Incremental diagnostic value of targeted biopsy using mpMRI-TRUS fusion versus 14-fragments prostatic biopsy: a prospective controlled study

Inherited risk assessment and its clinical utility for predicting prostate cancer from diagnostic prostate biopsies

BACKGROUND

Many studies on prostate cancer (PCa) germline variants have been published in the last 15 years. This review critically assesses their clinical validity and explores their utility in prediction of PCa detection rates from prostate biopsy.

METHODS

An integrative review was performed to (1) critically synthesize findings on PCa germline studies from published papers since 2016, including risk-associated single nucleotide polymorphisms (SNPs), polygenic risk score methods such as genetic risk score (GRS), and rare pathogenic mutations (RPMs); (2) exemplify the findings in a large population-based cohort from the UK Biobank (UKB); (3) identify gaps for implementing inherited risk assessment in clinic based on experience from a healthcare system; (4) evaluate available GRS data on their clinical utility in predicting PCa detection rates from prostate biopsies; and (5) describe a prospective germline-based biopsy trial to address existing gaps.

RESULTS

SNP-based GRS and RPMs in four genes (HOXB13, BRCA2, ATM, and CHEK2) were significantly and consistently associated with PCa risk in large well-designed studies. In the UKB, positive family history, RPMs in the four implicated genes, and a high GRS (>1.5) identified 8.12%, 1.61%, and 17.38% of men to be at elevated PCa risk, respectively, with hazard ratios of 1.84, 2.74, and 2.39, respectively. Additionally, the performance of GRS for predicting PCa detection rate on prostate biopsy was consistently supported in several retrospective analyses of transrectal ultrasound (TRUS)-biopsy cohorts. Prospective studies evaluating the performance of all three inherited measures in predicting PCa detection rate from contemporary multiparametric MRI (mpMRI)-based biopsy are lacking. A multicenter germline-based biopsy trial to address these gaps is warranted.

CONCLUSIONS

The complementary performance of three inherited risk measures in PCa risk stratification is consistently supported. Their clinical utility in predicting PCa detection rate, if confirmed in prospective clinical trials, may improve current decision-making for prostate biopsy.

MRI/Transrectal Ultrasound Fusion-Guided Targeted Biopsy and Transrectal Ultrasound-Guided Systematic Biopsy for Diagnosis of Prostate Cancer: A Systematic Review and Meta-analysis

Purpose

For men suspected of having prostate cancer (PCa), the transrectal ultrasound (TRUS)-guided systematic biopsy (SB) was performed. MRI/TRUS fusion guided-targeted biopsy (MRI-TB) could enhance PCa detection, allowing sampling of sites at higher risk which were not obvious with TRUS alone. The aim of this systematic review and meta-analysis was to compare the detection rates of prostate cancer by MRI-TB or MRI-TB plus SB versus SB, mainly for diagnosis of high-risk PCa.

Methods

A literature Search was performed on PubMed, Cochrane Library, and Embase databases. We searched from inception of the databases up to January 2021.

Results

A total of 5831 patients from 26 studies were included in the present meta-analysis. Compared to traditional TRUS-guided biopsy, MRI-TB had a significantly higher detection rate of clinically significant PCa (RR=1.27; 95%CI 1.15-1.40; p<0.001) and high-risk PCa (RR=1.41; 95% CI 1.22-1.64; p<0.001), while the detection rate of clinically insignificant PCa was lower (RR=0.65; 95%CI 0.55-0.77; p<0.001). MRI-TB and SB did not significantly differ in the detection of overall prostate cancer (RR=1.04; 95%CI 0.95-1.12; p=0.41). Compared with SB alone, we found that MRI-TB plus SB diagnosed more cases of overall, clinically significant and high-risk PCa (p<0.001).

