Is MRI-targeted biopsy enough?
Opposing views on the efficacy and significance of MRI-targeted biopsy were presented during “Is MRI-targeted biopsy enough?” the first debate in “Plenary Session 03: Imaging in prostate cancer: Is it time to change paradigms?”, chaired by Dr. Jochen Walz (FR) and Prof. Dr. Francesco Montorsi (IT).
Prior to the deliberations, moderator Dr. Arnout Alberts (NL) asked the audience “Which biopsy strategy would you use in men with a clinical suspicion of PCa?”. The audience keyed in their answers via the EAU Events App. About 55% of the audience chose MRI (+targeted biopsy in case of positive MRI), always combined with TRUS-biopsy; and 30% chose MRI (+targeted biopsy in case of positive MRI), TRUS biopsy depending on risk-stratification. The debate then commenced.
In the presence of a positive MRI, Dr. Veeru Kasivisvanathan (GB) shared his insights on the advantages of MRI-targeted biopsy without TRUS-biopsy. For example, patient burden and risk of (infectious) complications decrease when there are fewer biopsy cores per procedure. The detection rate of Grade Group (GG) 1 (Gleason 3+3) prostate cancer (PCa) is lower, and patients with a false negative MRI-targeted biopsy are not lost to follow up.
In summary, the counter-arguments of Dr. Guillaume Ploussard (FR) included the significant learning curve associated with multi-parametric MRI (mpMRI) reading and MRI-targeted biopsy, the possible registration errors in MRI-targeted biopsy, and the 10 to 20% of GG ≥ 2 (Gleason ≥ 3+4) tumours that are missed. Tumour evaluation (e.g. multifocality, heterogeneity) can be suboptimal if MRI-targeted biopsy is performed without TRUS-biopsy.
Negative MRI, no TRUS biopsy needed
Prof. Francesco Porpiglia (IT) agreed that in the presence of a negative MRI or native MRI-targeted biopsy, no TRUS-biopsy is needed due to the high negative predictive value (NPV) of up to 95% of MRI for GG ≥ 2 (Gleason ≥ 3+4) PCa. In addition, there is a 30% reduction in biopsies, which means a decrease in patient burden and costs, with fewer complications. Additionally, the detection rate of GG1 (Gleason 3+3) PCa is lower.
Dr. Christian Arsov (DE) raised opposing points such as the significant learning curve associated with mpMRI reading; a lack of mpMRI quality control; and 10 to 20% missed GG ≥ 2 (Gleason GG ≥ 3 + 4) tumours.
Dr. Alberts considered the pros and cons discussed, and concluded that there is no single right answer to the question of whether MRI-targeted biopsy is enough. He stated that the way forward seems to be an individual strategy with upfront risk-stratification and the combination of MRI-targeted biopsy and TRUS biopsy in case of elevated risk.