts’ comments: This is one of the most important papers yet published in the area of mpMRI prostate cancer and prostate biopsy. The authors are to be congratulated for designing and completing this study, which now defines a number of areas of interest in the diagnosis of early prostate cancer. So, what have we learned? First, that high-quality mpMRI performs very well in predicting the presence of clinically significant prostate cancer, with sensitivity of 93%. Second, that TRUS biopsy of the prostate performs particularly poorly in detection of significant cancer, with sensitivity of less than 50%. Third, that one-quarter of patients could avoid biopsy if the results of mpMRI were embraced in clinical practice. This latter point is contentious. While we do not agree with the definition of clinically significant prostate cancer as described in this study (Gleason grade group 3 or above, or maximum core length
>5 mm), it is most reassuring to see that more strict definitions as detailed within the paper lead to mpMRI sensitivity of 87% when significance is defined as any amount of Gleason pattern 4. This paper helps to clarify the high value of mpMRI as part of a multivariable approach to early detection of prostate cancer [1–3] and provides compelling evidence to funders that mpMRI should be supported as part of the diagnostic paradigm. It also highlights the extraordinarily poor performance characteristics of TRUS biopsy, especially in light of concerns about infectious complications [4,5]. A new paradigm of mpMRI and transperineal prostate biopsy is emerging for early detection of prostate cancer. Conflicts of interest: The authors have nothing to disclose.
References [1] Murphy DG, Ahlering T, Catalona WJ, et al. The Melbourne Consensus Statement on the early detection of prostate cancer. BJU Int 2014;113:2. [2] Futterer JJ, Briganti A, De Visschere P, et al. Can clinically significant prostate cancer be detected with multiparametric magnetic resonance imaging? A systematic review of the literature. Eur Urol 2015;68:1045–53. [3] Moore CM, Kasivisvanathan V, Eggener S, et al. Standards of reporting for MRI-targeted biopsy studies (START) of the prostate: recommendations from an international working group. Eur Urol 2013;64:544–52. [4] Murphy DG, Grummet JP. Planning for the post-antibiotic era—why we must avoid TRUS-guided biopsy sampling. Nat Rev Urol 2016;13:559–60. [5] Bennett HY, Roberts MJ, Doi SA, Gardiner RA. The global burden of major infectious complications following prostate biopsy. Epidemiol Infect 2016;144:1784–91. Jada Kapoora,b,c, Alastair D. Lamba,b,c, Declan G. Murphya,b,c,* a
Division of Cancer Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia b
Australian Prostate Cancer Research Centre, Epworth Healthcare, Richmond, Australia
c
The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia *Corresponding author. Division of Cancer Surgery, Peter MacCallum
Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3002, Australia. E-mail address: [email protected] (D.G. Murphy).
http://dx.doi.org/10.1016/j.eururo.2017.02.014 0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.