History is littered with poor judgments, often on the part of a very small handful of people—or even a single individual. If you’re a trivia buff, you’d recognize the name of J. Bruce Ismay, owner of the Titanic, who determined a mere 20 lifeboats would be enough for an unsinkable ship. Or how about Willem Janszoon, the Dutch captain who came upon Australia? Based on a relatively small section of coast and a number of hostile natives, he decided it was a useless desert land and reported it as such. Sorry, Dutch colonizers, you lost a continent to the British!

But here’s an example of excellent judgment: twelve authors from Milan, Italy who have studied and implemented MRI-guided in-bore prostate biopsy. They are in agreement with international experts who have “confirmed the superiority of the ‘MRI pathway’.”^[i] To put it boldly, 18,000 Europeans can’t be wrong.

The MRI pathway outperforms the conventional diagnostic method of transrectal ultrasound (TRUS) guided biopsies. TRUS biopsies are basically blind and random needle sticks of the gland. They are blind because ultrasound cannot visualize distinctions between normal prostate tissue and prostate cancer (PCa). And, despite a doctor mentally dividing the gland into 12 or more sections to be sampled, placing one or more needle into each section is like shooting a gun into a dark room where there might (or might not) be a tiger lurking. As the authors point out, “This involves the risk of not diagnosing a high percentage of tumors (up to 30%) and of an incorrect risk stratification.”

In other words, TRUS biopsy has a margin of error in two directions. It oversamples insignificant PCa and undersamples significant PCa. In turn, this can lead to a treatment plan that is inappropriate. For instance, a patient with a tumor that might never become dangerous is recommended for radical prostatectomy or whole gland radiation; or a patient whose Gleason 4+4 tumor at the apex of the gland was missed is advised he can safely go on Active Surveillance (AS). These recommendations may not be errors in judgment if the facts had been correct, just as the decision to ignore Australia would not have been a mistake if, in fact, it had merely been a 200-mile desert island.

Why is in-bore biopsy superior?

According to the Milanese researchers, the evidence from large-scale published studies is compelling. They cite the PROMIS study, the PRECISION study, and the prospective head-to-head comparison between standard vs. in-bore biopsy conducted by van der Leest, et al. (2019).^[ii] Based on these and other single-center papers, as well as their own experience, they identify the key advantages of the new MRI pathway:

• Multiparametric MRI (mpMRI) before biopsy can identify lesions suspicious for clinically significant disease. If none are detected, it reduces the need for biopsy in up to 50% of cases.^[iii]
• mpMRI improves the accuracy of identifying significant PCa which requires treatment.
• Real-time MRI guidance means in-bore biopsy precisely samples even very small tumors.
• By reducing the diagnosis of insignificant disease, it avoids the sexual and urinary risks of overtreatment.
• Accurate diagnosis through in-bore biopsy means better treatment planning and fewer unpleasant surprises (that is, positive surgical margins or tumor upgrades) after surgery.

The dozen Italian authors are certainly not alone in their evaluation of in-bore biopsy as superior over conventional TRUS biopsies. In fact, the 18,000 member European Association of Urology (EAU) has “introduced the concept of [in-bore MRI targeted biopsy] into its guidelines for the PCa diagnostic process, with a specific indication to perform prostate mpMRI before any biopsy…”^[iv]

At our Center, we recognize that our pioneering use of mpMRI and in-bore biopsy was in the vanguard of what has become an international consensus. Ismay and Janszoon stood alone in their unfortunate mistakes. We, on the other hand, are not alone in our choice of MRI-based prostate services. Our initial assessment about the future of mpMRI and the advantages of in-bore biopsy has been repeatedly bolstered by study after study—and we saw that the clinical science was rapidly gaining momentum in the right direction for PCa patients. MRI has been the imaging-based game changer, and we join our colleagues in Milan in correctly perceiving it as The King of Prostate Cancer Imaging.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Gurgitano M, Ancona E, Maresca D, Summers PE et al. In-bore MRI targeted biopsy. Acta Biomed. 2020 Sep 23;91(10-S):e2020012.
[ii] van der Leest M, Cornel E, Israël B, Hendriks R et al. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy-naïve Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. Eur Urol. 2019 Apr;75(4):570-578.
[iii] Ibid.
[iv] Gurgitano, ibid.