Prostate Magnetic Resonance Imaging and Magnetic Resonance Imaging Targeted Biopsy in Patients with a Prior Negative Biopsy: A Consensus Statement by AUA and SAR.
After an initial negative biopsy there is an ongoing need for strategies to improve patient selection for repeat biopsy as well as the diagnostic yield from repeat biopsies.



As a collaborative initiative of the AUA (American Urological Association) and SAR (Society of Abdominal Radiology) Prostate Cancer Disease Focused Panel, an expert panel of urologists and radiologists conducted a literature review and formed consensus statements regarding the role of prostate magnetic resonance imaging and magnetic resonance imaging targeted biopsy in patients with a negative biopsy, which are summarized in this review.



The panel recognizes that many options exist for men with a previously negative biopsy. If a biopsy is recommended, prostate magnetic resonance imaging and subsequent magnetic resonance imaging targeted cores appear to facilitate the detection of clinically significant disease over standardized repeat biopsy. Thus, when high quality prostate magnetic resonance imaging is available, it should be strongly considered for any patient with a prior negative biopsy who has persistent clinical suspicion for prostate cancer and who is under evaluation for a possible repeat biopsy. The decision of whether to perform magnetic resonance imaging in this setting must also take into account the results of any other biomarkers and the cost of the examination, as well as the availability of high quality prostate magnetic resonance imaging interpretation. If magnetic resonance imaging is done, it should be performed, interpreted and reported in accordance with PI-RADS version 2 (v2) guidelines. Experience of the reporting radiologist and biopsy operator are required to achieve optimal results and practices integrating prostate magnetic resonance imaging into patient care are advised to implement quality assurance programs to monitor targeted biopsy results.



Patients receiving a PI-RADS assessment category of 3 to 5 warrant repeat biopsy with image guided targeting. While transrectal ultrasound guided magnetic resonance imaging fusion or in-bore magnetic resonance imaging targeting may be valuable for more reliable targeting, especially for lesions that are small or in difficult locations, in the absence of such targeting technologies cognitive (visual) targeting remains a reasonable approach in skilled hands. At least 2 targeted cores should be obtained from each magnetic resonance imaging defined target. Given the number of studies showing a proportion of missed clinically significant cancers by magnetic resonance imaging targeted cores, a case specific decision must be made whether to also perform concurrent systematic sampling. However, performing solely targeted biopsy should only be considered once quality assurance efforts have validated the performance of prostate magnetic resonance imaging interpretations with results consistent with the published literature. In patients with negative or low suspicion magnetic resonance imaging (PI-RADS assessment category of 1 or 2, respectively), other ancillary markers (ie PSA, PSAD, PSAV, PCA3, PHI, 4K) may be of value in identifying patients warranting repeat systematic biopsy, although further data are needed on this topic. If a repeat biopsy is deferred on the basis of magnetic resonance imaging findings, then continued clinical and laboratory followup is advised and consideration should be given to incorporating repeat magnetic resonance imaging in this diagnostic surveillance regimen.
Department of Radiology, NYU Langone Medical Center, New York, New York. Electronic address: Andrew.Rosenkrantz@nyumc.org.
Andrew B
AB
Rosenkrantz
Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Sadhna
S
Verma
Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
Peter
P
Choyke
Department of Radiology, University of New Mexico, Albuquerque, New Mexico.
Steven C
SC
Eberhardt
Section of Urology, University of Chicago Medicine, Chicago, Illinois.
Scott E
SE
Eggener
Department of Urology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Krishnanath
K
Gaitonde
Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
Masoom A
MA
Haider
Department of Radiology, Weill Cornell Medical College, New York, New York.
Daniel J
DJ
Margolis
Department of Radiology and Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California.
Leonard S
LS
Marks
Urologic Oncology Branch, National Cancer Institute & NIH Clinical Center, National Institutes of Health, Bethesda, Maryland.
Peter
P
Pinto
Department of Urology, Stanford University School of Medicine, Stanford, California.
Geoffrey A
GA
Sonn
Department of Urologic Oncology, NYU Langone Medical Center, New York, New York.
Samir S
SS
Taneja
D032921:Consensus; D006801:Humans; D061705:Image-Guided Biopsy / Q000379:methods*; D008279:Magnetic Resonance Imaging / Q000379:methods*; D053783:Magnetic Resonance Imaging, Interventional / Q000379:methods*; D008297:Male; D011467:Prostate / Q000000981:diagnostic imaging / Q000473:pathology*; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology*
biopsy; consensus; magnetic resonance imaging; prostatic neoplasms