10th SEEM: New developments in prostate biopsy

There are new options that may improve prostate tumour detection but the cautionary tone of current guidelines and prohibitive costs are among the factors that limit the widespread use of these new technologies in prostate cancer detection and biopsy.

Dr. Theodore Anagnostou (GR) spoke on new developments in the biopsy of prostate cancer (PCa) at the EAU 10th South Eastern European Meeting (SEEM) which opened today in Belgrade, Serbia, and gave an overview of the role of three-dimension mapping biopsy.

“Current clinical guidelines do not call for the use of MR-US (ultrasound) fusion targeted prostate biopsy. Moreover, the cost of prostate MRI and image-targted biopsy is commonly cited as a deterrent to adoption,” said Anagnostou.

He discussed the rational of pursuing appropriate biopsy techniques as he noted that changes in the management of PCa require a much more careful assessment of the prostate cancer.

Underscoring the evolution or changes in imaging techniques, he discussed multi-parametric ultra sound (US), or enhanced US in combination with elastography, which in some cases unfortunately carries a significant number of false negatives.

“Elastography is a promising tool with the potential to assist detection. However, the results are still inconsistent. Besides, elastography is not recommended for initial biopsies in the EAU Guidelines,” he added

The so-called new kid in the block, he said is the emergence of MRI. Currently there are three techniques available such as targeting within the magnet, superimposition, and the cognitive method which involves cognitive image registration. Anagnostou, however, pointed out that there are disadvantages of cognitive fusion due to human error when attempting to mentally fuse the MRI with TRUS.

Anagnostou also discussed MR-TRUS fusion. The fusion method can either be rigid fusion or elastic, but the latter is more sophisticated than rigid fusion since it attempts to compensate for changes in prostate shape or position.

He said: “These new techniques require fewer biopsies, but there are dilemmas with MRI, such as the query what constitutes an adequate MRI, or what are the hallmarks of positive lesions?”

In his key messages, Anagnostou underscored the following:

• At face value the new image-based approach seems more expensive than conventional TRUS biopsy. However this does not take into account the repercussions of missed diagnoses on conventional biopsy or overtreatment because of uncertainty from systematic TRUS biopsy, and
• Additional data are needed to conclusively prove that targeted biopsy will increase benefit and reduce harm before incorporation into guidelines.