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SIU 2019 39th Annual Society of International Urology Congress

SIU 2019: mpMRI is the Next Step to Improve the Device or the Community Expert

Athens, Greece (UroToday.com) The multiparametric MRI (mpMRI) was formed from the need to have enhanced locoregional staging. The mpMRI is composed of 3 parameters:

  1. Anatomy – T2 weighted imaging
  2. Biology – Diffusion-weighted imaging (DWI)
  3. Vascularity – Dynamic enhanced contrast (DCE)

The DCE is essential in local recurrence with high sensitivity. It has limited standardization with low specificity. The negative predictive value of mpMRI for significant prostate cancer is between 63%-98%.1

In the next part of the discussion, several landmark randomized trials comparing mpMRI to systematic biopsies were described with the main results elaborated.

The first study described was the PRECISION trial2 (Figure 1), which randomized men to systematic biopsy or mpMRI targeted biopsies. The results demonstrated that in the mpMRI arm:

  1. 28% avoid biopsy after negative mpMRI
  2. More Gleason >=3+4 significant cancers (12%+) 
  3. 13% fewer insignificant cancers 
  4. 4 cores per patient (2788 cores vs. 967)

Figure 1 – PRECISION trial:

SIU19_PRECISION.png

The next study was MRI-FIRST3 (Figure 2). The results in this trial demonstrated:

  1. 18-21% can avoid biopsy after negative MRI (missing 11% of clinically significant prostate cancer)
  2. No difference in Gleason score >=3+4
  3. 14% fewer insignificant cancers in the mpMRI arm
  4. 3 cores per patient (3070 vs. 810)

Figure 2 – MRI-FIRST trial:

SIU19_MRI.png

The third and last study mentioned was the 4M4 (Figure 3) study that showed:

  1. 49% avoid biopsy after negative mpMRI (missing 3-4% clinically significant prostate cancer)
  2. More Gleason >=3+4 significant cancers in PIRADS 3-4
  3. 11% fewer insignificant cancers 
  4. 3 cores per patient (7512 vs. 849)

 Figure 3 – 4M trial:

SIU19_4M_trial.png

MpMRI has several challenges that are important to mention. First, not all radiologists can interpret it well and there is a significant learning curve. Prostates are significantly different from one another and that makes the learning curve more difficult. There is also large variability with a negative predictive value (NPV) for clinically significant prostate cancer ranging between 55% and 99%.

It is still not clear if mpMRI is the biomarker we are looking for. Reaching its ideal potential would mean that it would be able to show the exact location of the most aggressive part of the tumor with fewer cores and increased yield. However, the data being constantly reported is going that direction.

In conclusion, the state of the art mpMRI helps to detect clinically significant prostate cancer. The NPV for significant prostate cancer is 89%-98%. To reach the full potential of mpMRI we still require more education, training, and quality control. Future directions will include the development of artificial intelligence with machine learning to improve results.


Presented by: Jurgen Futterer, MD, PhD, Professor, Nijmegen, The Netherlands

Written by: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, New York, USA, Twitter: @GoldbergHanan at the 39th Congress of the Société Internationale d'Urologie, SIU 2019, #SIUWorld #SIU2019, October 17-20, 2019, Athens, Greece

References:

  1. Fütterer 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. European Urology2015; 68(6): 1045-53.
  2. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. New England Journal of Medicine2018; 378(19): 1767-77.
  3. Rouvière O, Puech P, Renard-Penna R, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. The Lancet Oncology2019; 20(1): 100-9.
  4. van der Leest M, Cornel E, Israël B, et al. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy-naïve Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. European Urology2019; 75(4): 570-8.