Conclusion

Compared with systematic protocols, MRI-TB detects more clinically significant and high-risk PCa cases, and fewer clinically insignificant PCa cases. MRI-TB combined with SB enhances PCa detection in contrast with either alone but did not reduce the diagnosis rate of clinically insignificant PCa.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#searchadvanced, CRD42021218475.

Safety and Diagnostic Yield of 68Ga Prostate-specific Membrane Antigen PET/CT Guided Robotic-assisted Transgluteal Prostatic Biopsy

Background Transrectal US-guided biopsy with or without MRI fusion is performed for diagnosing prostate cancer (PCa) but has limitations. Gallium 68 (⁶⁸Ga) prostate-specific membrane antigen (PSMA) PET/CT-guided targeted biopsy has the potential to improve diagnostic yield of PCa. Purpose To evaluate the safety and diagnostic yield of ⁶⁸Ga PSMA PET/CT-guided, robotic-arm assisted transgluteal prostatic biopsy. Materials and Methods In this single-center nonrandomized prospective trial, participants with a clinical suspicion of PCa (serum prostate-specific antigen level > 4 ng/mL) were recruited from January 2019 to September 2020. After whole-body ⁶⁸Ga PSMA PET/CT, participants with PSMA-avid intraprostatic lesions underwent PET-guided transgluteal biopsy by using an automated robotic arm. To assess safety and diagnostic yield, procedure-related complications and histopathologic results were documented. Pain during the procedure was scored by a visual analog scale. Descriptive statistics were applied; qualitative variables were reported in percentages. Results Seventy-eight participants (mean age, 66 years ± 7 [standard deviation]; 36 participants [46%] with prior negative results at transrectal US-guided biopsy) were enrolled. Fifty-six (72%) participants had PSMA-avid lesions (prior negative results at transrectal US-guided biopsy in 22 of 56 [39%]) and underwent targeted biopsy. PCa was confirmed in 54 of 56 (96%) participants, and clinically significant PCa (Gleason score ≥ 7) was confirmed in 24 of 54 (44%). Two participants had nonrepresentative samples that required rebiopsy. All participants experienced pain during the procedure, mild (median visual analog scale score, 1; interquartile range, 1-2) in 36 of 56 (64%) and moderate (median visual analog scale score, 5; interquartile range, 5-6) in 20 of 56 (36%). Postprocedure complications were noted in five of 56 (9%) participants and were minor (hematuria, four participants; hematospermia, one participant; and gluteal pain, two participants). No participant developed a postprocedural infection. Conclusion Transgluteal prostate-specific membrane antigen (PSMA) PET/CT-guided, robotic-targeted prostatic biopsy is safe with a high diagnostic yield of prostate cancer for PSMA-avid lesions. Clinical trial registration no. NCT05022576 © RSNA, 2022.

MRI-targeted prostate biopsy: the next step forward!

Aim

For decades, the gold standard technique for diagnosing prostate cancer was the 10 to 12 core systematic transrectal or transperineal biopsy, under ultrasound guidance. Over the past years, an increased rate of false negative results and detection of clinically insignificant prostate cancer has been noted, resulting into overdiagnosis and overtreatment. The purpose of the current study was to evaluate the changes in diagnosis and management of prostate cancer brought by MRI-targeted prostate biopsy.

Methods

A critical review of literature was carried out using the Medline database through a PubMed search, 37 studies meeting the inclusion criteria: prospective studies published in the past 8 years with at least 100 patients per study, which used multiparametric magnetic resonance imaging as guidance for targeted biopsies.

Results

In-Bore MRI targeted biopsy and Fusion targeted biopsy outperform standard systematic biopsy both in terms of overall and clinically significant prostate cancer detection, and ensure a lower detection rate of insignificant prostate cancer, with fewer cores needed. In-Bore MRI targeted biopsy performs better than Fusion biopsy especially in cases of apical lesions.

