Showing results for 
Search instead for 
Did you mean: 

BLOG: MRI Pathways

Community Manager
Community Manager
0 0 237

MRI Pathways

Pre-prostate biopsy MRI can yield a 27–49% reduction of patients undergoing transrectal ultrasound (TRUS)-guided biopsy. A meta-analysis of seven clinical trials with 2582 patients found that MRI with or without a targeted biopsy offered a 57% increase in clinically significant prostate cancer (csPCa) detection, a 33% decrease in the total number of biopsies, and a 77% reduction in cores per biopsy procedure1. The PRECISION trial further reported 13% fewer insignificant cancers in an MRI-targeted biopsy group compared with a systematic TRUS-biopsy group2. High level evidence shows that a diagnostic pathway is able to identify clinically significant disease and detect fewer insignificant cancers. From July 2018, patients in Australia meeting the Medicare Benefits Schedule (MBS) criteria were able to undergo multiparametric MRI (mpMRI) with no out-of-pocket expenses3. This addition of mpMRI to the diagnostic pathway has led to a reduction in biopsies in younger men.

Once the decision to biopsy is made, the biopsy route then needs to be selected and the international literature has varied recommendations. The transperineal (TP) route has significant advantages in terms of minimal post-operative infection and access to the anterior gland when compared to transrectal (TR) biopsies. The current standard in Australia is the TP approach. General anaesthetic TP biopsies (TPB) take longer to schedule compared to TR biopsy, impacting diagnostic target time. There has been a recent trend towards a local anaesthetic approach for TP biopsy with fewer cores to limit scheduling delays. Several biopsy techniques have been proposed, currently a systematic biopsy (SB) is recommended in the setting of a negative MRI and in the work-up of focal therapy, SB with a targeted biopsy (TB) is considered as the standard in patients with a MRI target. TB alone might be considered in the active surveillance setting, and saturation TB approaches have recently been proposed as a means of reducing the number of cores and biopsy related complications, with high detection rates reported especially in those with low PSA levels and small prostate volumes.

In a study led by Professor Manish Patel at the University of Sydney the team found that adding SB to TB increases the detection of csPC4 by 16% and diagnosis of a higher Gleason Grade Group by 19% at the expense of slightly increased cost of an insignificant cancer diagnosis (5%). Furthermore, increasing PIRADS score is associated with higher rates of csPC on SB; thus, the authors recommend a combination of both techniques for diagnostic accuracy especially those with higher PIRADS scores.

A retrospective study was conducted at the Royal Brisbane hospital examining the experience of a mpMRI-based triage system at a tertiary referral, public teaching hospital5. They looked at progression to a TPB, with (target or systematic +target) or without (TPB only) cognitive fusion, for cancer detection. This referral pathway resulted in a reduced number of men proceeding to prostate biopsies with a cost benefit while also achieving a high diagnostic accuracy. They found that significant cancer was identified in 60.5% of all biopsied men and 78.6% of men with a MRI classification PIRADS score ≥ 3 who underwent biopsy. These numbers are higher than those reported in the PRECISION (38%) and PROMIS (50%) trials. The distribution of PIRADS scores was different in their series in comparison to the other studies. In their cohort, 56% of men were assigned a PIRADS 2 and 8.8% (58/653) of men a PIRADS 3 on mpMRI. This contrasts to lower numbers of PIRADS 1–2 mpMRI being reported in the PRECISION (28%) and PROMIS (27%) trials. They deduced that the subspecialty interest and experience of radiologists in collaboration with urologists at their hospital allowed for a smaller number of indeterminate reports. A selective approach to biopsy in patients with PIRADS 2 or 3, which included age, clinical factors, PSA kinetics and density has allowed them to achieve greater yield of patients with csPCa. Patients who had a biopsy were significantly younger for both PIRADS 2 and 3 cohorts, while those in the PIRADS 2 cohort had significantly higher PSA density. If considering the entire PIRADS 2 and 3 cohort, irrespective of men proceeding to biopsy, the overall detection of prostate cancer was 6.5% and 21%, respectively. However, this approach resulted in 70% and 50% less biopsies for patients in PIRADS 2 and 3 cohorts. For men who then had a prostate biopsy, the diagnostic yield was higher than other studies, specifically 22% for PIRADS 2 (a threefold improvement) and 43% for PIRADS 3 (a twofold improvement) cohorts.

Even though 30% of patients with PIRADS 2 mpMRI were biopsied in their cohort, the proportion of overall patients who avoided a biopsy (47.3%) was higher than in PRECISION (28%) and higher than what would have been achieved in PROMIS (27%) if only patients with PIRADS ≥ 3 proceeded to biopsy. This was possible mainly because of the high proportion of PIRADS 2 scans and to a lesser degree due to the discretionary approach employed for PIRADS 3 scans. Reducing the number of patients subjected to biopsy has clear benefits in minimising complications and cost.

The team postulates that PSA density may further risk stratify patients with equivocal MRI results. It has been previously reported that in patients with PIRADS 1–2, a PSA density of less than 0.15 increases the negative predictive value (the ratio of patients truly diagnosed as negative to all those who had negative test results) from 79 to 89%. In their study, when employing a PSA density cutoff of 0.15 to patients with PIRADS 2 who underwent biopsy, a statistically significant difference in detection of significant cancer was apparent (37% vs 16%).

The biopsy detection rates were maintained across the study period, suggesting that the clinicians were beyond the learning curve. Cognitive fusion is a widely used, inexpensive and reproducible. The biopsies were performed by training registrars with consultant supervision, showing that a cognitive fusion biopsy technique is a skill readily acquired by training registrars and clinicians. Their results correlate with previous studies suggesting no difference in cancer detection of targeted lesions between experienced physicians and residents.

