National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, Bristol, United Kingdom.
Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.
JAMA Netw Open. 2019 Aug 2;2(8):e198427. doi: 10.1001/jamanetworkopen.2019.8427.
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.
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.
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."
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 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.
Detection rate of clinically significant and insignificant PCa, number of biopsy procedures, number of biopsy cores taken, and complications.
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.
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.
目前疑似前列腺癌（PCa）患者的诊断途径包括前列腺活检。很大一部分接受活检的患者要么没有 PCa，要么患有不需要治疗的低风险疾病。通过活检前成像，可以避免不必要的活检。
比较系统经直肠超声引导前列腺活检与活检前双参数或多参数磁共振成像（MRI），然后进行靶向活检与或不进行系统活检的性能。
通过 MEDLINE、Embase、Cochrane、Web of Science、临床试验注册处以及最近综述的参考文献列表，检索了截至 2018 年 12 月使用“前列腺癌”和“MRI”术语的随机临床试验。
比较诊断途径的随机临床试验，包括活检前 MRI 与系统经直肠超声引导活检，在有 PCa 临床怀疑的活检初治男性中。
使用随机效应荟萃分析汇总数据。使用修订后的 Cochrane 工具评估偏倚风险。遵循系统评价和荟萃分析的首选报告项目（PRISMA）指南。所有审查阶段均由 2 名审查员进行。
临床显著和非显著 PCa 的检出率、活检程序数量、活检芯数量和并发症。
纳入了 7 项高质量试验（2582 例患者）。与单独系统经直肠超声引导活检相比，MRI 联合或不联合靶向活检可使临床显著 PCa 的检出率提高 57%（95%CI，2%-141%），活检程序数量减少 33%（95%CI，23%-45%），每个程序的活检芯数量减少 77%（95%CI，60%-93%）。一项试验显示疼痛和出血不良事件减少。与单独系统活检相比，在获取靶向芯的基础上对前列腺进行系统抽样并不能显著提高临床显著 PCa 的检出率。
在这项荟萃分析中，与单独系统经直肠超声引导活检相比，活检前 MRI 联合靶向活检与临床显著 PCa 的检出率提高有关，尽管试验之间存在很大的异质性。活检前 MRI 与每个程序的活检芯数量减少和不良事件减少有关，并且在某些个体中可能预防了不必要的活检。该证据支持将活检前 MRI 纳入疑似 PCa 的诊断途径。