Conclusion

Targeted biopsy is an emerging and developing technique which offers the needed improvements in diagnosing clinically significant prostate cancer and lowers the incidence of insignificant ones, providing a more accurate selection of the patients for active surveillance and focal therapies.

Pelvic phased-array mpMRI versus saturation biopsy: a diagnostic performance analysis in men with suspected advanced prostate cancer

Objective: Saturation biopsy is more sensitive than transrectal biopsy in the detection of prostate cancer but is an invasive method and has a risk of overdiagnosis. Multiparametric magnetic resonance imaging (mpMRI) provides imaging and working information of the prostate. The purpose of the study was to compare the performance of pelvic phased-array mpMRI against saturation biopsies in men with suspected advanced prostate cancer considering pathology of the surgical specimen as the reference standard.Materials and methods: Data of men (n = 81) with prostate-specific antigen >10 ng/mL, low free-to-total ratio <0.1, and/or prostate-specific antigen density >0.15 who underwent mpMRI and saturation biopsy prior to radical prostatectomy were reviewed. The mpMRI was characterized as per Prostate Imaging Reporting and Data System v2.1. Gleason scores ≥3 + 4 were considered as prostate cancer. The beneficial score was evaluated for each diagnostic method for the decision-making of prostatectomy.Results: mpMRI was positive in 72 men, while saturated biopsies reported 57 men with positive prostate cancer. The histopathology of the surgical specimen reported prostate cancer in 76 men. mpMRI and saturated biopsies reported 0.934 and 0.737 sensitivities and 0.926 and 0.741 specificities, respectively. mpMRI had cancer detectability between 0.55 and 0.965 diagnostic confidence and saturation biopsies had cancer detectability between 0.85 and 0.952 diagnostic confidence. Above 0.965 and 0.952 diagnostic confidence, mpMRI and saturation biopsies had the risk of overdiagnosis.Conclusions: mpMRI can provide additional information for the detection of prostate cancer before saturation biopsies.Level of Evidence: III.

Endorectal power Doppler/grayscale ultrasound-guided biopsies vs. multiparametric MRI/ultrasound fusion-guided biopsies in males with high risk of prostate cancer: A prospective cohort study

Multiparametric MRI fusion with transrectal ultrasound (mpMRI/TRUS)-guided biopsy has the sensitivity of mpMRI with the practicality of TRUS, but males with no cancerous lesion(s) detected on mpMRI have a considerable remaining risk of cancer. Endorectal power Doppler ultrasound improves the sensitivity of grayscale ultrasound-guided biopsies. The objective of the present study was to evaluate the beneficial effect of endorectal power Doppler/grayscale ultrasound-guided biopsy over that of mpMRI/TRUS-guided biopsy for decision-making regarding prostatectomy in males with a high risk of prostate cancer. Data regarding endorectal power Doppler/grayscale ultrasound-guided biopsies and mpMRI/TRUS-guided biopsies of 1,094 males with elevated specific prostate antigen, were included. Radical prostatectomy was performed in males aged <70 years with Gleason scores ≥3+4 in any one of the biopsy reports. The histopathological data of the surgical specimen of 776 males were included in the analysis. Compared to the histopathology of the surgical specimen, endorectal power Doppler/grayscale ultrasound-guided biopsies had a lower sensitivity (0.930 vs. 1.000; P<0.0001) but mpMRI/TRUS-guided biopsies had the same sensitivity (0.990 vs. 1.000; P=0.02). The accuracy of mpMRI/TRUS-guided biopsies was higher than that of endorectal power Doppler/grayscale ultrasound-guided biopsies (0.944 vs. 0.783). On mpMRI, lesions of 105 subjects (10%) with a Likert scale score of <3 were identified. Among them, 14 subjects (2%) had Gleason scores of ≥3+4 as determined by endorectal power Doppler/grayscale ultrasound-guided biopsies. In addition, 20 (2%) false-positive lesions compared to the histopathological analysis of the surgical specimen were identified from mpMRI/TRUS-guided biopsies. In conclusion, mpMRI/TRUS-guided biopsy was indicated to have a moderate performance and endorectal power Doppler/grayscale ultrasound-guided biopsy had a scant performance for decision-making regarding prostatectomy.

