Underestimated role of MRI in EAU guidelines on prostate cancer.

Cancer guidelines should be clear, accurate and precise for an optimal diagnosis and management. We have read with great interest the “European Association of Urology (EAU) Guidelines on Prostate Cancer. Part1: Screening, Diagnosis, and Local Treatment with Curative Intent-Update 2013” of Heidenreich et al. [1]. In the chapter 6 Diagnosis and staging of prostate cancer (PCa), the role of imaging and in particular of magnetic resonance imaging (MRI) in the diagnosis of PCa is underestimated. Conventional transrectal ultrasound (TRUS) guided biopsy for the diagnosis of PCa results in high false negative rates because neither targeting nor tracking the spatial location of tumor within the prostate is a part of this routine procedure [2]. The literature data indicate an emerging role for multiparametric MRI (mpMRI) combining T2-weighted imaging, diffusion-weighted imaging, contrast-enhanced MRI, and spectroscopy as the most accurate tool available in targeted biopsies for patients with high PSA levels suggestive of PCa and previously negative biopsies. However, this method is not used as first approach for PCa diagnosis [3], [4] and [5]. MpMRI offers greatly improved imaging of PCa. In particular, mpMRI-US fusion allows the informations to be used to direct needle biopsy under US guidance, with improvement of prostate biopsy in an office-based procedure [2]. In EAU guidelines on PCa the statement “The main tools to diagnose PCa include DRE, serum concentration of PSA, and transrectal ultrasound (TRUS)-guided biopsy” is incomplete. This statement should include the fusion of MRI with US to guide biopsy, as follows: “The main tools to diagnose PCa include DRE, serum concentration of PSA, multiparametric magnetic resonance imaging-ultrasound (mpMRI-US) fusion-guided prostate biopsy and transrectal ultrasound (TRUS)-guided biopsy”. Also, the EAU guidelines state that “Ultrasound-guided transrectal or transperineal laterally directed 18G core biopsy has become the standard way to obtain material for histopathologic examination [6] and [7]”. The correct statement is “mpMRI is the method of choice in the detection of PCa, but it, used in certain centers and in specific patient populations, is expensive and time consuming, requires MRI-compatible equipment, often a general anesthetic, and is not available in most hospitals. Consequently, ultrasound-guided transrectal or transperineal laterally directed 18G core biopsy remains the standard way to obtain material for histopathologic examination [2], [6] and [7]”. In conclusion, to date mpMRI is the more accurate procedure in the detection and staging of PCa. MpMRI-US fusion improves the false negative results of TRUS-guided biopsy.