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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EMultiparametric magnetic resonance imaging (MRI) enhances the detection of prostate cancer, patient selection for prostate biopsy, and definition of biopsy targets. It has a high sensitivity for detecting high-grade tumors, although low-grade tumors are often not detected. This article discusses the use of prebiopsy MRI and MRI-targeted biopsy, fusion biopsy, and fused MRI\/ultrasound systems.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ereproductive cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eultrasonography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emagnetic resonance imaging\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EMultiparametric (MP) magnetic resonance imaging (MRI) enhances the detection of prostate cancer, patient selection for prostate biopsy, and definition of biopsy targets. It has a high sensitivity for detecting high-grade tumors, although low-grade tumors are often not detected. The use of prebiopsy MRI and MRI-targeted biopsy for negative biopsies and active surveillance is increasingly accepted by urologists, and its value in biopsy-na\u00efve patients is being evaluated, stated Andrew Rosenkrantz, MD, New York University Langone Medical Center, New York, New York, USA.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EOne MRI-targeted approach fuses MRI and ultrasound (US) images of the prostrate in real time using specialized software. In the fusion biopsy (FB), US guidance of the needle to the MRI lesion is achieved via a mechanical semirobotic arm or freehand scanning with electromagnetic navigation, depending on which approved fusion system is used. The FB approach is becoming increasingly used within the field, stated Dr Rosenkrantz. Nonetheless, the visual estimation method and the direct in-bore method are also used, and evidence supports the benefit of all of these methods over standard systematic biopsy (SSB); few data compare the 3 targeting methods with one another.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EUrologists familiar with US most commonly perform FB in their clinic, which is conducted after a radiologist performs and interprets an MP-MRI and a biopsy planning session is completed. The planning session includes segmentation of the prostate boundary by the radiologist or technologist, annotation of the MRI targets, and loading of the MRI-based biopsy plan into the fusion US system.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThe ability of FB to better detect and classify prostate cancer was shown in a study of 195 men with negative transrectal US biopsies [Vourganti S et al. \u003Cem\u003EJ Urol.\u003C\/em\u003E 2012]. The study found that 39% of patients had a higher Gleason score (GS) as defined by FB than by SSB, and that 12 of 21 cases of GS \u2265 8 cancer were detected by FB but not by SSB. Another study, conducted by Dr Rosenkrantz and his colleagues, compared FB against SSB and visual-targeted biopsy (VTB) in 125 patients [Wysock JS et al. \u003Cem\u003EEur Urol.\u003C\/em\u003E 2014]. In this head-to-head comparison, 2 different surgeons performed FB and VTB to reduce possible bias by the urologist.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ETumor detection was slightly better with FB than with VTB (32% vs 27%, respectively; \u003Cem\u003EP\u003C\/em\u003E = .137), as was high-grade tumor detection (20% vs 15%; \u003Cem\u003EP\u003C\/em\u003E = .052). The lack of statistical significance may be related to the small sample size, acknowledged Dr Rosenkrantz. Notably, FB performed significantly better than VTB for detecting any histologic abnormality, such as tumor, atypia, and high-grade prostatic intraepithelial neoplasia (77 vs 60 targets, respectively; \u003Cem\u003EP\u003C\/em\u003E = .010). Multivariate analysis revealed that FB may have a particular advantage in small lesions.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn \u0026gt; 600 patients in whom FB and SSB have been compared at Dr Rosenkrantz\u0027s institution, the detection of low-grade tumors was lower with FB than using systematic biopsy at each level of magnetic resonance imaging suspicion score (mSS) from 2 to 5. By contrast, there was a strong association between detection rates of tumors with a GS \u0026gt; 6 and the mSS, with FB detecting significantly more such tumors than systematic biopsy at mSS 4 and 5. According to Dr Rosenkrantz, this supports the use of FB to optimize risk prognosis in prostate cancer patients.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EProstate Imaging Reporting and Data Systems (PI-RADS) classification may be a useful scheme to indicate the level of suspicion on MRI and guide patient selection to optimize the use of FB. For the PI-RADS 1 or 2 category, a significant cancer is unlikely and deferral of biopsy may be considered, while targeted biopsy is usually performed for a PI-RADS 4 or 5. However, for a PI-RADS 3, the risk profile of the patient will likely drive the decision about a targeted biopsy, because the data are not yet clear for this score. In FB, 1 or 2 MRI targets are usually biopsied.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EData from comparison of 2 fused MRI\/US systems (direct in-bore MRI-guided biopsy and MRI\/US fusion targeting), presented by David J. A. Margolis, MD, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA, have shown that both systems provide improved targeting over systematic biopsies with low complication rates.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EIn-bore MRI-guided biopsy can target all locations in about 15 minutes per target and generally requires sedation. Confirmation of targeting is achieved with imaging. MRI\/US fusion targeting uses local anesthesia. Image fusion is accurate to within 3 mm and takes \u0026lt; 30 minutes for 12 core plus targets. Both systems require dedicated hardware and software. Three fusion methods are compared in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16399\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16399\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16399\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EComparison of Fusion Methods\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EWith the mechanical articulated arm method, the prostate is segmented in 1 or 2 planes and then segmentation is refined. A region of interest for each target is selected on each slice and suspicion levels are chosen. Each target is presented with or without guides in a 3D presentation over which a systematic biopsy template can be overlaid. Location of prior positive biopsies can be fused with future biopsy sessions.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EWith electromagnetic tracking, prostate auto-segmentation is supplemented by user refinement. A 6-up view provides coronal maximum intensity projection (MIP), a time-intensity curve, an axial T2 MRI, dynamic contrast-enhanced MRI, apparent diffusion coefficient map, and a diffusion-weighted image. Prostate segmentation on T2 can be overlaid on axial T2 and\/or coronal MIP. An initial slice is chosen to start the 3D segmentation of a target with additional slices added to create a single solid region of interest. The selection of the region of interest in the dynamic contrast-enhanced image reveals the time-intensity curve. At this point, the PI-RADS suspicion level can be assigned and an automatic report generated.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EA software-based MRI\/US fusion targeted biopsy system can detect more clinically significant cancers (median 33.3% vs 23.6%) than would have been missed by using only standard biopsy using fewer cores (median 9.2 vs 37.1 per patient) [Valerio M et al. \u003Cem\u003EEur Urol.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EIt is difficult to determine which system is best because they are all continually undergoing enhancements and direct comparisons should be version specific. When choosing which system to purchase, clinicians will need to consider which one is compatible with the equipment used by most urologists. The choice of fusion package and accompanying software may also influence MRI parameters. It is important to know which one you will be getting before starting hands-on training.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EImprovements are being made for all components of MRI targeting biopsy, including scan techniques, automatic segmentation, and deformable coregistration, all of which improve accuracy. Training is required for radiologists and clinicians. Importantly, 3D processing is reimbursed but image fusing targeting is not.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/53\/22.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlsn2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlsn2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}