New England Section of the American Urological Association

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Is Gadolinium Really Necessary? Moving from Multiparametric to Biparametric Prostate MRI
Benjamin T. Ristau, MD, MHA, Joseph Testa, MDc, Mary Soyster, MD, Krithika Srikanthan, MD, Marco Molina, MD, Peter C. Albertsen, MD
University of Connecticut, West Hartford, CT

Introduction and Objective: Multiparametric magnetic resonance imaging (mpMRI) has been increasingly incorporated into prostate cancer care. Traditionally, mpMRI (mpMRI) combines T2-weighted (T2W), diffusion-weighted (DWI), and dynamic contrast-enhanced (DCE) sequences. Recent data have challenged routine use of DCE, since these images are only helpful for peripheral zone (PZ) lesions with equivocal DWI findings. Our objective was to determine how often DCE MRI provided actionable information among men undergoing prostate mpMRI.
Methods: We performed a retrospective review of our prostate MRI database from January 2012 through January 2018. PIRADS v2 was used as standard. Patients were characterized as active surveillance (AS), biopsy na´ve (BN), or prior negative biopsy (PNB). DCE sequences were considered actionable if a PZ lesion deemed PIRADS 3 on DWI was upgraded to PIRADS 4 based on contrast-enhancement. Cost data were obtained from the Medicare Physician Fee Schedule Search.
Results: 153 patients (124 AS, 15 BN, 14 PNB) were included. Median age was 64 (IQR 58-64) years and the median PSA was 7.0 (IQR 5.0-11) ng/ml. Median PSA density was 0.15 (IQR 0.11-0.23 ng/ml/cc). One hundred twenty-seven PIRADS 1, four PIRADS 2, five PIRADS 3, fourteen PIRADS 4, and three PIRADS 5 lesions were identified. DCE provided actionable information in 4 men (2.6%). Eliminating DCE sequences would have saved $121.99 per MRI or $18,664.47 for the entire cohort (Table 1) at the risk of needing to repeat MRI imaging in 4 men.
Conclusions: DCE sequences provide little additional information over T2W and DWI in the vast majority of men undergoing prostate MRI. Routine use of DCE may represent low value care.
Table 1. Cost analysis of multiparametric versus biparametric prostate MRI

MRI pelvis with and without contrast$476.75
MRI pelvis without contrast$354.76
Cost differential per MRI$476.75 - $354.76 = $121.99
Cost differential for entire cohort$121.99 * 153 = $18,664.47

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