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Zattoni F, Fasulo V, Kasivisvanathan V, Kesch C, Marra G, Martini A, Falagario U, Soeterik T, van den Bergh R, Rajwa P, Gandaglia G. Enhancing Prostate Cancer Detection Accuracy in Magnetic Resonance Imaging-targeted Prostate Biopsy: Optimizing the Number of Cores Taken. EUR UROL SUPPL 2024; 66:16-25. [PMID: 39027654 PMCID: PMC11254588 DOI: 10.1016/j.euros.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/20/2024] Open
Abstract
Background and objective The shift toward targeted biopsy (TBx) aims at enhancing prostate cancer (PCa) detection while reducing overdiagnosis of clinically insignificant disease. Despite the improved ability of TBx in identifying clinically significant PCa (csPCa), the optimal number and location of targeted cores remain unclear. This review aims to assess the optimal number of prostate biopsy magnetic resonance imaging (MRI)-targeted cores to detect csPCa. Methods A narrative literature search was conducted using PubMed, focusing on studies published between January 2014 and January 2024, addressing factors influencing targeted core numbers during prostate biopsy. The search included both retrospective and prospective studies, prioritizing those with substantial sample sizes and employing terms such as "prostate biopsy", "mpMRI", "core number", and "cancer detection". Key findings and limitations Two biopsy cores identified csPCa in 55-65% of cases. This detection rate improved to approximately 90% when the number of cores was ≥5. The inclusion of perilesional and systematic biopsies could maximize the detection of csPCa (from 10% to 45%), especially in patients under active surveillance or with prior negative biopsy results, although there is an increase in the overdiagnosis of indolent tumors (from 4% to 20%). Transperineal software-assisted target prostate biopsy may enhance cancer detection, particularly for tumors located at the apex/anterior part of the prostate. Increasing the number of TBx cores may incrementally raise the risk of complications (by 2-14% with each added core) and result in severe pain and significant discomfort for up to 17% and 25% of TBx patients, respectively. However, the overall rate and severity of these complications remain within acceptable limits. Conclusions and clinical implications The optimal number of cores for targeted prostate biopsies should balance minimizing sampling errors with effective cancer detection and should be tailored to each patient's unique prostate characteristics. Up to five cores per MRI target may be considered to enhance the detection of csPCa, with adjustments based on factors such as prostate and lesion volume, Prostate Imaging Reporting and Data System, biopsy techniques, complications, patient discomfort, and anxiety. Patient summary In this report, we found that increasing the number of biopsy cores up to ≥5 improves the detection rates of significant prostate cancer significantly to around 90%. Although inclusion of nearby and systematic biopsies enhances detection, increasing the biopsy count may lead to higher risks of complications and indolent tumors. A customized biopsy approach based on multiple variables could be helpful in determining the appropriate number of targeted biopsies on a case-by-case basis.
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Affiliation(s)
- Fabio Zattoni
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Department of Medicine - DIMED, University of Padua, Italy
| | - Vittorio Fasulo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Veeru Kasivisvanathan
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Claudia Kesch
- Department of Urology, University Hospital Essen, Essen, Germany
| | - Giancarlo Marra
- Department of Surgical Sciences, Division of Urology, University of Turin and Città della Salute e della Scienza, Turin, Italy
| | - Alberto Martini
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Ugo Falagario
- Department of Urology, University of Foggia, Foggia, Italy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Timo Soeterik
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Giorgio Gandaglia
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - EAU-YAU Prostate Cancer Working Party (PCa-WP)
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Department of Medicine - DIMED, University of Padua, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Urology, IRCCS Humanitas Research Hospital, Milan, Italy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Urology, University Hospital Essen, Essen, Germany
- Department of Surgical Sciences, Division of Urology, University of Turin and Città della Salute e della Scienza, Turin, Italy
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
- Department of Urology, University of Foggia, Foggia, Italy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Medical University of Silesia, Zabrze, Poland
- Unit of Urology/Division of Oncology, Urological Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
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Berridge C, Omer A, Lopez F, Bryant RJ, Lamb AD. Perspectives on technology - prostate cancer: is local anaesthetic transperineal prostate biopsy really better than transrectal biopsy? BJU Int 2024; 134:166-174. [PMID: 38584582 DOI: 10.1111/bju.16349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
For many years, transrectal ultrasound-guided (TRUS) prostate biopsies have been performed to establish a histological diagnosis of prostate cancer. This has been the recommended standard of care procedure, but has always carried risks, in particular the risk of post-procedural sepsis, and the associated antibiotic burden and risk of development of antibiotic resistance. Transperineal (TP) prostate biopsies performed under local anaesthetic (LA) have been proposed as a possible solution to these issues, with potentially lower infectious complications, and avoidance of need for antibiotic prophylaxis. The European Association of Urology produced guidance in 2023 with 'weak' recommendations in favour of LATP biopsy as a new standard of care, citing its safety profile. Both the National Institute for Health and Care Excellence in the UK, and the American Urological Association in the United States, have concluded for now that the body of evidence is inadequate and not offered a similar recommendation. We discuss the available evidence, pros and cons of each technique, and the status of current trials in the field. We believe that clinical equipoise remains necessary, given the disparity in national and international guidelines highlighting the need for large randomised controlled trials to answer the question: is LATP biopsy really better than TRUS biopsy?
