Prostate cancer diagnostics: innovative imaging in case of multiple negative biopsies

According to international guidelines, a primary set of TRUS-guided systematic biopsy should consist of 10-12 tissue samples. If a clinical suspicion of a prostate carcinoma persists, a secondary biopsy session should also involve 10-12 samples. However, if there still is a clinical suspicion of prostate cancer is there a role for innovative imaging guided biopsies? The available innovative imaging techniques range from MRI, Doppler techniques with and without contrast agents, a renaissance of elastography to computer-assisted evaluation of TRUS signal information. All of these methods attempt to make more specific statements on the imaged tissue. Before routine clinical use, a review of the literature is recommended to be able to differentiate between the different methods. Sophisticated modern MRI techniques allow for excellent high-resolution prostate imaging. However, MRI guided biopsies so far are not routine practice and are not recommended in urological guidelines. A literature review reflects differences in stage of development, biopsy performance and clinical validity of the different imaging modalities. Elastography, contrast imaging and C-TRUS/ANNA guided biopsies have been investigated in clinical trails suggesting possible benefits over additional systematic random biopsies alone. Because of the differences in design and clinical maturity of the innovative imaging methods, it is essential to be able to inform the patients about individual evidence-based performance prior to its clinical utilization. The ideal time for innovative imaging techniques seems to be in patients with multiple series of negative systematic biopsies possibly leading to a more specific PCa detection. However, patients often ask for a qualitative diagnostic approach right from the beginning. This should only be performed after educating the patient on the experimental and 'non-guideline-conform' character of such a proceeding.