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Finally, all published studies were conducted in special-
ised centres. The broad use of mpMRI as a triage test
assumes good interobserver reproducibility. Unfortunately,
interobserver reproducibility of existing scoring systems
remains moderate even with the use of the PI-
RADS v2 score . Studies evaluating on a large scale
the reproducibility of mpMRI findings between expert and
nonexpert centres are currently lacking.
3.6.4. How this review compares with other reviews
Three systematic reviews (including two meta-analyses)
regarding the role of mpMRI in localised PCa have been
published recently . Crucially, all three reviews
focused exclusively on the sensitivity of mpMRI-targeted,
guided, or fusion biopsies in diagnosing overall PCa and
csPCa, using TRUS-guided prostate biopsies as reference
standards. The impact of systematic biopsies on the
outcome was not addressed in any of the reviews, within
either the index test or the reference standard. Our review
had a totally different research question and objective,
focusing on NPV of mpMRI to see if a negative mpMRI can
avoid the need for a prostate biopsy. As MRI-targeted/
guided/fusion biopsies are not relevant if the mpMRI was
negative for cancer, it can be argued that the three reviews
assessed a different index test altogether. As such, we
believe that the findings of this review are novel and unique,
and pave the way for further focused clinical studies.
3.6.5. Strengths and limitations
The current study represents the first systematic review
addressing the role of mpMRI as a triage test before biopsy.
The review elements were developed in conjunction with a
multidisciplinary panel of experts (EAU Prostate Cancer
Guidelines Panel), which included a patient representative,
and the review was performed robustly in accordance with
recognised standards. However, it is limited by the major
heterogeneity of the existing literature in patient popula-
tion, study design, and definitions of positive mpMRI and
csPCa. It highlighted further areas of research that could
help in defining the best use of mpMRI in the early detection
of aggressive PCa in the future.
4. Conclusions
Although mpMRI can detect aggressive PCa with excellent
sensitivity, a definitive conclusion on its role as a triage test
before prostate biopsywill be possible only when three main
issues are addressed. Firstly, because NPV depends on
prevalence, and because overall PCa and csPCa prevalence
was highly variable in the published series, it becomes
mandatory to define the optimal way to pre-evaluate the
risk of csPCa in patients with a suspicion of PCa. Depending
on the risk category, mpMRI could then be used to obviate
biopsies or not. Secondly, there is a need for consensus
definitions of csPCa on biopsy findings to allow interstudy
comparisons. Thirdly, although efforts have been made to
standardise mpMRI technical protocols and interpretation in
the past few years , there is still a crucial need to
improve mpMRI specificity and inter-reader reproducibility.
This systematic review was performed under the
auspices of:
- The European Association of Urology Guidelines Office
Board
- The European Association of Urology Prostate Cancer
Guideline Panel
Author contributions: Olivier Rouvie`re had full access to all the data in
the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Rouvie`re, Mottet, Cornford.
Acquisition of data: Rouvie`re, Moldovan, Van den Broeck, Yuan.
Analysis and interpretation of data: Rouvie`re, Moldovan, Van den Broeck,
Lam.
Drafting of the manuscript: Rouvie`re, Moldovan, Van den Broeck, Lam.
Critical revision of the manuscript for important intellectual content: Bellmunt,
van den Bergh, Bolla, Briers, Van den Broeck, Cornford, Cumberbatch, De
Santis, Fossati, Gross, Henry, Joniau, Lam, Matveev, Moldovan, van der
Poel, van der Kwast, Rouvie`re, Schoots, Wiegel, Mottet.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: Yuan, Sylvester, Marconi.
Supervision: None.
Other: None.
Financial disclosures: Olivier Rouvie`re certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: Bellmunt is a
company consultant for Janssen, Astellas, Pierre Fabre, Genentech,
Merck, Ipsen, Pfizer, Novartis, and Sanofi Aventis. He has received
research support from Takeda, Novartis, and Sanofi, and received travel
grants from Pfizer and Pierre Fabre. Bolla has received company speaker
honoraria from Ipsen and Astellas, honoraria or consultation fees from
Janssen, and fellowship and travel grants from Janssen, AstraZeneca, and
Astellas. Briers has received grant and research support from Ipsen,
European Association of Urology, and Bayer; is an ex officio board
member for Europa UOMO; is an ethics committee and advisory group
member for REQUITE; is a member patient advisory board member for
PAGMI; and is a member of SCA and EMA PCWP. Cornford is a company
consultant for Astellas, Ipsen, and Ferring. He receives company speaker
honoraria from Astellas, Janssen, Ipsen, and Pfizer; participates in trials
from Ferring; and receives fellowships and travel grants from Astellas
and Janssen. De Santis is a company consultant for GlaxoSmithKline,
Janssen, Bayer, Novartis, Pierre Fabre, Astellas, Amgen, Eisai Inc., ESSA,
Merck, and Synthon; has received company speaker honoraria from
Pfizer, Takeda, Sanofi Aventis, Shionogi, Celgene, and Teva OncoGenex;
has participated in trials for Pierre Fabre, Astellas, Exelixis, Bayer, and
Roche; has received fellowship and travel grants from Bayer, Novartis,
Ferring, Astellas, Sanofi Aventis, and Janssen; has received grant and
research support from Pierre Fabre; has received honoraria from
AstraZeneca; and is associated with Amgen. Joniau is a company
consultant for Astellas, Ipsen, Bayer, Sanofi, and Janssen; has received
company speaker honoraria from Astellas, Amgen, Bayer, Sanofi, Janssen,
and Ipsen; has participated in trials for Astellas, Janssen, and Bayer; has
received fellowship and travel grants from Astellas, Amgen, Bayer,
Sanofi, Janssen, Ipsen, and Pfizer; and has received grant and research
support from Astellas, Bayer, and Janssen. Matveev has received
company speaker honoraria from Sanofi and Astellas, has participated
in trials for Astellas, Pfizer and Novartis. Lam is a company consultant for
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