Prostate MRI: Do You Need a Random Biopsy? | Off The Cuff with Mark Moyad, MD

PCRI’s resident moderator, Mark Moyad, MD, MPH, and radiologist Daniel Margolis, MD, discuss the current state of the 12-core prostate biopsy and whether it still has a place in the diagnosis of prostate cancer or whether it should be totally replaced by the MRI targeted biopsy.

Daniel Margolis, MD, is an Associate Professor of Radiology at the Weill Cornell Medical College and an Associate Attending Radiologist at New York-Presbyterian Hospital. He received a B.A. from UC Berkeley in 1992 and his medical degree at the Keck School of Medicine of USC in 1998. He went on to serve his community by completing an internship at the Los Angeles Department of Veterans Affairs. He then finished his residency at the UCLA Medical Center in 2003 and completed a prestigious fellowship at Stanford University sponsored by the National Cancer Institute. Dr. Margolis specializes in abdominal imaging and has co-authored nearly 100 publications, many of which focus on prostate imaging.

0:08 Dr. Moyad asks Dr. Margolis why with all of the improvements in imaging a doctor would order a biopsy without first doing an MRI. Dr. Margolis responds by describing a rigorous international study published recently in the New England Journal of Medicine by University College London. It compared two groups of men: One that used an MRI to determine whether a biopsy was necessary and where to perform it, and another group that did not use the MRI. The study found that the group who used MRI found more significant cancers in their biopsies, less insignificant cancers, and had fewer biopsies overall than the group that did not have MRI. The data was so strong that the study ended early. It is unclear if the FDA will use this study to determine protocol in the United States because they are wary of studies that do not include American patients, however, this study may be an exception because it included so many different countries.

2:25 Dr. Moyad asks Dr. Margolis if the MRI targeted biopsy will completely replace the random 12 core biopsy in the coming years given the strength of the evidence. Dr. Margolis says that this has not happened yet (apart from bureaucratic inefficiencies) because there is a small percentage of men whose cancer will be missed by an MRI. Normally cancer that is missed by an MRI is insignificant, and there is now an attempt to find signs to help predict which men would have significant cancer that does not show up on MRI, but that is still a work in progress. In England, the protocol is already moving towards the exclusive use of MRI targeted biopsies and their strategy for filling this gap is to ensure follow up MRIs. Even if the cancer is still not detectable on the follow-up MRIs, a radiologist will be able to see suspicious changes from the first MRI and can then order a targeted biopsy.

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[TheLastDay-BobReese]

GREAT VIDEO GUYS!!! Yes, yes yes....by all means NO more "Poke and Hope (TRUS 12-Core Biopsies)...do an mpMRI or bpMRI. But you need to ADD a couple of things:
(1.) Make sure you're getting your initial MRI on a 3T (3-TESLA) MRI machine (not 1.5T) so you don't have to use 'contrast' or Gadolinium... NO GADOLINIUM injection at this point is necessary (bpMRI) because the 3T magnet will give you a very accurate v2 PI-RADS score without the contrast. Most MRI's done for initial diagnosis of PC are done without GAD because both mpMRI and bpMRI have similar diagnostic accuracy. If you have a suspicious area, get an "In-bore MRI-targeted Biopsy" from a facility that marries the needle to the MRI image within 1mm accuracy for a very accurate Gleason Score.
(2.) If you get a nasty Gleason score of (4-3 or 4-4 or worse and no penetration of the capsule), DON'T let your physician automatically 'arm-twist' you into a Prostatectomy... check out the high-powered seeds with external beam radiation. Check with your Doc first, but you should know this combo provides the highest cure rate today according to the LATEST clinical studies.


5 Reasons To Say GOOD-BYE forever to the 'Poke n' Hope 12-Core Random TRUS Biopsy:
(1.) It can't tell you if your cancer has become metastatic (moved outside the capsule) which is CRITICAL to know if you have advanced cancer.
(2.) Needlessly annihilates your poor prostate with several random stabs that aren't necessary and might not find anything.
(3.) You can acquire the possibility of a life-threatening serious infection that results from all those unnecessary stabs to your prostate.
(4.) Major cancers are MISSED 30%-40% of the time with just 'Poke n' Hope' random 12-cores.
(5.) If an MRI can show little need for a biopsy, you will have just saved yourself a lot pain, blood, discomfort, time, money, worry, fear and stress at having to undergo a 12-core random biopsy.

[thomasmiccolis]

Hear me on this! INSIST on a MRI BEFORE any biopsy! Insist on a transperineal biopsy if MRI shows a lesion.
Also, examine RATE OF CHANGE in PSA over the years & NOT if it’s simply below 4.0 (and assuming things are just fine!).

