MR-TRUS Fusion Biopsy
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1 MR-TRUS Fusion Biopsy Silvan Boxler Department of Urology
2 Prostate cancer mortality according to risk groups Prevention of overdiagnosis and overtreatment Rider J, Eur Urol 2013 MR-TRUS Fusion Biopsy / Silvan Boxler 2
3 The problem of standard TRUS biopsies recommendation: 10-12x TRUS guided (detection rates 24-44%) up to 90% prevalence of false negative bilaterality in RPx specimens upstaging 40-60% upgrading (Gleason) 35-65% high rate of misses in ant. tumors no registration of biopsy sites Falzarano, J Urol, 2010 Heidenreich, Eur Urol, 2011 Roehrborn, Eur Urol 2011 de la Rosette, J Urol 2009 Barzell et al.: J Urol 2012 Hambrock, J Urol 2010 MR-TRUS Fusion Biopsy / Silvan Boxler 3
4 The problem of standard TRUS biopsies high rate of underdiagnosis of aggressive disease high rate of overdiagnosis of insignificant disease problem of «gold standard» reference Lecornet, J Urol 2012 MR-TRUS Fusion Biopsy / Silvan Boxler 4
5 Key definitions START consortium Moore, START Cons., Eur Urol 2013 MR-TRUS Fusion Biopsy / Silvan Boxler 5
6 The multiparametric MRI 1.5/3T mpmri w/wh endorectal coil Consists of: high resolution T2 sequences mutiparametric methods diffusion weighted MRI (DWI) dynamic contrast enhanced MRI (DCE) hydrogen-spectroscopy (H-MRS) MR-TRUS Fusion Biopsy / Silvan Boxler 6
7 PI-RADS classification prostate imaging-reporting and data system (according to BI-RADS breast cancer diagnostics) score 1-5 for every modality Röthke et al, 2013 Forschr. Röntgenstr. MR-TRUS Fusion Biopsy / Silvan Boxler 7
8 PI-RADS Reporting MR-TRUS Fusion Biopsy / Silvan Boxler 8
9 The multiparametric MRI sensitivity 78%, specificity 79% detection of clinically significant disease 44-87% negativ predictive value 63-98% excellent correlation between MRI and tumor volume (RPx) Fütterer, Review, Eur Urol 2015 Hamoen, Meta Analysis, Eur Urol 2014 Turkbey, Pinto, J Urol 2012 MR-TRUS Fusion Biopsy / Silvan Boxler 9
10 MR-TRUS fusion biopsy MR-TRUS Fusion (In-bore MRI) transrectal or perineal approach most popular systems: Artemis, UroNav, UroStation, Biopsee site of biopsy is recorded MR-TRUS Fusion Biopsy / Silvan Boxler 10
11 Transrectal vs. perineal biopsy the role of saturation biopsy (random) remains unclear feasibility in every day practice detection rates: better detection of anterior localized tumors with the transperineal approach, otherwise no difference complications related to serious infection: transrectal 3-5% transperineal < 1% Linder, J Urol 2013 Bjurlin, J Urol 2013 Hossak, J Urol 2012 MR-TRUS Fusion Biopsy / Silvan Boxler 11
12 Indication and patient flow Suspicion of PCa PSA elevation DRE active surveillance 3T mpmri Interdisc. review conturing of ROIs MRI-TRUS fusion biopsy registration of TRUS 3D model MRI-TRUS fusion target and template (12x) biopsies Saving of DICOM img 3D model incl. exact cores taken MR-TRUS Fusion Biopsy / Silvan Boxler 12
13 Results Bern (Artemis Eigen) since Jan patients 92 patients with lesion in MRI (76%) no significant cancer in patients with normal MRI median of 2 lesions per patient and 18 bx 68 patients (56%) with positive biopsies Sonn, Margolis, Marks, Eur Urol 2013 MR-TRUS Fusion Biopsy / Silvan Boxler 13
14 MR-TRUS fusion biopsy detection rates > 50% accordance of stage compared to RPx specimen 95% concordance Gleason score 90% deflection of systematic sextant biopsies 1mm (freehand TRUS 9mm) Radtke, Boxler J Urol 2015 Baco, Eur Urol 2014 Han, J Urol 2013 MR-TRUS Fusion Biopsy / Silvan Boxler 14
15 Set up MR-TRUS Fusion Biopsy / Silvan Boxler 15
16 Set up MR-TRUS Fusion Biopsy / Silvan Boxler 16
17 Set up MR-TRUS Fusion Biopsy / Silvan Boxler 17
18 Video biopsy MR-TRUS Fusion Biopsy / Silvan Boxler 18
19 Prostate cancer risk inflation as a consequence of image-targeted biopsy of the prostate Robertson, Eur Urol 2013 MR-TRUS Fusion Biopsy / Silvan Boxler 19
20 Wrap up... more precise diagnosis with MR-TRUS fusion biopsy should be considered in initial diagnosis setting number of biopsy sessions and number of cores will be reduced in the future problems to be solved: overdiagnosis of insignificant disease further improvement of MRI (e.g. detection small lesions) algorithms for treatment decisions need to be adapted cost-effectiveness studies need to follow MR-TRUS Fusion Biopsy / Silvan Boxler 20
21 Thank you! MR-TRUS Fusion Biopsy / Silvan Boxler 21
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