18F-Choline PET/MRI: The Additional Value of PET for MRI-Guided Transrectal Prostate Biopsies

We assessed the value of fusion F-18-fluoromethylcholine (F-18-choline) PET/MRI for image-guided (targeted) prostate biopsies to detect significant prostate cancer (Gleason >= 3 + 4) compared with standard (systematic 12-core) biopsies. Methods: Within an ongoing prospective clinical trial, hybrid F-18-choline PET/CT and multiparametric 3T MRI (mpMRI) of the pelvis were performed in 36 subjects with a rising prostate-specific antigen for known (n = 15) or suspected 21) prostate cancer before a prostate biopsy procedure. BET and T2-weighted MR volumes of the prostate were spatially, registered using commercially available software. Biopsy targets were selected on the basis of visual appearance on MRI and graded as low, intermediate, or high risk for significant disease. Volumes of interest were defined for MR-identified lesions. F-18-choline uptake measures were obtained from the MR target and a mirrored background volume of interest. The biopsy procedure was performed after registration of real-time transrectal ultrasound with-T2-weighted MR and included image guided cores plus standard cores. Histologic results were determined from standard and targeted biopsy cores as well as prostatectomy specimens (n = 10). Results: Fifteen subjects were ultimately identified with Gleason >= 3 + 4 prostate cancer, of which targeted biopsy identified significantly more (n = 12) than standard biopsies (n = 5; P = 0.002). A total of 52 lesions were identified by mpMRI (19 low, 18 intermediate, 15 high risk), and mpMRI-assigned risk was a strong predictor of final pathology (area under the curve = 0.81; P < 0.001). When the mean F-18-choline target-to-background ratio was used, the addition of F-18-choline to mpMRI significantly improved the prediction of Gleason >= 3 + 4 cancers over mpMRI alone (area under the curve = 0.92; P < 0.001). Conclusion: Fusion PET/MRI transrectal ultrasound image registration for targeted prostate biopsies is clinically feasible and accurate. The addition of F-18-choline PET to mpMRI improves the identification of significant prostate cancer.