New technology promises precise diagnosis, less invasive treatment for prostate cancer

The challenges in diagnosing and treating prostate cancer range far beyond simply suspecting a cancer and supplying a treatment. A range of approaches is available — both for screening and diagnosis and for management of an established cancer — and a discerning physician needs advanced tools to provide the information needed to select the most effective, yet least invasive, course of action.

Among these tools, multiparametric MRI (mpMRI) improves providers’ ability to identify clinically significant lesions, determine the extent of the lesions and tell whether the lesions have penetrated surrounding structures. Research has demonstrated that mpMRI performed prior to targeted biopsy “is superior to a systematic biopsy alone in diagnostic pathways for [prostate cancer].”¹

At Penn State, mpMRI allows urologic oncologists to find cancers early and, perhaps just as important, identify which patients do not have cancer, avoiding unnecessary follow-up and treatment.

“Multiparametric MRI has the ability to detect clinically significant or important prostate cancer lesions in the prostate,” said Dr. Alireza Aminsharifi, urologic surgeon at Penn State Health and an associate professor of urology, urologic oncology and minimally invasive surgery at Penn State College of Medicine. “Penn State Health is one of the few programs in the region to offer multiparametric MRI-transrectal ultrasound image-guided fusion prostate biopsy, or MRI fusion biopsy, which is a more efficient and accurate means of prostate cancer diagnosis when compared with conventional biopsy.”

Dr. Aminsharifi explained that performing preliminary mpMRI before biopsy allows physicians to omit biopsy for select patients altogether.

“If MRI is negative with a sensitivity of 90%, the patient likely does not have significant prostate cancer,” he said. “So in some patients, we may forgo doing a biopsy, which means we can prevent overuse of biopsy in patients who don’t need it or for whom it may be risky.”

Augmented reality, real-time data: MRI-transrectal ultrasound image-guided fusion prostate biopsy

If biopsy is needed, mpMRI offers precise delineation and staging of suspected cancer. Combined with transrectal ultrasound guidance, mpMRI is a game-changer for patients and their physicians. Together, Dr. Aminsharifi says, the modalities work as a sort of augmented reality.

First the radiologist reconstructs the prostate MRI, delineating and segmenting any lesions suspicious for prostate cancer. Next, the urologist overlays the reconstructed MRI with real-time transrectal ultrasound. This allows for a precise determination of the location to biopsy.

Unlike the more random approach of needle-guided biopsy, the ultrasound image-guided procedure ensures the urologist samples the potentially cancerous areas in the prostate thoroughly, cutting down on the need for future biopsies.

Surgical planning enhances safety

The fusion of mpMRI with transrectal ultrasound image guidance also helps with surgical planning. Using this approach for patients who already have a diagnosis of prostate cancer, the urologist can more accurately stage the cancer, assess its size, and determine its relationship to nearby structures, such as neurovascular bundles and the seminal vesicle.

“This is very helpful prior to a patient’s surgery because we can see if the cancer is close to neurovascular bundles and know whether to remove any of them because the chance of recurrence would be higher,” Dr. Aminsharifi said. “This is also true regarding the extraprostatic extension. If we see a concern on MRI, we can counsel the patient that he needs a wide dissection during surgery, which is crucial to reducing the rate of cancer recurrence after surgery.”

Solving the prostate monitoring paradox: how much is too much?

While prostate cancer screening detects cancers and saves lives, the screening and diagnostic processes also contains known harms, such as anxiety, the chance of treating cancers which would not have become clinically significant and treatment side effects.² They also include biopsy-associated side effects. A small but significant fraction of men — between 0.5% and 1.6% according to one systematic review—must be hospitalized due to biopsy complications.³

Multiparametric MRI allows urologists to reduce the frequency of biopsies in patients under active surveillance, potentially reducing pain and side effects.

“Conventionally, we would biopsy these patients [in active surveillance] every six or 12 months, which can be very invasive,” Dr. Aminsharifi said. “But now we can monitor prostate cancer with an MRI. If there is any change in the imaging, it would be a warning sign to perform a biopsy. However, if the MRI is negative, we can likely defer a biopsy and continue monitoring.”

Improved quality of life for central Pennsylvania men

As one of few academic medical centers available to the patients in its catchment area, Penn State Health prioritizes adopting advanced technology in the wider context of improving life for patients in the community.

“Prostate MRI is performed in many institutes, but quality improvement is very important because the accuracy of the MRI depends on the interpretation of MRI, which requires a specialized radiologist,” Dr. Aminsharifi said, noting that multidisciplinary collaboration and a culture of continuous improvement are key. “To best interpret the MRI, you need a close collaboration between radiologists and urologists, so we are able to detect and target significant lesions in different locations in the prostate. Not all health systems have this, but here at Penn State Health we have a multidisciplinary team of urologists, radiologists and pathologists to clearly interpret the prostate MRI and to target the lesion while offering the highest-quality care.”

Learn more about ongoing clinical research at Penn State College of Medicine.

A version of this article appeared in MD News Central Pennsylvania on Sept. 28, 2021.

References

1. Elwenspoek MMC, Sheppard AL, McInnes MDF, et al. Comparison of Multiparametric Magnetic Resonance Imaging and Targeted Biopsy With Systematic Biopsy Alone for the Diagnosis of Prostate Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(8):e198427. doi:10.1001/jamanetworkopen.2019.8427
2. Grossman DC, Curry SJ, Owens DK, et al; US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(18):1901-1913. doi:10.1001/jama.2018.3710
3. Fenton JJ, Weyrich MS, Durbin S, Liu Y, Bang H, Melnikow J. Prostate-Specific Antigen-Based Screening for Prostate Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018 May 8;319(18):1914-1931. doi: 10.1001/jama.2018.3712