A new technology that fuses MRI with ultrasound images is changing prostate cancer biopsies. Duke doctors are also using it to differentiate prostate cancer that requires aggressive treatment from prostate cancer that requires only active surveillance.
Mark Youngquist of Cary knew something was wrong when his prostate cancer screening results spiked in one year. Although follow up tests indicated he didn’t have cancer, Youngquist wasn’t buying it. He sought a second opinion at Duke where prostate cancer specialists used advanced MRI imaging techniques to detect an aggressive tumor that had started to spread. “If I hadn’t been my own advocate, I don’t know if I would be here today,” 58-year-old Youngquist said.
Blind Biopsies are Standard of Care for Prostate Cancer
Duke is one of only a handful of U.S. medical centers using MRI to detect prostate cancer and guide diagnosis-confirming biopsies. ”I use it routinely but outside of Duke, it’s not routine at all,” said Thomas Polascik, MD, a urologic surgeon and prostate cancer specialist. “It is not considered the standard of care in the community.”
More than 230,000 men are diagnosed with prostate cancer each year, and their journey typically starts with a PSA test. If it finds elevated levels of prostate-specific antigen in the blood, the next step is a digital rectal exam, followed by a biopsy.
Unlike other cancers, which use high-quality images to identify the specific location of a suspicious mass and guide the biopsy, standard prostate cancer biopsies are performed with ultrasound images, which help guide the placement of the needle as tissue samples are taken from throughout the prostate gland. Because ultrasound images cannot always definitively identify cancer in the prostate, these biopsies are often called “blind biopsies,” and sometimes miss a tumor.
MRI-Targeted Prostate Cancer Biopsies
Duke doctors are performing targeted prostate cancer biopsies using new software that combines precise MRI images, which can detect suspicious cancer masses, with ultrasound. “For the first time, we have a 3D road map of the prostate cancer and are able to biopsy the lesions that have the most significance,” says Duke radiologist Rajan Gupta, MD. “We can now take the best of what MRI has to offer, which is high quality imaging that has the ability to differentiate aggressive from non aggressive disease, and combine it with the real-time guidance of ultrasound, which is a fast, office-based procedure.”
The first step is to perform an MRI, which the Duke doctors used to spot a mass on a section of Youngquist’s prostate gland not easily accessed in standard biopsies. The MRI showed the cancer had possibly broken through the capsule that housed his prostate gland, and had the potential to spread to the nerve bundles that control erections.
Youngquist underwent robotic surgery several months later to remove the cancer and surrounding tissue, and now has a clean bill of health.
“Everything fell into place and now I’m cured," Youngquist said. “All the things that are important to a guy about quality of life he gave back to me. At the end of the day, I’m fully functional and feel great.”
MRI Guides Prostate Cancer Treatment Recommendations
Dr. Polascik says the ability to fuse MRI with ultrasound can bring prostate cancer in line with how breast cancer and other cancers are routinely detected and biopsied. “That, for sure, is a game-changer,” he said.
MRI-guided targeted prostate cancer biopsies should “reduce the number of biopsies you take in areas that are negative for cancer,” says Dr. Gupta. “It allows us to get a better understanding of the size and extent of the tumor, and a better sense of what the most aggressive part of the tumor is. That has significant implications for treatment and prognosis.”
The new technology can also help determine who will benefit from active surveillance, and which tumors require more immediate treatment. That is important because aggressive prostate cancer is more difficult to treat and has a lower survival rate.
“We want to make sure we are treating non aggressive prostate cancer appropriately,” says Dr. Gupta. The fusion of MRI and ultrasound “helps us define people who can be on active surveillance and be watched versus people who need more definitive therapy.”