Richard Hindley

TRUS Biopsy

2

TRUS Biopsy•  Random•  Blind to Location of Disease•  Poor repeatability

•  Miss disease •  Over sample clinically

insignificant disease  

Geometric evaluation of systematic transrectal ultrasound guided prostate

biopsy.

M Han, D Chan, C Kim et al. J Urol 2012

3

4

Progression or re-classification?Core length 12mm

CCLmax 8mm

First biopsy Second biopsy

Gleason pattern 3

Gleason pattern 4

CCLmax 3mm

5

Targeted biopsies

Fewer cores•  Less discomfort ?LA•  Less side effects•  Less OR/path time

Better risk classification•  Grade•  Volume•  Location

Less insignificant disease

Advantages

Under-calling on mpMRI

Missing with targeted biopsies…..

Warnings

6

PROMIS: Prostate MRI Imaging StudyEvaluation of Multi-Parametric Magnetic Resonance Imaging

in the Diagnosis and Characterisation of Prostate Cancer

Chief Investigator: Mark Emberton, UCL (Sponsor)Co- CI: Hashim Ahmed, Richard Hindley and Christopher Parker

MRC Clinical Trials UnitProgramme Lead: Richard Kaplan, Project Lead: Louise BrownClinical Operations Manager: Yolanda Collaco-MoraesTrial Manager: Cybil Kwakye, Data Manager: Sophie Stewart

This project was funded by the NIHR Health Technology Assessment programme (project number 09/22/67) and will be published in full in Health Technology Assessment. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

7

8

Advantages of the new pathway•  Less over-diagnosis and over-

treatment•  Improved detection of clinically

significant cancers•  Better treatment allocation as a

result of better sampling•  Reduced side-effects of biopsy

9

MRI / US Fusion•  Process of aligning one

imaging modality with another

•  Rigid or Elastic

•  Transperineal or Transrectal

•  Multiple systems now available

10

Fusion targeted biopsy

MRI

TRUS

Rigid

Overlay

Elastic

11

Manufacturers•  UroNav (In vivo/Philips)•  Artemis (Eigen)•  Urostation (Koelis)•  BiopSee (PiMedical/BK)•  Virtual Navigator (Esoate)•  HI RVS/Real time virtual sonography•  MIMS (Nuada)•  Bioject (BK medical)

WCE London 2015

12

A Collaborative Suite for Radiology and Urology

13

MIM software

14

MRI scoring systems: What lies behind a 3/5 (equivocal) score

•  140 men undergoing MIM fusion targeted biopsy•  69 men scored as 3/5 – 103 distinct lesions

•  67 of 103 benign (34 cancer)•  22 low volume 3+3•  12 had pattern 4 (12% Intermediate risk)•  Of those scored as 5/5 – only 4% benign

15

Platinum Priority – Collaborative Review – Prostate CancerEditorial by Stacy Loeb on pp. 20–21 of this issue

Detection of Clinically Significant Prostate Cancer Using MagneticResonance Imaging–Ultrasound Fusion Targeted Biopsy:A Systematic Review

Massimo Valerio a,b,c,*,y, Ian Donaldson a,b,y, Mark Emberton a,b, Behfar Ehdaie d,Boris A. Hadaschik e, Leonard S. Marks f, Pierre Mozer g,h, Ardeshir R. Rastinehad i,Hashim U. Ahmed a,b

aDivision of Surgery and Interventional Science, University College London, London, UK; bDepartment of Urology, University College London Hospitals NHS

Foundation Trust, London, UK; cDepartment of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; dUrology Service, Sidney Kimmel

Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; eDepartment of Urology, University Hospital

Heidelberg, Heidelberg, Germany; fDepartment of Urology, University of California, Los Angeles, Los Angeles, CA, USA; gDepartment of Urology, Pitie-

Salpetriere Academic Hospital, Pierre et Marie Curie University, Paris, France; h Institut des Systemes Intelligents et de Robotique, l’Universite Pierre et Marie

Curie, Paris, France; iArthur Smith Institute for Urology and Departments of Radiology and Interventional Radiology, Hofstra North Shore-Jewish School of

Medicine, New Hyde Park, NY, USA

E U RO P E AN U RO LOG Y 6 8 ( 2 0 1 5 ) 8 – 1 9

avai lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Article info

Article history:Accepted October 16, 2014

Keywords:Image-guided biopsyImage processingcomputer assistedMagnetic resonance imagingProstate neoplasmsSoftwareTargeted biopsy

Please visitwww.eu-acme.org/europeanurology to read andanswer questions on-line.The EU-ACME credits willthen be attributedautomatically.

