MRI - a more precise way to diagnose prostate cancer

A new approach

When the possibility of prostate cancer appears, usually as the result of an elevated PSA level, the next step, traditionally, is to recommend a transrectal punch biopsy—which delivers a success rate of just 30-35%. That’s not good enough for us… or for you.

Here at Vitus, we prefer to use the most up-to-date procedures: MRI (Magnetic Resonance Imaging) and MRI-guided and transperineal 3D mapping, giving a successful detection rate of 85-100%. So we can avoid unnecessary invasive procedures.

The traditional method

In a standard prostate cancer biopsy, the cancer can only be found if it happens to be in one of the places sampled. If no cancer is found, and the PSA level increases again, another biopsy is carried out, and so on, until the cancer is large enough to be detected or it’s detected by chance.

With this sort of transrectal biopsy, it is also possible that the danger of the cancer may be underestimated and, because it is an invasive procedure, there is always the chance of infection.

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Prostate MRI

Our first step is always an MRI (Magnetic Resonance Imaging), by far the best imaging procedure for the prostate. With multimodal and 3D MRI images, cancer can be identified and precisely located with 85-100% success.

The MRI also shows if the cancer is only present in the prostate or has also moved into nearby tissue, and provides the basis for an MRI-guided biopsy.

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3D Biopsy

If a biopsy is called for, we use a short-acting anesthesia and, under sterile conditions, gain access through the pelvic floor for a procedure that is painless, accurate, and carries no risk of infection.

To make sure we’ve found all the areas affected, we use ultrasound to locate all places on the MRI images that seem “suspicious”, then take several samples using a precise grid.

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PSA Level

An elevated PSA (Prostate-specific Antigen) is often the first indicator of suspicion of prostate cancer, but it is never a diagnosis. So you may well ask: “How likely is it that I have prostate cancer if my PSA level is raised?”.

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Diagnosis FAQ

1. I have an increased PSA level. My urologist would like to carry out a biopsy. How should I proceed?

The first sensible step is an MRI examination. This non-invasive risk-free examination has a sensitivity of approximately 85%, as opposed to the 30-35% sensitivity of a biopsy.

Demonstration and localization of a carcinoma at MRI examination allows a targeted biopsy to be undertaken. This approach may prevent the frustration felt when a negative biopsy result is received following a non-targeted biopsy, especially alongside rising PSA values, requiring the biopsy to be repeated, thereby increasing the risk of prostatitis (inflammation of the prostate tissue).

However, the MRI examination is not a biopsy replacement. A tissue sample gained through biopsy is required to provide a tissue characterization and the Gleason score (tissue type and aggressiveness indicator of tumor growth) to be established.

The problem with a transrectal non-targeted biopsy is its sensitivity of approximately 35%. This means that a negative result from such a biopsy is by no means an all-clear, and can only confirm that no cancer cells were found in the samples taken. This frustrating result often leads to a repeated biopsy and therefore an associated increased risk of prostatitis.

A better choice would be the 3D mapping biopsy, a procedure with an accuracy of 80-100%.

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2. What information is provided by the MRI examination?

MRI is a non-invasive, pain-free method of medical imaging, in which examination can be undertaken without radiation. MRI boasts 3D capabilities and a host of physical diagnostic parameters. Combined, these parameters provide exceptionally reliable evidence about tissue characteristics in a particular location within the prostate such as in the case of a carcinoma. MRI examination is—without question—the best method of medical imaging for prostate diagnostics, and should, in the case of suspected prostate cancer, be undertaken at the earliest convenience.

MRI also shows the extent of the prostate carcinoma, thereby identifying if the tumor is confined within the prostate or whether it has already started to spread and invade surrounding structures (staging)—a very important factor when considering therapy options. MRI is also considered superior to ultrasound, histoscanning, elastography, CT (Computed Tomography) and PET/CT (Positron Emission Tomography). For optimal results, MRI examination of the prostate should be carried out at either 1.5 or 3.0 Tesla using an endorectal coil.

Advances in MRI have lead to the availability of whole body MRI examination as a replacement for both the isotope bone scan and CT examination, as a staging tool for secondary metastasis and lymph node invasion. Without using any ionizing radiation, MRI boasts an increased rate of accuracy and a reduction in examination time from 4-6 hours with the isotope bone scan to approximately 1 hour examination time.

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3. My PSA value is continuing to increase. I have already undertaken a number of rectal biopsies. What should I do?

4. Can I get my MRI scan at any radiology practice?

For best results, the MRI scan should be carried out using an endorectal coil (even at 3 Tesla). Often the results of an examination undertaken using a 3 Tesla MRI scanner are worse than those at 1.5 Tesla, due to increased magnetic susceptibility artifacts and higher energy deposition (SAR—Specific Absorption Rate) associated with the increased magnetic field strength.

The endorectal coil must be filled with a susceptibility-neutral substance. In addition, the calculation and interpretation of many parameters such as diffusion, perfusion and MR-spectroscopy is highly complex and can only be undertaken by a few specialists.

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5. The MRI shows a suspicious area. What now?

We recommend a transperineal 3D (mapping) biopsy, as opposed to a transrectal punch biopsy, as this method has a greatly reduced infection rate. This is due to samples being acquired through the skin of the perineum under sterile conditions, as opposed to through the wall of the rectum. The procedure is carried out under general anesthetic.

