Die Echtzeit-MRT/US-Fusionsbiopsie verbessert die Detektionsrate des Prostatakarzinoms nach mehrfach negativen Vorbiopsien

 

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Zusammenfassung

Hintergrund: Patienten mit steigenden PSA-Werten oder positivem Tastbefund in der digital rektalen Untersuchung (DRU) oder einer atypischen mikroazinären Proliferation nach einer negativen Prostatabiopsie erhalten nach den Leitlinien der Europäischen Gesellschaft für Urologie eine Wiederholungsbiopsie. Die geringen Detektionsraten bei der transrektal Ultraschall (TRUS) gestützten Wiederholungsbiopsie zeigen das Dilemma in der Prostatakarzinom (PCa) Diagnostik. Die Kombination des dynamischen TRUS mit den hohen Spezifitäten und Sensitivitäten der Prostata Magnet Resonanz Tomografie (MRT) im Rahmen der sogenannten Echtzeit MRT/US-Fusion, wurde für die Detektion klinisch signifikanter Karzinome evaluiert.

Material und Methoden: Es wurden 128 konsekutive Patienten in der Zeit von Januar 2012 bis August 2013 in die Studie eingeschlossen. Alle Patienten hatten mindestens eine vorausgegangene negative Prostatabiopsie und es bestand weiterhin der klinische Verdacht auf ein PCa. Alle Patienten erhielten zuvor eine multiparametrische 3 Tesla MRT ohne Endorektalspule. Es folgte die Datenfusion der MR-Sequenzen mit folgenden US-Techniken: B-Bild, Farbdoppler, Elastografie, CEUS zur Charakterisierung der MR-suspekten Herde. Diese Herde wurden mittels der genannten US-Techniken mit einem US-Summen-Score bewertet und anschließend gezielt biopsiert. Unmittelbar im Anschluss daran folgte eine systematische 10-fach Biopsie.

Ergebnisse: Unter 128 Patienten konnte in 51 Fällen ein PCa diagnostiziert werden; dies entspricht einer Rate von 39,8%. Von den 51 PCa Patienten konnten klinisch signifikante PCa häufiger durch die MRT/US-Fusion nachgewiesen werden: Gleason Score >7 in 9 von 10 Fällen; Gleason Score=7 in 14 von 20 Fällen und Gleason Score <7 in 13 von 21 Patienten. Eine positive Korrelation zeigte sich zwischen dem US-Summen-Score und dem Gleason Score aller biopsierten Areale und dem PI-RADS Score einer Subgruppe von 65 Patienten, deren MR suspekten Herde mittels PI-RADS klassifiziert wurden. Von insgesamt 51 PCa wurden 30 PCa kombiniert durch MRT/US-Fusion und TRUS-Biopsie, 6 PCa durch MRT/US-Fusion allein und 15 PCa durch die TRUS gestützte Biopsie singulär detektiert.

Schlussfolgerung: Die MRT/US-Fusion erhöht die Detektionsrate in zuvor negativ biopsierter Patienten. Insbesondere Tumoren mit einem Gleason Score ≥ 7 sind nahezu ausschließlich durch die MRT/US-Fusionsbiopsie detektiert und biopsiert worden.

Abstract

Background: According to the guidelines of the European Association of Urology (EAU) on prostate cancer (PCa) in 2013, patients with increasing prostate-specific antigen (PSA) levels, suspicious digital rectal examination (DRE) or high-grade prostatic intraepithelial neoplasia after negative prostate biopsy (PB) should undergo a repeat biopsy. Low cancer detection rates in the repeat biopsy illuminate the dilemma of the international gold standard of transrectal ultrasound (TRUS) guided PB in the detection of PCa. Our study evaluated the combination of TRUS and prostate magnetic resonance imaging (MRI) and its reported high sensitivities and high specificities by using real-time MRI/US fusion-guided biopsy. The detection of clinically significant PCa was investigated.

Material and Methods: 128 consecutive patients in the period of January 2012 to August 2013 were included. All patients had at least one TRUS-guided biopsy with negative findings and the clinical indication for a systematic re-biopsy. Prior to the MRI/US fusion all patients underwent a 3 Tesla prostate MRI without endorectal coil. The MRI data were uploaded to a modern US system. The B-mode, power-mode, elastography and CEUS imaging were used to classify the suspicious lesions from the MRI on a scale of 0–3 and a US sum score was calculated. The lesion was consecutively biopsied by real-time MRI/US fusion followed by a systematic 10 core biopsy.

Results: Among 128 patients 51 PCa could be detected (39.8%). From these 51 PCa cases, clinically significant PCa was detected by MRI/US fusion-guided biopsy as follows: Gleason score >7 in 9 of 10 patients; Gleason score=7 in 14 of 20 patients and Gleason score <7 in 13 of 21 patients. A positive correlation was shown between the US sum score and the associated PI-RADS score in 65 patients in whom lesions were classified by PI-RADS. A positive correlation was further shown between the US sum score and the Gleason score of all suspicious and biopsied lesions. MRI/US fusion and TRUS-guided biopsy combined, detected 30 of 51 PCa; 6 of 51 PCa were detected by MRI/US fusion alone and 15 of 51 PCa by conventional TRUS-guided biopsy alone.

Conclusion: Real-time MR/US fusion increases detection rates of PCa in patients undergoing repeat biopsy. Especially, clinically significant PCa with a Gleason score ≥ 7 were almost exclusively detected by MR/US fusion-guided biopsy.

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