Not long after performing an operation, Dr Gopal Gupta wastes no time in expounding on the various benefits of MRI ultrasound fusion biopsies.
“Really, there’s been very little change to the technique of the prostate biopsy,” he explains. However, thanks to a new device, an MRI and ultrasound can be performed silmultaneously, saving patients from experiencing the discomfort of multiple cancer check-ups.
Despite less than 5% of men dying within ten years of diagnosis, prostate cancer is still a cruel disease that robs the patient of their quality of life. Age is the greatest risk factor, as it can strike at any time, meaning that the longer you live, the more you have to get checked; this can be up to once a year for many individuals. Gupta says that, up until recently, check-ups involved multiple visits to the doctor and the use of a contraption called a transrectal ultrasound – all of this is unpleasant and inconvenient for the patient. This method of detection is also not the most reliable technique – so why continue using the process?
The new device improves on this by using software to ‘fuse’ detailed MRI scans with live and real-time ultrasound images of the prostate, which creates a 3D map that doctors can use to pinpoint what part of the prostate may be hiding cancerous cells. Patients that used to need two separate procedures can now have everything done in one session, thus improving the accuracy of finding and monitoring legions.
Dissecting the issues with screening and biopsies
Gupta was part of a scientific research team that worked on these new handheld devices. The MRI ultrasound fusion for lesion targeting is likely to result in the need for fewer, and more accurate, prostate biopsies than the present use of systematic biopsies with ultrasound guidance alone.
This important research stems from the prevalence of prostate cancer and how it is checked for. The current screening test involves measuring the level of prostate-specific antigens (PSA) in a man’s blood, which is then analysed by a laboratory. “We know that there are issues with PSA as a screening test,” states Gupta. “If there’s an indication that a male may have a higher risk of prostate cancer, given a PSA, we would encourage that person to undergo a prostate biopsy.”
Historically, the prostate biopsy has been performed in a doctor’s surgery, where the patient is put under local anaesthesia, so a transrectal ultrasound can be used to enable doctors to visualise the prostate. This gives them a sense of the prostate’s dimensions, but its results have never been particularly clear.
“We don’t use the ultrasound as a diagnostic modality,” explains Gupta. “This is one of the big flaws, as the ultrasound doesn’t have a very good resolution that can determine where the cancer might be.
“What we’re actually using it for is to divide the prostate into six sections, splitting it down the middle into right and left, and then a front, middle and back. We take two random biopsy cores – which are very small slivers of the prostate – and two biopsies from each of these six areas.” Medical staff then test some of these and make their best estimate concerning the cancer’s location and its level of severity.
Developing a better device
This is where some change was needed, as cancer diagnoses were missed and many biopsies were inconclusive. Fortunately, performing a multiparametric MRI is the new diagnostic modality; doctors use technique to take high-resolution and – according to Gupta – “jawdropping” images of the prostate.
“But not only that, it allowed us to get the multiparametric portion of the MRI and to determine areas in the prostate that are suspicious for cancer.”
Armed with this new information, Gupta states that prostate cancer concerns are raised when a patient has an elevated PSA and “maybe a family history too.” He adds, “The aim is to obtain a multiparametric MRI of the prostate; a radiologist will then determine – by using a prostate imaging reporting and data system (PI-RADS) score, which has a scale of one to five – a score for the likelihood of a particular area having cancer on the MRI.
“When radiologists see a 1cm legion on the front of the left side of the prostate, and the PI-RADs score is five, we then know that there is a very high likelihood,” says Gupta. “We, therefore, know that when the centre of the legion is biopsied it will show a significant chance of having prostate cancer.”
Previously, a patient would then have their results scanned in a lab – and this is an area where few developments have come to fruition. If there is an unclear diagnosis, the use of imaging technology still means that the patient will need to have a second test. With the new software component, doctors can now simply compare 3D images that have been produced by the ultrasound and MRI following a biopsy, which could not be done previously.
The ultrasound biopsy probe now has a guide on it that can track when the hand and probe reach a threedimensional space. “So once that happens, you can accurately target the areas of suspicion on the MRI at the same time as the ultrasound,” says Gupta.
Doctors can perform a biopsy on the heart of the legion. “We know with certainty that we’re biopsying the area that was suspicious on the MRI, and this technique that we now call MRI ultrasound fusion biopsy is really a sea change.”
This technology has been adopted very rapidly because urologists understand that it has brought about a big improvement.
“The first clinical adoption derived from a scenario where patients had rising PSA after a negative biopsy. We call this ‘the head scratcher’,” states Gupta. They all had signs of prostate cancer but the biopsy came back negative.
“What do we do at this point?” asks Gupta, who then states that the patient care aspect is the most important in these types of cases. “Traditionally, they would do a repeat biopsy or would say ‘let’s increase a saturation biopsy’ because they may have missed it the first time. This process involves more needles, post-biopsy bleeding, risk of infection and it’s uncomfortable for patients.”
Previously, urologists would perform two separate biopsies, depending on the clarity of the initial MRI results; with the MRI fusion biopsy, some centres saw that there was actually more value in combining these two methods.
Gupta is excited about this change, and says: “You have a patient who has a reason to suspect that they may have cancer, but why should they have an ultrasound biopsy? First of all, there’s no other malignancy that can be biopsied without proper imaging. Not a single one.” He goes on to explain that other types of cancer are checked far more; for example, breast cancer can be detected with a mammogram, and CT scans check for brain cancer and lung cancer, which is found with MRI and PET scans.
So, why should a patient undergo a biopsy if an MRI has not discovered any highly suspicious legions that suggest the individual has cancer? This is a new and radical concept, as it was previously thought to be impossible that a doctor can perform two procedures at once to cut down on the number of biopsies; the technology of the time simply could not cater to implementing this kind of major development. The industry now knows that this can be done, based on an influx of new information.
Another key feature of the new device is its ability to obtain better readings for the progression of less aggressive cancers that require check-ups rather than treatment.
“If you have the radiographic baseline of a particular patient, there is no need to repeat a biopsy every one to two years – you just repeat the MRI to see if there has been any progression of the known cancer,” says Gupta. “That way, you don’t have to conduct a reflexive biopsy, which all men hate. I haven’t come across a man who enjoys a prostate biopsy.”
One of the major barriers to adopting active surveillance is that men want the cancer to be removed entirely, so they do not have to endure humiliating and painful checks – even when the cancer is not really much of a risk to them. “If you’re 55 and we say ‘Well, we can help you reach 85, but you’ll have to have a biopsy every one or two years,’ patients will respond with, ‘Just treat it because I can’t tolerate that’,” Gupta adds.
Bright future for doctors and their patients
The device has restored peace of mind to patients and their doctors by improving the rates at which cancers are not being missed. It also reduces the need for visitation and check-ups, specifically for those that are monitored following the discovery of legions. Doctors also hope to curb the number of other procedures and checks for men through new procedures and methods of checking for malignancy.
Medical teams also experience less stress by using the device, and have more time at their disposal with fewer appointments. In addition, 20–30% of men who were monitored have been relieved of their cancer worries, as they have a better knowledge of what their cells are doing and if they will require medical intervention.
“I’m very excited about this technology and I have no doubt that it’s going to get even better,” states Gupta. With evidence to substantiate this claim, there is no doubt that using these new devices will become the new normal.