Abstract

Context: The current standard for diagnosing prostate cancer in men at risk relies on atransrectal ultrasound–guided biopsy test that is blind to the location of the cancer. Toincrease the accuracy of this diagnostic pathway, a software-based magnetic resonanceimaging–ultrasound (MRI-US) fusion targeted biopsy approach has been proposed.Objective: Our main objective was to compare the detection rate of clinically significantprostate cancer with software-based MRI-US fusion targeted biopsy against standardbiopsy. The two strategies were also compared in terms of detection of all cancers,sampling utility and efficiency, and rate of serious adverse events. The outcomes ofdifferent targeted approaches were also compared.Evidence acquisition: We performed a systematic review of PubMed/Medline, Embase(via Ovid), and Cochrane Review databases in December 2013 following the PreferredReported Items for Systematic reviews andMeta-analysis statement. The risk of biaswasevaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.Evidence synthesis: Fourteen papers reporting the outcomes of 15 studies (n = 2293;range: 13–582) were included. We found that MRI-US fusion targeted biopsies detectmore clinically significant cancers (median: 33.3% vs 23.6%; range: 13.2–50% vs 4.8–52%) using fewer cores (median: 9.2 vs 37.1) comparedwith standard biopsy techniques,respectively. Some studies showed a lower detection rate of all cancer (median: 50.5% vs43.4%; range: 23.7–82.1% vs 14.3–59%). MRI-US fusion targeted biopsy was able todetect some clinically significant cancers that would have been missed by using onlystandard biopsy (median: 9.1%; range: 5–16.2%). It was not possible to determine whichof the two biopsy approaches led most to serious adverse events because standard andtargeted biopsies were performed in the same session. Software-based MRI-US fusiontargeted biopsy detected more clinically significant disease than visual targeted biopsyin the only study reporting on this outcome (20.3% vs 15.1%).

y Contributed equally.* Corresponding author. Division of Surgery and Interventional Science, University College London,London, UK, W1P 7NN. Tel. +44 20 3447 9194; Fax: +44 20 3447 9303.E-mail address: massimo.valerio.12@ucl.ac.uk (M. Valerio).

http://dx.doi.org/10.1016/j.eururo.2014.10.0260302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Platinum Priority – Collaborative Review – Prostate CancerEditorial by Stacy Loeb on pp. 20–21 of this issue

Detection of Clinically Significant Prostate Cancer Using MagneticResonance Imaging–Ultrasound Fusion Targeted Biopsy:A Systematic Review

Massimo Valerio a,b,c,*,y, Ian Donaldson a,b,y, Mark Emberton a,b, Behfar Ehdaie d,Boris A. Hadaschik e, Leonard S. Marks f, Pierre Mozer g,h, Ardeshir R. Rastinehad i,Hashim U. Ahmed a,b

aDivision of Surgery and Interventional Science, University College London, London, UK; bDepartment of Urology, University College London Hospitals NHS

Foundation Trust, London, UK; cDepartment of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; dUrology Service, Sidney Kimmel

Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; eDepartment of Urology, University Hospital

Heidelberg, Heidelberg, Germany; fDepartment of Urology, University of California, Los Angeles, Los Angeles, CA, USA; gDepartment of Urology, Pitie-

Salpetriere Academic Hospital, Pierre et Marie Curie University, Paris, France; h Institut des Systemes Intelligents et de Robotique, l’Universite Pierre et Marie

Curie, Paris, France; iArthur Smith Institute for Urology and Departments of Radiology and Interventional Radiology, Hofstra North Shore-Jewish School of

Medicine, New Hyde Park, NY, USA

E U RO P E AN U RO LOG Y 6 8 ( 2 0 1 5 ) 8 – 1 9

avai lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Article info

Article history:Accepted October 16, 2014

Keywords:Image-guided biopsyImage processingcomputer assistedMagnetic resonance imagingProstate neoplasmsSoftwareTargeted biopsy

Please visitwww.eu-acme.org/europeanurology to read andanswer questions on-line.The EU-ACME credits willthen be attributedautomatically.

Abstract

Context: The current standard for diagnosing prostate cancer in men at risk relies on atransrectal ultrasound–guided biopsy test that is blind to the location of the cancer. Toincrease the accuracy of this diagnostic pathway, a software-based magnetic resonanceimaging–ultrasound (MRI-US) fusion targeted biopsy approach has been proposed.Objective: Our main objective was to compare the detection rate of clinically significantprostate cancer with software-based MRI-US fusion targeted biopsy against standardbiopsy. The two strategies were also compared in terms of detection of all cancers,sampling utility and efficiency, and rate of serious adverse events. The outcomes ofdifferent targeted approaches were also compared.Evidence acquisition: We performed a systematic review of PubMed/Medline, Embase(via Ovid), and Cochrane Review databases in December 2013 following the PreferredReported Items for Systematic reviews andMeta-analysis statement. The risk of biaswasevaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.Evidence synthesis: Fourteen papers reporting the outcomes of 15 studies (n = 2293;range: 13–582) were included. We found that MRI-US fusion targeted biopsies detectmore clinically significant cancers (median: 33.3% vs 23.6%; range: 13.2–50% vs 4.8–52%) using fewer cores (median: 9.2 vs 37.1) comparedwith standard biopsy techniques,respectively. Some studies showed a lower detection rate of all cancer (median: 50.5% vs43.4%; range: 23.7–82.1% vs 14.3–59%). MRI-US fusion targeted biopsy was able todetect some clinically significant cancers that would have been missed by using onlystandard biopsy (median: 9.1%; range: 5–16.2%). It was not possible to determine whichof the two biopsy approaches led most to serious adverse events because standard andtargeted biopsies were performed in the same session. Software-based MRI-US fusiontargeted biopsy detected more clinically significant disease than visual targeted biopsyin the only study reporting on this outcome (20.3% vs 15.1%).