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Affiliation(s)
- Christopher Berridge
- Department of Urology, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Coventry, UK
| | - Altan Omer
- Department of Urology, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Coventry, UK
| | - Francisco Lopez
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Richard J Bryant
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alastair D Lamb
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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3
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Zattoni F, Rajwa P, Miszczyk M, Fazekas T, Carletti F, Carrozza S, Sattin F, Reitano G, Botti S, Matsukawa A, Dal Moro F, Karnes RJ, Briganti A, Novara G, Shariat SF, Ploussard G, Gandaglia G. Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Prostate Biopsy: A Systematic Review and Meta-analysis of Prospective Studies. Eur Urol Oncol 2024:S2588-9311(24)00182-2. [PMID: 39095298 DOI: 10.1016/j.euo.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/28/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND OBJECTIVE The benefits of the detection of clinically significant prostate cancer (csPCa) and safety of magnetic resonance imaging (MRI)-targeted transperineal (TP) prostate biopsy (TP-Tbx) versus transrectal (TR) approaches are still a matter of debate. This review aims to compare the efficacy and safety of TP-Tbx and MRI-targeted TR biopsy (TR-Tbx). METHODS A systematic literature search was performed in PubMed/Medline, Scopus, and Web of Science to identify records of prospective randomized controlled trials (RCTs) comparing TP-Tbx and TR-Tbx published until May 2024. The primary outcomes included detection rates of csPCa (International Society of Urological Pathology [ISUP] ≥2) and rates of complications. KEY FINDINGS AND LIMITATIONS Three RCTs (PREVENT, ProBE-PC, and PERFECT) met the inclusion criteria. The TR technique was commonly administered with antibiotic prophylaxis to mitigate infection risks or after a rectal swab. No difference was found between TP-Tbx and TR-Tbx in terms of either csPCa (odds ratio [OR] 0.9, 95% confidence interval [CI]: 0.7-1.1) or ISUP 1 prostate cancer (PCa; OR 1.1, 95% CI: 0.8-1.4) detection. Postprocedural infection (OR 0.8, 95% CI: 0.4-1.8), sepsis (OR 0.6, 95% CI: 0.1-4.5), and urinary retention rates (OR 0.5, 95% CI: 0.1-1.6) were similar. Pain during the TP approach was slightly higher than during the TR approach, but after 7 d of follow-up, the differences between the two approaches were minimal. Variations in biopsy numbers per patient, patient selection, use of 5-alpha reductase inhibitors, needle sizes, TP techniques, and pain scores (reported in only one RCT), along with the multicenter nature of RCTs, limit the study. CONCLUSIONS AND CLINICAL IMPLICATIONS TP-Tbx and TR-Tbx show similar results in detecting PCa, with comparable rates of infections, urinary retention, and effectiveness in managing biopsy-associated pain. TP-Tbx can safely omit antibiotics without increasing infection risk, unlike TR-Tbx. The tendency to exclude from practice TR-Tbx with prophylactic antibiotics due to infection concerns could be moderated; however, the directionality of some key outcomes, as infections and sepsis, favor the TP approach despite a lack of statistical significance. PATIENT SUMMARY There were no significant differences in the prostate biopsy approaches (transperineal [TP] vs transrectal [TR]) for prostate cancer detection and complications. However, the MRI-targeted TP prostate biopsy approach may be advantageous as it can be performed safely without antibiotics, potentially reducing antibiotic resistance.
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Affiliation(s)
- Fabio Zattoni
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy; Department of Medicine - DIMED, University of Padua, Padua, Italy.
