Comparison of Multiparametric Magnetic Resonance Imaging and Targeted Biopsy With Systematic Biopsy Alone for the Diagnosis of Prostate Cancer: A Systematic Review and Meta-analysis

Abstract

Importance: The current diagnostic pathway for patients with suspected prostate cancer (PCa) includes prostate biopsy. A large proportion of individuals who undergo biopsy have either no PCa or low-risk disease that does not require treatment. Unnecessary biopsies may potentially be avoided with prebiopsy imaging.

Objective: To compare the performance of systematic transrectal ultrasonography-guided prostate biopsy vs prebiopsy biparametric or multiparametric magnetic resonance imaging (MRI) followed by targeted biopsy with or without systematic biopsy.

Data sources: MEDLINE, Embase, Cochrane, Web of Science, clinical trial registries, and reference lists of recent reviews were searched through December 2018 for randomized clinical trials using the terms "prostate cancer" and "MRI."

Study selection: Randomized clinical trials comparing diagnostic pathways including prebiopsy MRI vs systematic transrectal ultrasonography-guided biopsy in biopsy-naive men with a clinical suspicion of PCa.

Data extraction and synthesis: Data were pooled using random-effects meta-analysis. Risk of bias was assessed using the revised Cochrane tool. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. All review stages were conducted by 2 reviewers.

Main outcomes and measures: Detection rate of clinically significant and insignificant PCa, number of biopsy procedures, number of biopsy cores taken, and complications.

Results: Seven high-quality trials (2582 patients) were included. Compared with systematic transrectal ultrasonography-guided biopsy alone, MRI with or without targeted biopsy was associated with a 57% (95% CI, 2%-141%) improvement in the detection of clinically significant PCa, a 33% (95% CI, 23%-45%) potential reduction in the number of biopsy procedures, and a 77% (95% CI, 60%-93%) reduction in the number of cores taken per procedure. One trial showed reduced pain and bleeding adverse effects. Systematic sampling of the prostate in addition to the acquisition of targeted cores did not significantly improve the detection of clinically significant PCa compared with systematic biopsy alone.

Conclusions and relevance: In this meta-analysis, prebiopsy MRI combined with targeted biopsy vs systematic transrectal ultrasonography-guided biopsy alone was associated with improved detection of clinically significant PCa, despite substantial heterogeneity among trials. Prebiopsy MRI was associated with a reduced number of individual biopsy cores taken per procedure and with reduced adverse effects, and it potentially prevented unnecessary biopsies in some individuals. This evidence supports implementation of prebiopsy MRI into diagnostic pathways for suspected PCa.

Figure 1.. Three Diagnostic Pathways Used to Detect Clinically Significant Prostate Cancer

Flowcharts show, from left to right, a transrectal ultrasonography–guided systematic biopsy alone pathway (control), in which all patients with clinical suspicion of prostate cancer undergo this procedure; a magnetic resonance imaging (MRI) plus targeted biopsy pathway, in which individuals with a positive prebiopsy MRI undergo a transrectal ultrasonography–guided targeted biopsy alone; and an MRI plus targeted and systematic biopsy pathway, in which individuals with positive prebiopsy MRI findings undergo a transrectal ultrasonography–guided targeted biopsy combined with a systematic biopsy. In both hypothetical MRI pathways, individuals with negative MRI findings do not undergo a prostate biopsy procedure.

Figure 2.. Diagram of Inclusion Criteria for Randomized Clinical Trials

Figure 3.. Study Designs of the Included Randomized Clinical Trials

Designs A and B allowed for sufficient data extraction to analyze the systematic biopsy alone pathway vs the magnetic resonance imaging (MRI) plus targeted biopsy pathway. Design C allowed for sufficient data extraction of the systematic biopsy alone and the MRI plus targeted and systematic biopsy pathways, but not the MRI plus targeted biopsy pathway because separate data were not reported for the content of targeted and systematic biopsy prostate cores. Designs D and E allowed for sufficient data extraction of the systematic biopsy alone, MRI plus targeted and systematic biopsy, and MRI plus targeted biopsy pathways, except for the study by Panebianco et al, which did not separately report the content of targeted and systematic biopsy prostate cores. Randomized clinical trials with design E performed targeted biopsies on the basis of digital rectal examination or ultrasonography findings, which may have resulted in an improved prostate cancer detection in the systematic biopsy alone pathway compared with other study designs.

Figure 4.. Detection Rate of Clinically Significant Prostate Cancer

Risk ratios (RRs) are represented by boxes, with the size of each box representing its weight. Horizontal lines represent 95% CIs. Diamonds represent combined-effect estimates and their 95% CIs. MRI indicates magnetic resonance imaging.