y Contributed equally.* Corresponding author. Division of Surgery and Interventional Science, University College London,London, UK, W1P 7NN. Tel. +44 20 3447 9194; Fax: +44 20 3447 9303.E-mail address: massimo.valerio.12@ucl.ac.uk (M. Valerio).

http://dx.doi.org/10.1016/j.eururo.2014.10.0260302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Platinum Priority – Collaborative Review – Prostate CancerEditorial by Stacy Loeb on pp. 20–21 of this issue

Detection of Clinically Significant Prostate Cancer Using MagneticResonance Imaging–Ultrasound Fusion Targeted Biopsy:A Systematic Review

Massimo Valerio a,b,c,*,y, Ian Donaldson a,b,y, Mark Emberton a,b, Behfar Ehdaie d,Boris A. Hadaschik e, Leonard S. Marks f, Pierre Mozer g,h, Ardeshir R. Rastinehad i,Hashim U. Ahmed a,b

aDivision of Surgery and Interventional Science, University College London, London, UK; bDepartment of Urology, University College London Hospitals NHS

Foundation Trust, London, UK; cDepartment of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; dUrology Service, Sidney Kimmel

Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; eDepartment of Urology, University Hospital

Heidelberg, Heidelberg, Germany; fDepartment of Urology, University of California, Los Angeles, Los Angeles, CA, USA; gDepartment of Urology, Pitie-

Salpetriere Academic Hospital, Pierre et Marie Curie University, Paris, France; h Institut des Systemes Intelligents et de Robotique, l’Universite Pierre et Marie

Curie, Paris, France; iArthur Smith Institute for Urology and Departments of Radiology and Interventional Radiology, Hofstra North Shore-Jewish School of

Medicine, New Hyde Park, NY, USA

E U RO P E AN U RO LOG Y 6 8 ( 2 0 1 5 ) 8 – 1 9

avai lable at www.sciencedirect .com

journal homepage: www.europeanurology.com

Article info

Article history:Accepted October 16, 2014

Keywords:Image-guided biopsyImage processingcomputer assistedMagnetic resonance imagingProstate neoplasmsSoftwareTargeted biopsy

Please visitwww.eu-acme.org/europeanurology to read andanswer questions on-line.The EU-ACME credits willthen be attributedautomatically.

Abstract

Context: The current standard for diagnosing prostate cancer in men at risk relies on atransrectal ultrasound–guided biopsy test that is blind to the location of the cancer. Toincrease the accuracy of this diagnostic pathway, a software-based magnetic resonanceimaging–ultrasound (MRI-US) fusion targeted biopsy approach has been proposed.Objective: Our main objective was to compare the detection rate of clinically significantprostate cancer with software-based MRI-US fusion targeted biopsy against standardbiopsy. The two strategies were also compared in terms of detection of all cancers,sampling utility and efficiency, and rate of serious adverse events. The outcomes ofdifferent targeted approaches were also compared.Evidence acquisition: We performed a systematic review of PubMed/Medline, Embase(via Ovid), and Cochrane Review databases in December 2013 following the PreferredReported Items for Systematic reviews andMeta-analysis statement. The risk of biaswasevaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.Evidence synthesis: Fourteen papers reporting the outcomes of 15 studies (n = 2293;range: 13–582) were included. We found that MRI-US fusion targeted biopsies detectmore clinically significant cancers (median: 33.3% vs 23.6%; range: 13.2–50% vs 4.8–52%) using fewer cores (median: 9.2 vs 37.1) comparedwith standard biopsy techniques,respectively. Some studies showed a lower detection rate of all cancer (median: 50.5% vs43.4%; range: 23.7–82.1% vs 14.3–59%). MRI-US fusion targeted biopsy was able todetect some clinically significant cancers that would have been missed by using onlystandard biopsy (median: 9.1%; range: 5–16.2%). It was not possible to determine whichof the two biopsy approaches led most to serious adverse events because standard andtargeted biopsies were performed in the same session. Software-based MRI-US fusiontargeted biopsy detected more clinically significant disease than visual targeted biopsyin the only study reporting on this outcome (20.3% vs 15.1%).

y Contributed equally.* Corresponding author. Division of Surgery and Interventional Science, University College London,London, UK, W1P 7NN. Tel. +44 20 3447 9194; Fax: +44 20 3447 9303.E-mail address: massimo.valerio.12@ucl.ac.uk (M. Valerio).

http://dx.doi.org/10.1016/j.eururo.2014.10.0260302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

When high quality mpMRI is available an image fusion approach might be offered in addition to standard sampling