In this study, only 7.8% of patients underwent targeted-only biopsy, but in these, the detection rate of csPCA was 96.3%, suggesting that extra cores were appropriately avoided. In those who had separate systematic and targeted cores (stTPB), systematic cores detected cancer with a higher Gleason grade than targeted biopsies in 3.2% and 5% of men with PIRADS 4 and 5 MRI lesions, respectively. While the additional yield is small (3.2–5%), systematic biopsies may alter treatment decisions by detection of higher-grade cancer even in the presence of a high-risk lesion seen on mpMRI, likely due to inaccuracies in characterisation of multifocal disease and tumour volume by mpMRI and limitations in identifying microscopic foci with current imaging modalities.

The MRI pathway has evolved alongside the development of several biopsy methods and techniques. The currently available array of alternatives enables centres to offer biopsy procedures tailored to individual patient-specific risk, comorbidity, and preference. Combining imaging, TP biopsy and a more widespread use of local anaesthetic in an outpatient setting seems a reasonable solution to balance costs and benefits. Local choices, however, are likely to depend on the expertise and experience of clinicians and on the technology available.



  1. Ippoliti S, Fletcher P, Orecchia L, Miano R, Kastner C, Barrett T. Optimal biopsy approach for detection of clinically significant prostate cancer. Br J Radiol 2021; 94: 20210413.
  2. Luzzago et al. MRI-targeted or systematic random biopsies for prostate cancer diagnosis in biopsy naïve patients: follow up of a PRECISION trial-like retrospective cohort. Prostate Cancer Prostatic Dis 2021 24:406–413
  3. Wei G, Papa N, Kelly B, Bolton D, Perera M. Trends in the uptake of diagnostic multiparametric MRI of the prostate with federal funding: Australia population data. Urology 2021; 155: 9-11.
  4. Lahoud J, Doan P, Kim LH, Patel M. Transperineal systematic biopsies in addition to targeted biopsies are important in the detection of clinically significant prostate cancer. ANZ J Surg 2021. 91: 584-589.
  5. Donato P, Morton A, Yaxley J, Teloken PE, Coughlin G, Esler R, Dunglison N, Gardiner RA, Robert MJ. Improved detection and reduced biopsies: the effect of a multiparametric magnetic resonance imaging‑based triage prostate cancer pathway in a public teaching hospital. World J Urol 2020; 38:371–379.



 About the Author

Kalli Spencer

MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)

Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.

Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.


Help is Available

Prostate Cancer Specialist Telenursing Service:

If your life has been impacted by prostate cancer, our Specialist Telenursing Service is available to help. If you would like to reach out to the PCFA Prostate Cancer Specialist Telenurse Service for any questions you have about your prostate cancer experience, please phone 1800 22 00 99 Monday - Friday 9am - 5pm, Wednesday 10am-8pm (AEST).


Prostate Cancer Support Groups:

PCFA is proud to have a national network of affiliated support groups in each state and territory of Australia consisting of men and women who have a passion for assisting others who encounter prostate cancer. This network is made up of over 170 affiliated groups who meet locally to provide one-to-one support, giving a vision of life and hope after treatment. Call us on 1800 22 00 99 to find your local group.


MatesCONNECT Telephone-based peer support:

MatesCONNECT is a telephone-based peer support program for men affected by prostate cancer. If you’ve recently been diagnosed with prostate cancer, our MatesCONNECT service can connect you to a trained volunteer who understands what you’re going through. All of our volunteers have been through prostate cancer. Simply call us on 1800 22 00 99 to be connected with a volunteer.


Newly diagnosed? or need to find more information -Access the PCFA resources here!


House Rules

To help keep this community a welcoming, supportive and caring place we have put together a small list of dos and don'ts for you to think about when posting on our forum, research blog or video gallery. For further information please see our  terms and conditions.

Adhere to PCFA’s five core values of Integrity, Optimism, Compassion, Respect and Commitment.

Our online forum is for you to share experiences with others and does not contain specific medical, counselling or legal advice.  If you require professional advice specific to your individual circumstances we encourage you to see a medical professional, legal professional or counsellor.

No commercial or promotional activity. While members may share information about resources they have found helpful, the PCFA Online Community forum should not be used for the promotion of goods and services. This includes commercial entities passing themselves off as individuals and people who frequently post links to external health professionals or other services.

Be kind to each other - many people using the community are going through a difficult time. A few kind words can go a long way. Please welcome new posters – it can be very nerve-wracking to post on the forum for the first time.

If you or someone you know is suffering from mental health issues, such as depression or anxiety, we encourage you to seek assistance and contact Beyond Blue Tel:1300 224 636 or Lifeline Tel:13 11 14

Speak your mind freely, but please be sensitive to the feelings and experiences of others - you might not always agree, but you can agree to disagree in a peaceful manner.

Don't use offensive language -if a user is found to be using offensive language during their conversations the moderators reserve the right to edit the thread, without warning.

Don't use all capital letters in your posts - it's considered ‘shouting' online and it makes posts difficult to read.

Give each other the benefit of the doubt - please remember that it is all too easy for the tone and meaning of posts to be misinterpreted. Think carefully before replying to a discussion. it It is important to remember that things written rather than said can feel much stronger, so please bear this in mind when reading other people's messages.

Please respect the moderators - their job is to keep the forum safe and constructive so that everybody gets to have his or her fair say.

Stay on topic - try to focus on the original topic. In particular, don't change subject in the middle of an existing thread - just start a new thread.

Read what's already on the forum before posting - you may be repeating what others have already said or asked.

We want PCFA's Online Community to be a secure and helpful environment for all of the community. So please remember that by using PCFA's Online Community you are agreeing to follow our terms and conditions.