Prostate CancerValue of Targeted Prostate Biopsy Using Magnetic Resonance–Ultrasound Fusion in Men with Prior Negative Biopsy and Elevated Prostate-specific Antigen
Introduction
Prostate needle biopsy, when performed by the conventional method [1], may fail to detect the presence of cancer. The false-negative rate of ultrasound-guided systematic biopsy may be as high as 47% [2]. Men with prior negative biopsies and persistently elevated serum prostate-specific antigen (PSA) levels, a group numbering in the millions, constitute a diagnostic dilemma [3], [4]. Repeated biopsy sessions and PSA-related anxiety will follow in many of these men. In fact, 38% of Medicare patients undergo a repeat biopsy within 5 yr of an initial negative biopsy [5]. Attempts to reduce the false-negative rate by additional sampling, anterior sampling, and apical sampling have been only marginally successful [6], [7]. Transperineal template biopsy may detect additional prostate cancer (PCa) [1], [8], both serious and trivial, but it requires general anesthesia and risks increased morbidity [2], [9].
Targeted prostate biopsy, which uses findings from magnetic resonance imaging (MRI) to guide needle aiming, may help to establish a correct diagnosis for men in this group [10]. The technology involves either direct in-bore biopsy, performed by a radiologist [11], [12], [13], [14], or fusion biopsy, wherein the MRI features are combined with ultrasound guidance in a traditional urologic biopsy suite [15], [16], [17], [18], [19], [20]. Using one such fusion device (Artemis, Eigen, Grass Valley, CA, USA), we found that level of suspicion on MRI correlated with biopsy diagnosis of cancer; when MRI indicated a focus of greatest suspicion, cancer was diagnosed by fusion biopsy in 15 of 16 men [21].
In the present study, we sought to test the value of an office-based fusion device in the detection of PCa in men with prior negative biopsies and persistently elevated PSA levels. Conduct of the present study and preparation of this report were guided by conclusions from a recent international conference on this subject [22].
Section snippets
Study design
Subjects were culled from a prospective trial of magnetic resonance–ultrasound (MR–US) fusion biopsy at the University of California, Los Angeles (UCLA), which was approved in advance by the UCLA Institutional Review Board. Those included in the present study were all 105 men with one prior negative prostate biopsy or more and persistently elevated serum PSA levels who underwent multiparametric MRI (mpMRI) and MR–US fusion biopsy between March 2010 and August 2012. Prior biopsies were performed
Demographics and clinical characteristics
Table 2 displays demographics and clinical characteristics. The median interval from negative biopsy to MR–US fusion biopsy was 14 mo (interquartile range [IQR]: 9–26). At prior biopsies, a median of 13 cores was obtained (IQR: 12–16). At fusion biopsy, the median PSA level was 7.5 ng/ml (IQR: 5.0–11.2) and median prostate volume was 58 ml (IQR: 39–82). Targets were identified on mpMRI in 101 of the 105 patients (maximum image grade of 1, n = 4; grade 2, n = 11; grade 3, n = 42; grade 4, n = 34; and
Discussion
In the present study of men with a prior negative biopsy and persistently elevated PSA levels, a dilemma group, we found that MR–US fusion biopsy yielded a 34% cancer-detection rate. When highly suspicious MRI lesions were targeted, the great majority of cancers found were clinically significant, and few were insignificant. Because of these and other supporting data [15], [18], fusion biopsy can now be considered for men in the dilemma group. Although experience is limited, the fusion device
Conclusions
Office-based MR–US fusion biopsy improves detection of PCa in men with prior negative biopsies and elevated PSA levels. The majority of detected cancers are clinically significant.
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