The 3D biopsy demonstrates a sensitivity of 80-100% for confirming the presence of carcinoma in comparison to a 30-35% sensitivity demonstrated with conventional transrectal punch biopsy. This technique also delivers a reliable Gleason score and an exact map of cancer distribution within the prostate. Repeat 3D biopsy is very rarely required.

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6. Can MRI replace the need for a biopsy?

Concerning evidence and localization of a carcinoma: yes.

Concerning tissue characterization: only occasionally.

During MRI-spectroscopy, the relationship between citrate and choline can demonstrate evidence towards the aggressiveness of the carcinoma. A suggestion which can only be confirmed through histopathological analysis of tissue samples removed during a biopsy. The resulting evidence is documented as the Gleason score.

However, a biopsy alone cannot replace the need for an MRI examination. MRI allows verification and localization of carcinomatous tissue, directing the then accurately targeted biopsy to bring cancerous tissue to light for histopathological testing, thereby allowing the stage and extent of the tumor to be defined.

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7. Why are transrectal biopsies inadequate?

In the case of transrectal biopsies between 6-12 biopsy probes will be taken. Access to the prostate is achieved via the rectum, with biopsy probes either being taken blindly or with the assistance of ultrasound guidance. The sensitivity of a transrectal biopsy, even when the number of probes taken is increased to a maximum of 24, is at 30-35%. When the size of the tissue sample within each probe is considered (<1mm diameter by 10-25mm length) it becomes clear that tissue is only actually taken from a small area of the prostate. If the tumor does not happen to be in these sampled areas, no carcinomatous tissue will be
collected.

Transrectal biopsies are undertaken through the oblique insertion of the biopsy needle into a predetermined area of the prostate. As no coordinate system is used for tissue acquisition, the exact origin of the sample cannot be determined (accuracy of just 5-10cm³). Furthermore, not all areas of the prostate can be easily biopsied due to the narrow proportions within the rectum and the angle of insertion required for the biopsy needle. Also, with the transrectal approach every tissue probe introduces fecal material into the prostate, thereby, due to the increased risk of prostatitis, limiting the number of probes that can be taken. Whether the probes acquired using this technique contain carcinomatous tissue is ultimately left to chance.

The transperineal biopsy, on the other hand, uses a more anatomically accurate method of probe acquisition and boasts an accuracy of 0.5-1cm³. This method is 5-20 times more precise than a transrectal biopsy concerning the accuracy of probe localization and all areas of the prostate being accessible. In addition, this method poses no risk of fecal contamination.

Despite these statistics, the transrectal biopsy does still have a place in the diagnosis of large carcinomas. Prior to a radical prostatectomy, it is sufficient that the carcinoma is confirmed with a positive probe before the prostate is surgically removed. However, a more gentle focal therapy requires a wealth of locational information not available following a traditional biopsy. This information is acquired using a 3D mapping biopsy, which provides a 3D histological model of the prostate to assist therapy planning, as well as permitting accurate treatment, with only the cancerous cells selectively targeted and destroyed.

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8. What are the advantages and disadvantages of transperineal or 3D mapping biopsies?

9. Cancer is diagnosed after a biopsy. How should I proceed?

A prerequisite for choosing the best treatment is an exact knowledge as to the extent and type of carcinoma, known as the staging and grading.

Staging:

a. Distribution of the carcinoma within the prostate.

b. Extension of the carcinoma out of the prostate into other pelvic organs (seminal vesicles, pelvic floor, etc.)

c. Spread of the carcinoma into other organs, lymph nodes and/or bones.

Grading:

a. Histological appearance of the carcinoma

b. Carcinoma type

c. Aggressiveness of the tumor

Personal factors are also taken into consideration:

a. Age of the patient

b. General health

c. Sexual and general activity

d. Size of the prostate

e. PSA value

When all of these parameters are ascertained, this information may be used to identify the most appropriate treatment, chosen from a broad range of possibilities:

a. Watch and wait—active surveillance

b. Focal therapy: HIFU, laser, RDA, NanoKnife, etc.

c. Partial or radical prostatectomy

d. Brachytherapy, Afterloading, Gamma Knife, Proton therapy, Conventional radiotherapy, etc.

e. Hormone blockade therapy

f. Chemotherapy

g. Immunotherapy

We are happy to advise you with regard to both conventional and modern therapy methods.

Don’t panic, due to the typically slow growth of the prostate and therefore most prostate cancers, you have enough time to let yourself become fully informed, and to gather some expert opinions.

The target of any therapy should be the control of the prostate cancer whilst avoiding complications such as impotence, incontinence or radiation damage.

Together we can identify a strategy to provide the optimal diagnostic and therapeutic approach to your prostate cancer.

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10. Will my health insurance company cover the costs for diagnostic and treatment?

In order to discover which costs will be covered you should first discuss this question directly with your statutory health insurance company. However, the costs for endorectal MRI and 3D biopsy are not covered by health insurance.

We also recommend that even when you are privately insured you clarify exactly which diagnostic and treatment costs will be covered by your health insurance company before undertaking any procedures. We are happy to provide you with information.

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11. If I decide to carry the costs myself, how much can I expect to pay?