Magnetic Resonance Imaging-targeted Biopsy Versus Systematic Biopsy in the Detection of Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Magnetic resonance imaging (MRI)-targeted prostate biopsy (MRI-TB) may be an alternative to systematic biopsy for diagnosing prostate cancer.

OBJECTIVE

The primary aims of this systematic review and meta-analysis were to compare the detection rates of clinically significant and clinically insignificant cancer by MRI-TB with those by systematic biopsy in men undergoing prostate biopsy to identify prostate cancer.

EVIDENCE ACQUISITION

A literature search was conducted using the PubMed, Embase, Web of Science, Cochrane library, and Clinicaltrials.gov databases. We included prospective and retrospective paired studies where the index test was MRI-TB and the comparator test was systematic biopsy. We also included randomised controlled trials (RCTs) if one arm included MRI-TB and another arm included systematic biopsy. The risk of bias was assessed using a modified Quality Assessment of Diagnostic Accuracy Studies-2 checklist. In addition, the Cochrane risk of bias 2.0 tool was used for RCTs.

EVIDENCE SYNTHESIS

We included 68 studies with a paired design and eight RCTs, comprising a total of 14709 men who either received both MRI-TB and systematic biopsy, or were randomised to receive one of the tests. MRI-TB detected more men with clinically significant cancer than systematic biopsy (detection ratio [DR] 1.16 [95% confidence interval {CI} 1.09-1.24], p<0.0001) and fewer men with clinically insignificant cancer than systematic biopsy (DR 0.66 [95% CI 0.57-0.76], p<0.0001). The proportion of cores positive for cancer was greater for MRI-TB than for systematic biopsy (relative risk 3.17 [95% CI 2.82-3.56], p<0.0001).

CONCLUSIONS

MRI-TB is an attractive alternative diagnostic strategy to systematic biopsy.

PATIENT SUMMARY

We evaluated the published literature, comparing two methods of diagnosing prostate cancer. We found that biopsies targeted to suspicious areas on magnetic resonance imaging were better at detecting prostate cancer that needs to be treated and avoiding the diagnosis of disease that does not need treatment than the traditional systematic biopsy.

The current role of prostate multiparametric magnetic resonance imaging

Prostate multi-parametric magnetic resonance imaging (mpMRI) has shown excellent sensitivity for Gleason ≥7 cancers, especially when their volume is ≥0.5 mL. As a result, performing an mpMRI before prostate biopsy could improve the detection of clinically significant prostate cancer (csPCa) by adding targeted biopsies to systematic biopsies. Currently, there is a consensus that targeted biopsies improve the detection of csPCa in the repeat biopsy setting and at confirmatory biopsy in patients considering active surveillance. Several prospective multicentric controlled trials recently showed that targeted biopsy also improved csPCa detection in biopsy-naïve patients. The role of mpMRI and targeted biopsy during the follow-up of active surveillance remains unclear. Whether systematic biopsy could be omitted in case of negative mpMRI is also a matter of controversy. mpMRI did show excellent negative predictive values (NPV) in the literature, however, since NPV depends on the prevalence of the disease, negative mpMRI findings should be interpreted in the light of a priori risk for csPCa of the patient. Nomograms combining mpMRI findings and classical risk predictors (age, prostate-specific antigen density, digital rectal examination, etc.) will probably be developed in the future to decide whether a prostate biopsy should be obtained. mpMRI has a good specificity for detecting T3 stage cancers, but its sensitivity is low. It should therefore not be used routinely for staging purposes in low-risk patients. Nomograms combining mpMRI findings and other clinical and biochemical data will also probably be used in the future to better assess the risk of T3 stage disease.