Urologic Oncology:

Prostate MRI 101

Jeffrey K. Mullins, MD

Director Urologic Oncology

CHI Memorial Chattanooga

Urology Associates

January 11, 2020

Disclosures

• No Financial Disclosures

Objective

• Provide a data driven approach to the use of

multi-parametric prostate MRI in the following

situations

• Elevated PSA

• Active Surveillance for Prostate Cancer

• Surgical Planning

MRI and PSA Screening

PSA Screening:

Understanding the Problem

Siegel et al. ACS Cancer Statistics 2019

PSA Screening

Understanding the Problem

False Negatives

Indolent Cancers

Morbidity of Treatment

USPTFS Decision Aid.

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFi

nal/prostate-cancer-screening1?ds=1&s=prostate

PSA Screening

Understanding the Problem

• USPTFS Issues “D” Recommendation for

ALL men (2012)

• Later updated to “C” in 2018

• Results

• Decreased Screening

• Decreased Incidence

• Increasing Mortality?

PSA Screening

Understanding the Problem

Bill-Axelson et al. NEJM 2018

PSA Screening

Solving the Problem

• Solutions to improve PSA screening

• Decrease # of biopsies

• Decrease detection of low risk prostate cancer

• Increase utilization of Active Surveillance

• Decrease Morbidity of Treatment

PSA Screening

MRI Solution Benefits of MRI

1. Reduces Biopsy

2. Decreases Detection of Indolent Prostate Cancer

3. Increases Detection of Significant Prostate Cancer

Kasivisvanathan et al. NEJM 2018

Ahmed et al. Lancet 2017

JAMA Netw Open 2019

MP-MRI for Elevated PSA

Important Caveat

FALSE NEGATIVE RATE

(1 – Sensitivity)

10 – 20% for Gleason ≥

3+4=7

Ahmed et al. Lancet 2017

MR-MRI

Important Caveat

Negative Predictive Value Of MRI1. PSA Density <0.07 = 86.52. PSA Density 0.07 – 0.15= 88.93. PSA Density > 0.15 = 66.9

Distler et al. Jurol 2017

MR-MRI for Elevated PSA

Take Home Points

Guideline Based Practice supported by 3 Trials

(Level 1 Evidence)

NCCN Guidelines on prostate cancer early detection. 2018

MR-MRI for Elevated PSA

Take Home Points

WE CANNOT COMPLETELY RELY ON MRI FOR EVALATION OF

ELEVATED PSA!!

However….

MP-MRI for Elevated PSA

What We Do

• MP-MRI First

• Prostate Biopsy if

• PIRADS 3-5 Lesion

• PSA Density >0.15 and negative MRI

• PSA continues to rise despite negative MRI

• Biopsy Technique

• Targeted (2- 4 cores) Fusion Biopsy

• Systematic Sampling (6 -12 cores)

• Transperineal Fusion Biopsy (First in TN)

MR-MRI for Elevated PSA

Take Home Points

Rosenkrantz et al. JUrol 2016

MRI and Active Surveillance

MP-MRI and Active Surveillance:

Safe to Enter?

Compared with men without an MRI lesion, a significant increase in biopsy reclassification was noted for men with

a MRI lesion (40 vs 12.5%, P = 0.04).

Mullins et al. BJU Int 2013

MP-MRI and Active Surveillance:

Safe to Continue?

MP-MRI and Active Surveillance:

Safe to Continue?

Significant # of upgrades were missed using either only Systematic or Targeted Biopsies

Jayadevan. JAMA Netw Open 2019

MR-MRI and Active Surveillance

Conclusions

• Important in choosing ideal AS candidates

(along with other factors)

• Important in detecting upgrading

• Not a stand-alone tool for surveillance. Biopsy

(systematic + targeted still needed)

MRI and Surgical Planning

MP-MRI and Surgical Planning:

My Preference:MRI for every surgical patient

Mehralivand et al. Radiology 2019

MRI and Surgical Planning

Conclusions and Recommendations

• MRI is a valuable tool in the evaluation of

elevated PSA and Prostate Cancer

• Urology Referral still recommended for

elevated PSA

• ALL Active Surveillance patients should be

followed by Urologist

THANK YOU!