You’re breezing along the railroad track of life. Like the steel wheels on a train, your choices in life have almost totally reduced friction and enhanced your midlife journey. Before you arrive at the next station, you’re at the peak of your career and in overall great health. Suddenly, where the steel meets the tracks, sparks fly and there’s an awful screeching. Your momentum grinds to a halt, and you find yourself in the middle of nowhere between stations. The emergency brake was activated when your annual PSA test came back high, and your prostate MRI shows a suspicious area.
Learning about prostate biopsy
Your doctor wants you to have a biopsy. This is the standard of care; taking tissue samples from your prostate is still the definitive way to diagnose prostate cancer (PCa). Given your personal track record of high standards, you want the best biopsy in your situation. If you’re like thousands of other internet-wise men, you dedicate hours of free time to researching. You read about conventional TRUS biopsy (12+ cores taken under real-time ultrasound guidance). You also read about fusion-guided biopsies—often erroneously called MRI-guided biopsies—that “fuse” previously captured MRI scans with real-time ultrasound. Finally, you read about real-time MRI guidance done in the tunnel, or bore, of the magnet and therefore called in-bore biopsies. Which method will be in the best interests of your prostate?
At the heart of the issue is the fact that not all PCa is created equal. There are two different types of prostate cancer: insignificant vs. significant PCa. Although experts differ in their views, there is increasing consensus that insignificant (low risk) PCa may never truly behave like cancer—that is, it can safely be monitored because it may never progress into a killer. On the other hand, significant cancer that harbors aggressive cells is not amenable to dallying around; it should be treated right away.
Thankfully, multiparametric MRI (mpMRI) of the prostate, performed in the bore of a powerful 3T magnet and interpreted by an experienced radiologist, optimizes the diagnosis of clinically significant PCa. This is the cancer you want to rule in or rule out, with the greatest accuracy and with the fewest needles in order to reduce biopsy side effects such as bleeding and infection. (In fact, studies now show that mpMRI is so good that if imaging alone does not detect clinically significant disease, no biopsy is needed at that time. And who wants to go through an unnecessary needle biopsy?)
The best biopsy for you
All that time you spent on the internet helped you conclude that the conventional TRUS biopsy has the highest error rate because it overdetects insignificant disease and underdetects significant disease. But you’re confused about fusion vs. in-bore, because they are both called MRI-guided targeted biopsies. But only one of them uses high resolution, analytic imaging to guide biopsy needles in real time, and that’s in-bore biopsy. How do we know it’s better?
Two recently published clinical studies put the two guidance systems to a head-to-head test.
a) Costa, et al. (2019) compared detection of clinically significant disease between 103 men who had in-bore guidance and 300 who had fusion guidance. All patients went on to surgical prostatectomy, so their prostate specimens were subject to further inspection. The authors found, “MRI-guided in-bore biopsies detected more clinically significant and fewer insignificant prostate cancers than MRI-TRUS fusion targeted biopsies.” Furthermore, after surgery more men in the fusion group were found to have more aggressive tumors than in the in-bore group.[i]
b) Prince, et al. (2021) compared 191 cases of in-bore biopsy vs. 95 fusion biopsy. This research team wrote that “…in-bore MRI-targeted prostate biopsy had a higher target-specific cancer detection rate than did fusion biopsy.”[ii]
It should also be pointed out that unlike in-bore biopsy, the fusion biopsy often routinely includes a systemic (12+ needle) sampling in addition to targeting the tumor. While this tends to pick up more insignificant than significant disease, it increases the risk of post-biopsy side effects.
At the Sperling Prostate Center, we have a very high degree of confidence in the real-time accuracy of our imaging due to our advanced equipment and our expertise. The two abovementioned studies affirm what our own experience shows us. If your doctor suspects you have prostate cancer, and you want the best course of action, before you have a biopsy, we recommend you have a 3T mpMRI of the prostate. Then, if your imaging reveals a suspicious area, choose an in-bore MRI targeted biopsy for the most accurate diagnosis using a minimal number of needles. You’ll be glad to get your life back on track, knowing you made a decision in keeping with your own high standards.
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] Costa DN, Goldberg K, de Leon AD, Lotan Y et al. Magnetic Resonance Imaging-guided In-bore and Magnetic Resonance Imaging-transrectal Ultrasound Fusion Targeted Prostate Biopsies: An Adjusted Comparison of Clinically Significant Prostate Cancer Detection Rate. Eur Urol Oncol. 2019 Jul;2(4):397-404.
[ii] Prince M, Foster BR, Kaempf A, Liu JJ et al. In-Bore Versus Fusion MRI-Targeted Biopsy of PI-RADS Category 4 and 5 Lesions: A Retrospective Comparative Analysis Using Propensity Score Weighting. AJR Am J Roentgenol. 2021 Sep 9;1-8.