Multi-parametric MRI Fusion-Guided Biopsy Finds Prostate Cancer Often Missed

Finding prostate cancer tumors isn’t always easy. Due to limitations in earlier technologies, some prostate cancer tumors may have been missed. The physicians at USMD Prostate Cancer Center are committed to finding these cancers with the latest state-of-the-art technology—prostate multi-parametric MRI fusion-guided biopsy.

“We’ve created a center of excellence to make sure we’re not missing somebody’s cancer,” says
Richard Bevan-Thomas, M.D., medical director of USMD Prostate Cancer Center.

““If we can get to men who have a Gleason 7, 8, 9 or even 10 prostate cancer early enough, we can really make a difference,” he says. “Prostate multi-parametric MRI fusion-guided biopsy is a great modality for men with a PSA between 4 and 10. And it’s vital for men who have had several biopsies and their PSA is 15, 20, 25 because they have a high risk for metastatic prostate cancer in the near future. These are men who have undergone multiple biopsies, but we can’t find their cancer. We’ve got to find that tumor so we can treat them properly.” 

To understand the significance of this next evolution in prostate cancer detection, it’s important to understand the original tools and their roles and limitations in the diagnosis of prostate cancer.

The Starting Point—PSA Testing
Despite the controversy surrounding PSA testing, this simple blood test to measure the level of prostate-specific antigen in the blood still provides our best early warning that a man may have prostate cancer. That doesn’t mean it’s always definitive, though. An elevated PSA level may be caused by an infection of the prostate, prostatitis or benign prostatic hyperplasia (enlarged prostate). On the other end of the spectrum, there are men with low PSA levels who have harbored aggressive cancer.

“Sometimes, tumors do not produce an elevated PSA until later in the disease process,” Dr. Bevan-Thomas explains.

Concerns about Standard Biopsies
Transrectal ultrasound-guided biopsies are used to help urologists gather tissue samples (cores) from suspicious areas of the prostate. But even this technology doesn’t always provide definitive answers.

“There are cases where men with PSAs of 20 or 30 have had multiple repeat biopsies that all come back negative. Their cancer couldn’t be located because the technology did not clearly reveal where the cancer was,” says Dr. Bevan-Thomas.

In an effort to get a clearer picture of the prostate and suspicious areas, many patients have a prostate MRI before their biopsy. Physicians use magnetic resonance imaging to guide where biopsy needles are inserted and tissue samples collected, rather than randomly extract up to 30 samples from throughout the prostate.

While it’s a good approach in theory, there were a few of flaws.

Not All MRIs Are the Same
“I see one or two patients every month who come in with a negative MRI,” Dr. Bevan-Thomas says. “They say, ‘I’m just coming here as a formality because I know I don’t have prostate cancer.’ And then we find they do. Cancerous tumors were probably missed in a lot of men. They were told their MRI was normal and they didn’t need to get a repeat biopsy, when in reality, they could have been walking around with an intermediate or high-grade prostate cancer—all because the resolution of their MRI was not clear enough.”

Not all prostate MRIs are equal—and that’s because not all MRI facilities are equal. A prostate multi-parametric MRI must be taken at a center of excellence that has the proper equipment, technology and personnel to do them—beginning with an MRI suite that has a magnet strong enough to capture clear images.

“The magnet is what makes it possible to delineate really small 7mm and 8mm lesions compared to normal tissue,” Dr. Bevan-Thomas explains. “You ideally should have a 3 Tesla (3T) magnet to produce the clear resolution needed to see lesions or suspicious areas. If your MRI is done with a less powerful magnet—say a .75T, 1T 1.5T or 2T—the resolution won’t be sharp enough. As a result, many of these facilities will try to improve the image with a balloon inserted into the rectum—which is much more uncomfortable for the patient. Even then, the images are not as clear as the one generated with a 3T magnet."

Along with the right magnet, the MRI center must also have special prostate sequencing software designed to correctly set-up the images it captures so they can be reviewed by a radiologist. 
And finally, you have to have a radiologist who is a specialist in evaluating prostate MRIs.

“You have to have a GU-trained radiologist who knows how to read these MRIs,” Dr. Bevan-Thomas advises. “If the radiologist doesn’t have the proper sequences, doesn’t know how to set up the images correctly or misreads them and says there are no lesions when there are, that’s a problem.”

Advantages of Prostate Multi-parametric MRI Fusion-Guided Biopsy
As a Siemens Center of Excellence, USMD Prostate Cancer Center has assembled all the critical components needed to perform state of the art prostate multi-parametric MRI fusion-guided biopsy under one roof, including:

  • Multi-resonance imaging equipment featuring a powerful 3Tesla magnet

  • Prostate-imaging and sequencing software needed to correctly view and read prostate MRI images

  • A team of Fellowship-trained radiologists who specialize in evaluating and classifying prostate MRIs according to the prostate imaging-reporting and data system (PI-RAD) scale

  • Highly experienced, skilled and dexterous urologists who perform fusion-guided biopsies every week

“We understand men’s lives depend on the outcomes of these biopsies,” says Dr. Bevan-Thomas. “There are no short cuts. We’ve invested in the technology, equipment and medical expertise needed to serve them in the best possible way.”

The radiologists at USMD review all of USMD’s prostate MRIs and classify any detected lesions according to the prostate imaging-reporting and data system (PI-RADS) scale. Men are given a PI-RADS score from one to five.

Lesions scored:

1 or 2 are likely caused by inflammation of the prostate and generally aren’t cause for concern

3 are suspicious and could be cancer

4 are suspicious

5 are very suspicious

How Prostate Multi-parametric Fusion-Guided Biopsy Works
“During a fusion-guided biopsy, we look at the MRI image, mark suspicious lesions and enter them in the computer using specialty software,” Dr. Bevan-Thomas explains. "The MRI has usually been completed several days or a week prior to the biopsy. The fusion biopsy is completely dependent upon whether we see an abnormality on the MRI. If we don't see an abnormality on the MRI, we can't do a fusion biopsy.  If we do see an abnormality on the MRI, we then pull the MRI image over to the ultrasound and superimposing one image on top of the other.”

Properly aligning the MRI image with the ultrasound image requires coordination and experience.

“Pulling that MRI image over to the ultrasound involves co-registration and that can be challenging because when we’re pushing on the prostate with the ultrasound, the image does not look exactly like the MRI.

“The physician has to look at several images at once—the MRI image, the ultrasound image, the fused image—all while moving one hand to target the right areas. If the doctor misses a lesion because of poor co-registration, a tiny 6mm lesion can be easily missed by a biopsy needle, and a cancerous lesion could go undiagnosed.”

Software maps the areas where biopsy needles have gathered samples in case additional biopsies are required in the future. The collected tissue samples are sent to pathology for evaluation.

By helping men understand all the critical components of prostate multi-parametric MRI fusion-guided biopsy, Dr. Bevan-Thomas and his colleagues at USMD Prostate Cancer Center hope to empower men so they can make more informed decisions about early detection, diagnosis and treatment of prostate cancer.

If you would like to schedule a prostate multi-parametric MRI fusion-guided biopsy, call us at 1-888-PROSTATE (1-888-776-7828).

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