The challenge of prostate biopsy guidance in the era of mpMRI detected lesion: ultrasound-guided versus in-bore biopsy

Auke Jager, Joan C Vilanova, Massimo Michi, Hessel Wijkstra, Jorg R Oddens, Auke Jager, Joan C Vilanova, Massimo Michi, Hessel Wijkstra, Jorg R Oddens

Abstract

The current recommendation in patients with a clinical suspicion for prostate cancer is to perform systematic biopsies extended with targeted biopsies, depending on mpMRI results. Following a positive mpMRI [i.e. Prostate Imaging Reporting and Data System (PI-RADS) ≥3], three targeted biopsy approaches can be performed: visual registration of the MRI images with real-time ultrasound imaging; software-assisted fusion of the MRI images and real-time ultrasound images, and in-bore biopsy within the MR scanner. This collaborative review discusses the advantages and disadvantages of each targeting approach and elaborates on future developments. Cancer detection rates seem to mostly depend on practitioner experience and selection criteria (biopsy naïve, previous negative biopsy, prostate-specific antigen (PSA) selection criteria, presence of a lesion on MRI), and to a lesser extent dependent on biopsy technique. There is no clear consensus on the optimal targeting approach. The choice of technique depends on local experience and availability of equipment, individual patient characteristics, and onsite cost-benefit analysis. Innovations in imaging techniques and software-based algorithms may lead to further improvements in this field.

Figures

Figure 1.
Figure 1.
(a) Robotic MRI in-bore-targeted biopsy (SoteriaTM). 62-year-old male with a PSA value of 16.6 ng ml−1. Axial T2 WI shows a 6 mm focal, PIRADS four lesion on the right peripheral zone (arrow). (b) The desired and planned target for the nodule is shown with restricted diffusion on DWI image (arrow). (c) Oblique axial Fast Imaging Employing Steady-State Acquisition (FIESTA) sequence shows the current position of the needle guide, represented by the orange line overlay from the needle guide with the optimal path after the remote movement of the guide. The needle track and sample core are represented by red line. (d) After the desired target for biopsy has been selected, the robotic device (arrow) is moved remotely to the target as shown (c); the table is moved out of the bore and a biopsy sample is taken with a standard compatible biopsy gun. Biopsy histopathology results showed a Gleason Score 4 + 3=7 adenocarcinoma.
Figure 2.
Figure 2.
Cognitive-targeted biopsy. (a/b) Visual registration of a 1.1 cm lesion (PIRADS 4) in the right dorsolateral periferal zone of the midprostate. (c) Targeting of the matching anatomical location of the lesion on real-time ultrasound imaging. Histopathology showed a Gleason score 4 + 3=7 adenocarcinoma in both targeted and systematic biopsies.
Figure 3.
Figure 3.
Example of MRI/TRUS fusion-targeted biopsy (ArtemisTM) (a) Identification and delineation of lesion on MRI. (b) MRI lesion is superimposed on US imaging. (c) Prostate biopsies are acquired with real-time ultrasound guidance. (d) Targeted biopsy locations are stored.

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