Department of Radiology, NYU Langone Medical Center, New York, New York.
Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
J Urol. 2016 Dec;196(6):1613-1618. doi: 10.1016/j.juro.2016.06.079. Epub 2016 Jun 16.
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.
初始阴性活检后，仍需要寻找策略来改善重复活检的患者选择，并提高重复活检的诊断率。
作为美国泌尿外科学会（AUA）和腹部放射学会（SAR）前列腺癌疾病重点专家组的合作倡议，一个由泌尿科医生和放射科医生组成的专家小组对文献进行了回顾，并就前列腺磁共振成像和磁共振成像靶向活检在阴性活检患者中的作用达成了共识声明，这些声明在本综述中进行了总结。
专家组认识到，对于之前有过阴性活检的男性有许多选择。如果建议进行活检，前列腺磁共振成像和随后的磁共振成像靶向活检似乎可以比标准重复活检更有效地检测到有临床意义的疾病。因此，当有高质量的前列腺磁共振成像时，对于任何有持续临床前列腺癌怀疑且正在评估重复活检可能性的先前阴性活检患者，都应强烈考虑进行前列腺磁共振成像检查。在这种情况下是否进行磁共振成像检查还必须考虑到任何其他生物标志物的结果以及检查的成本，以及是否可以进行高质量的前列腺磁共振成像解读。如果进行磁共振成像，则必须按照 PI-RADS 版本 2（v2）指南进行检查、解读和报告。需要有经验的报告放射科医生和活检医生来获得最佳结果，并建议将前列腺磁共振成像纳入患者治疗的实践中，以实施质量保证计划来监测靶向活检结果。
接受 PI-RADS 评估类别 3 至 5 的患者需要进行重复活检，并进行图像引导靶向活检。虽然经直肠超声引导下磁共振成像融合或腔内磁共振成像靶向可能对更可靠的靶向定位有价值，特别是对于较小或难以定位的病灶，但在没有这种靶向技术的情况下，认知（视觉）靶向在技术熟练的医生手中仍然是一种合理的方法。应从每个磁共振成像定义的靶标中获得至少 2 个靶向活检核心。鉴于多项研究表明，磁共振成像靶向活检核心可能会遗漏部分有临床意义的癌症，因此必须根据具体情况决定是否同时进行系统采样。然而，只有在质量保证工作已经验证了前列腺磁共振成像解读的性能并与已发表的文献结果一致的情况下，才应考虑仅进行靶向活检。在阴性或低度可疑的磁共振成像（分别为 PI-RADS 评估类别 1 或 2）患者中，其他辅助标志物（即 PSA、PSAD、PSAV、PCA3、PHI、4K）可能有助于确定需要重复系统活检的患者，尽管在这方面还需要更多的数据。如果根据磁共振成像结果推迟重复活检，则建议继续进行临床和实验室随访，并考虑将重复磁共振成像纳入该诊断监测方案。
