Can Multiparametric Magnetic Resonance of the Prostate Avoid Biopsies in Patients with Elevated PSA and Surgical Indication for Benign Prostatic Enlargement?

For men with surgical indication due to benign prostate enlargement (BPE) and concomitant elevated prostate-specific antigen (PSA), there is a clinical dilemma in terms of performing or not performing prostate biopsy prior to surgery. Some prior studies have investigated the role of multiparametric magnetic resonance imaging (mpMRI) in the context of prostate cancer with a high negative predictive value (NPV). In this study, we analyzed if a negative mpMRI could safely prescind the prostate biopsy in the BPE scenario.

This study evaluated 40 men with surgical indications due to BPE and concomitantly elevated PSA. They underwent mpMRI prior to TRUS-guided prostate fusion biopsy (all patients performed both exams in this sequence). Two scenarios were considered in the analysis. Scenario 1, considering mpMRI PI-RADS 1 and 2 as negative; and scenario 2, considering PI-RADS 1, 2 and 3 as negative. Clinically significant prostate cancer (CsPCa) was defined as ISUP 2 or greater. The standard result was considered prostate biopsy since this procedure will determine if the patient needs a cancer therapy (radical prostatectomy, radiation therapy) or a bladder outlet obstruction treatment (simple prostatectomy, transurethral resection, or endoscopic enucleation).

Our population median age was 68 years (IQR 65–73), the median PSA was 6.35 ng/dL (IQR 4.66–9.98) and the median prostatic volume was 116.5 cc (IQR 86.5–155). mpMRI results classified 20 (50%) patients as PI-RADS 2, 12 (30%) as PI-RADS 3, 6 (15%) as PI-RADS 4 and 2 (5%) as PI-RADS 5. Biopsy diagnosed 27 (67.5%) patients with benign findings, five patients (12.5%) as ISUP 1, six (15%) as ISUP 2, one (2.5%) as ISUP 3 and one (2.5%) as ISUP 4.

When Scenario 1 is considered, sensitivity, specificity, positive predictive value (PPV), NPV and accuracy of mpMRI for csPCa are 87.5%, 59.4%, 35%, 95%, and 65%, respectively. When Scenario 2 is analyzed, the sensitivity, specificity, PPV, NPV, and accuracy is 75%, 93.8%, 75%, 93.8%, and 90%, respectively.

After univariate analyses, only negative mpMRI [Scenario 1 OR 10.23 (1.12 - 93.34) p=0.03] [Scenario 2 OR 45 (5.25 – 385.17) p=0.001] and prostatic volume [OR 1.05 (1.01 – 1.09) p=0.01] were identified as significant predictors of a negative or ISUP 1 biopsy.

In accordance with our expectations, mpMRI of the prostate could be used to avoid unnecessary biopsies in patients with elevated PSA and surgical indication to BPE, since it presents a high negative predictive value. This approach allows a reduction of costs as well as complications related to the biopsy.

Written by: Breno Amaral, MD, Urology Resident, Sociedade Beneficiente Israelita Brasileira Albert Einstein, São Paulo, Brazil, and Marcelo Langer Wroclawski, MD, Renal Transplantation Program, Social Responsibility Institute, Sociedade Beneficiente Israelita Brasileira Albert Einstein, São Paulo, Brazil.

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