[salbers]

When are we going to see PC diagnosis via imaging WITHOUT BIOPSY?

[luismart]

Unfortunately I was only offered a 12 core biopsy. It is a horrible experience. I guess that MRIs are not as lucrative for the doctor.

[hourgmtchannel]

Age 55 with a 3.97 PSA which is up about 1.5 from three years ago and just got my 3T MP MRI results today. The report shows enlargement which was felt on the DRE and "1. no lesion of at least mild suspicion" but the Doc still wants to do a biopsy which is a bit perplexing. After doing some further research, it seems even radiologist are split on the need for follow up biopsy due to the small percentage that may be missed by the reading doctor. I looked up who did mine and he is 8 years out of med school. This is all a bit disappointing as I payed for the MRI to be done first in hopes that if negative findings were produced, it would avoid the 12 point ultrasound guided biopsy but I now get why a biopsy should still be performed.

[NathanLivengood]

Im 51 my psa is 4.1 and i have an appointment in 2 day to see a uroligist. I bleed excessively and always have. Im worried they will want a ramdom biopsy and that because of my profuse bleeding it will lead to longer healing. Normal guys bleed up to a week and a half i read. And then only 25% of those have cancer and only 10% of those are agressive.

[michaelmarshall]

Ime going for biopsy after they found a 11 mm mass on the left hand side of the prostate my main concern is infection.Even tho I've been given 4 lots of anti biotics to take 2 the night before 2 two hours before and after and another later on.My other concern is that when a biopsy is done that cancer can form from that procedure everything seems to be a risk .why can't another MRI be taken 3 months after if its slow growing.

[Phyllis.]

Hello. My husband is scheduled on Wednesday for a biopsy. He did have an MRI first...however, he had to ask for it. Yes, his PSA is crazy high @ 54. But he wanted to be certain they knew exactly where to go with those needles..or whatever they use. He is Pirad 5. I'm very worried!! 😥

[markk]

Is there a follow up video on what has happened over the last 4 years?

[tomslick]

Find a urologist that does perennial biopsys. They are easy. But get a mri first.

[jaimemarun]

Excellent video, I am PIRAD-2 with a big prostate (166 cc) and a PSA of 15 for a Prostate density less than 0.1. I will have a PAE (prostate arteries embolization), but first i will have a biopsy. I have the following questions: a. Probability of cancer? b. Probability of a significant cancer c. Is it necessary to have a biopsy before PAE? d. Is PAE a good option for me? According to this excellent video the best biopsy for me is the systematic... Is it right? Thank you in advance to your answer, I appreciate a lot you recommendations. Best regards

[MrMediterrano]

And what if PSA is slightly elevated, MRI is negative but liquid biopsy indicates the need for a biopsy (e.g. Proclarix score slightly above the cut-off value of 10)? In such a constellation, is it better to get a random biopsy, better to wait 6 months or better to get a PSMA PET/CT scan?

[bassbytes]

Is there any risk of the biopsy causing the cancer to spread outside of the prostate ?

[hectorsambolin]

Is it safe for MRI for patients with aortic valve and left coronary stent for the prostate

[JDinky]

I don't understand why biopsies are so common in prostate cancer, especially when the rich blood drainage into the spinal column from the prostatic plexus of veins occurs. Also from 2020: Tumor-Associated Release of Prostatic Cells into the Blood after Transrectal Ultrasound-Guided Biopsy in Patients with Histologically Confirmed Prostate Cancer

[johnstone]

I am having a mri on a 3T machine with contrast in a few days. My psa has gone from 1.7 to 3.4 over 4 years then fom 3.4 to 6.5 in a year, retested 3 months later and my psa is now 9. Not concerned with the overall number but i am concerned with the psa velocity. I have had and xontinue to have symptoms of an enlarged prostate, more recently i have discomfort. I am banking on the mri to help tell the story and help me with my next steps.

[SuperQdaddy]

Got mri results thru nyu medical...with 5k results of probability cancer...getting a targeted biopsy next week...what choice do I have...my psa is 14 from a 3 last year...hope for best I have no enlarged prostate or major symptoms..I'm 60 years old

[dougg]

I had MRI and he took 12 pops of the prostate . He said he hits the spots found on MRI and the other clear areas. He also said he’s found just as much cancer in the non MRI targeted sites.
Not fun but not bad either.

[markusrose]

When will we have the results from England’s switch to high PSA/negative MRI/no biopsy paradigm?

[kerrynball]

Makes no sense to do it without the MRI. 8 out of 51 of my samples were targeted by the MRI. And they showed way more problems than the rest.