mpMRI versus bpMRI: why and when should contrast be used?

1. Only perform bpMRI when image quality and radiological readings are of a high standard.
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2. Use high-quality bpMRI only for men for whom biopsy avoidance is a clinical priority, such as for early cancer detection in biopsy-naïve men with a low risk of clinically significant PCa.
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3. Perform mpMRI as the default for men with a high clinical suspicion for significant cancer, where the priority is cancer detection and not biopsy avoidance.
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4. Perform mpMRI for men with persisting clinical suspicion of a significant cancer after a previous negative biopsy (Fig. 1) or after a previous negative bpMRI, for men with previous prostate cancer treatment, and for men suspected to have cancer recurrence.

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1. Voer bpMRI alleen uit wanneer de beeldkwaliteit en de radiologische metingen van een hoog niveau zijn.
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2.2. Gebruik hoogwaardige bpMRI alleen bij mannen voor wie het vermijden van biopsie een klinische prioriteit is, zoals voor vroege opsporing van kanker bij biopsie-naïeve mannen met een laag risico op klinisch significante PCa.
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3. Voer mpMRI uit als standaard bij mannen met een hoog klinisch vermoeden op significante kanker, waarbij de prioriteit ligt bij het opsporen van kanker en niet bij het vermijden van een biopsie.
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4. Voer mpMRI uit bij mannen met aanhoudend klinisch vermoeden van een significante kanker na een eerdere negatieve biopsie (Fig. 1) of na een eerdere negatieve bpMRI, bij mannen na een eerdere behandeling van prostaatkanker, en bij mannen die worden verdacht van het hebben van een kanker recidief

New European Urology Words-of-Wisdom: In-depth analysis of PPV variance at 26 mostly USA centres.

Here is an in-depth analysis of PPV variance at 26 mostly USA centres. Multiple confounders. Remember PPV variance>NPV variance.

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PI-RADS Committee Position on MRI Without Contrast Medium in Biopsy Naive Men with Suspected Prostate Cancer: A Narrative Review

Consensus Statements

(1) Non-contrast MRI represents a potential solution for meeting the increasing demand for MRI in the prostate cancer diagnostic workup. The advantages and disadvantages for operational workflows, radiological assessments, and diagnostic performance must be weighed carefully, considering the likelihood of clinically significant disease being present and the clinical priorities of patients and their referrers. 

(2) Optimal image acquisition and data interpretations are mandatory on the premise that there is likely to be a degradation of non-contrast MRI performance in clinical practice. When non-contrast MRI examinations are undertaken, the proportion of men in the indeterminate category will likely increase.

 (3) Instituting patient recalls should be pursued in cases when there is insufficient image quality and in indeterminate cases, where contrast enhancement may add value to mitigate the risks of decreased MRI reading confidence or inaccurate diagnoses. As an alternative, on-table monitoring of image quality and/or tailoring the need for contrast enhancement according to patient risk can be explored.

(4) Higher quality data are needed before the PI-RADS Committee can make evidence-based recommendations about MRI without contrast as an initial diagnostic approach for prostate cancer work-up. Specifically, there is a need for prospective, comparative studies where biopsy decisions are based upon MRI with and without contrast in different patients. Such studies must define both clinical and operational benefits and identify which patient groups can be scanned successfully without contrast.

(5) The current analysis indicates the need to have both non-contrast MRI and contrast MRI approaches available for prostate cancer diagnosis. Greater evidence is needed to precisely define which patient groups benefit from contrast enhancement and who can safely avoid it.

ESUR/ESUI consensus statements on multi-parametric MRI for the detection of clinically significant prostate cancer: quality requirements for image acquisition, interpretation and radiologists’ training

Key Points:

• Multi-parametric MRI in the diagnostic pathway of prostate cancer has a well-established upfront role in the recently updated European Association of Urology guideline and American Urological Association recommendations.

• Suboptimal image acquisition and reporting at an individual level will result in clinicians losing confidence in the technique and returning to the (non-MRI) systematic biopsy pathway. Therefore, it is crucial to establish quality criteria for the acquisition and reporting of mpMRI.

• To ensure high-quality prostate MRI, experts consider checking and reporting of image quality mandatory. Prostate radiologist must attend theoretical and hands-on courses, followed by supervised education, and must perform regular self- and external performance assessments.

Download Full paper in European Radiology

Download Urologists' Synopsis in European Urology

“Discussing the role of MRI”: Platinum Opinion of Vickers et al and replies.

Platinum Opinion:

Routine Use of Magnetic Resonance Imaging for Early Detection of Prostate Cancer Is Not Justified by the Clinical Trial Evidence

 By: Vickers et al

“The routine use of MRI in-biopsy naïve men for detection of prostate cancer is not justified at present.”

Platinum Priority editorial:

Pre-biopsy MRI: Through the Looking Glass

By: EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel

“There is clear evidence that MRI and TB improve the detection of GG >2 cancer over SB. This higher rate should be interpreted with care. Some detected cancers may correspond to small cancers as a result of stage/grade migration, while others may be aggressive tumours that would otherwise have been missed. The urological community should adapt risk classification to correctly separate the wheat from the chaff in the MRI era. Importantly, growing evidence suggests that MRI, combined with clinical data, could also help in selecting patients with very low-risk cancer who do not need to undergo biopsy at all. The advantages of using pre-biopsy MRI outweigh the suggested harms.” 

Reply of Vickers et al.:

Pre-biopsy MRI: Through the Looking Glass

By: Vickers et al

“Neither the clear and obvious value of MRI in certain clinical indications, such as persistently elevated or rising PSA after a negative biopsy, the “potential” of MRI to reduce unnecessary biopsy nor the possibility that MRI could mitigate overtreatment (pending changes in guide-lines) warrants the routine use of pre-biopsy MRI at the current time.”

Platinum Opinion Counter view:

The Evidence Base for the Benefit of the MRI-directed Prostate Cancer Diagnosis is Sound

By: Padhani et al

“MRI-directed diagnosis of prostate cancer represents a paradigm shift for early detection of clinically relevant prostate cancers based on sound level 1 evidence. Pre-biopsy prostate MRI has a negative predictive value of 91% for noninvasively ruling out GG >2 cancers, with a narrow 95%-CI (88.1–93.1%).

Therefore, the focus of Vickers et al. on the lack of superiority of MRI in ruling in GG >2 cancers miss the point. Also, their statement replying the EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel that the routine use of pre-biopsy MRI at the current time is not warranted conflicts with the level 1A evidence papers that show at least a 30% reduction of unnecessary SB and the above mentioned 91% NPV.”

Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know

1. How to MAKE a good image.

    Video 1

2. How to READ the MRI and WHAT STRUCTURES are visualised.

    Video 2

3. Three ways to BIOPSY Trans-Rectally under MRI-GUIDANCE.

   Video 3

Updates on these papers

Papers on mpMRI

Researcher ID/Publons

Researcher-ID: D-3515-2009

310 publications

Google Schoolar

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