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Marcin Miszczyk
- Collegium Medicum - Faculty of Medicine, WSB University, Dąbrowa Górnicza, Poland
| | - Tamás Fazekas
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Filippo Carletti
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | - Salvatore Carrozza
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | - Francesca Sattin
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | - Giuseppe Reitano
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | - Simone Botti
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | - Akihiro Matsukawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Fabrizio Dal Moro
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | | | - Alberto Briganti
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giacomo Novara
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | | | - Giorgio Gandaglia
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
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Mussi TC, Stanzione A, Tirumani SH, Wu CJ. The Global Reading Room: A Patient With a Benign MRI-Targeted Biopsy of a PI-RADS Category 4 Lesion. AJR Am J Roentgenol 2024:1-2. [PMID: 37791732 DOI: 10.2214/ajr.23.30299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Affiliation(s)
- Thaís C Mussi
- Department of Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Arnaldo Stanzione
- Department of Advanced Biomedical Sciences, University of Naples "Federico II," Naples, Italy
| | - Sree Harsha Tirumani
- Department of Radiology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Chen-Jiang Wu
- Department of Radiology, First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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5
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Schroeder DW, Foster BR, Young DJ, Coakley FV. Targeted biopsy of the prostate. Abdom Radiol (NY) 2024:10.1007/s00261-024-04452-z. [PMID: 38976055 DOI: 10.1007/s00261-024-04452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/21/2024] [Accepted: 06/08/2024] [Indexed: 07/09/2024]
Abstract
Diagnostic multiparametric MRI of the prostate has steadily evolved over the last three decades and can now reliably depict the dominant tumor in most men with prostate cancer. In response, several methods of targeted biopsy to direct tissue sampling of suspected tumor foci seen at multiparametric MRI have been developed and successfully tested in recent years, including software-assisted MRI-ultrasound (US) fusion biopsy and direct MRI-guided in-bore biopsy. These advances are leading to a sea change in the approach to prostate cancer diagnosis, with the traditional approach of blind systematic biopsy increasingly being replaced by MRI directed targeted biopsy. This review aims to describe the current status of targeted biopsy, with an emphasis on the relative accuracy of different techniques. The results of several critical large multicenter trials are presented, while unanswered questions that require more research are highlighted.
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Affiliation(s)
- David W Schroeder
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR, 97239, United States
| | - Bryan R Foster
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR, 97239, United States
| | - Daniel J Young
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR, 97239, United States
| | - Fergus V Coakley
- Department of Diagnostic Radiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L340, Portland, OR, 97239, United States.
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6
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Hoeh B, Wenzel M, Humke C, Cano Garcia C, Siech C, Schneider M, Lange C, Traumann M, Köllermann J, Preisser F, Chun FKH, Mandel P. Transition from Transrectal to Transperineal MRI-Fusion Prostate Biopsy Does Not Comprise Detection Rates of Clinically Significant Prostate Cancer at a Tertiary Care Center. Diagnostics (Basel) 2024; 14:1184. [PMID: 38893710 PMCID: PMC11171881 DOI: 10.3390/diagnostics14111184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND A remarkable paradigm shift has emerged regarding the preferred prostate biopsy approach, favoring the transperineal (TP) over the transrectal (TR) approach due to the reduced risk of severe urinary tract infections. However, its impact on the detection of clinically significant prostate cancer (csPCa) remains unclear. MATERIALS AND METHODS We relied on a prospectively maintained tertiary care database to identify patients who underwent either TP or TR prostate biopsy between 01/2014 and 12/2023. Of those, only patients with suspicious magnetic resonance imaging (MRI) PIRADS lesions (Likert-scale: 3,4,5) received MRI-targeted and systematic biopsies. Detection rates of csPCa (International Society of Urological Pathology [ISUP] ≥ 2) were compared between biopsy approach (TP vs. TR) according to index lesion. Subsequently, uni- and multivariable logistic regression models were applied to investigate the predictive status of the biopsy approach within each subcohort. RESULTS Of 2063 patients, 1118 (54%) underwent combined MRI-guided and systematic prostate biopsy and were included in the final cohort. Of those, 127 (11%) and 991 (89%) underwent TP vs. TR. CsPCa rates, regardless of differences in patients' demographics and distribution of index PIRDAS lesions, did not differ statistically significantly and were 51 vs. 52%, respectively (p = 0.8). CsPCa detection rates for PIRDAS-3, PIRADS-4 and PIRADS-5 did not differ and were 24 vs. 23%, 48 vs. 51% and 72 vs. 76% for PIRADS-3, PIRADS-4 and PIRADS-5 subgroups for TP vs. TR, respectively (all p ≥ 0.9) Conclusions: The current results support the available data indicating that TP biopsy approach is comparable to transrectal biopsy approach regarding csPCa detection rates.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Clara Humke
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Cristina Cano Garcia
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Carolin Siech
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC H2X 3E4, Canada
| | - Melissa Schneider
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Carsten Lange
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Miriam Traumann
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Jens Köllermann
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, 60590 Frankfurt am Main, Germany
| | - Felix Preisser
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Felix K. H. Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
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Trecarten S, Sunnapwar AG, Clarke GD, Liss MA. Prostate MRI for the detection of clinically significant prostate cancer: Update and future directions. Adv Cancer Res 2024; 161:71-118. [PMID: 39032957 DOI: 10.1016/bs.acr.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
PURPOSE OF REVIEW In recent decades, there has been an increasing role for magnetic resonance imaging (MRI) in the detection of clinically significant prostate cancer (csPC). The purpose of this review is to provide an update and outline future directions for the role of MRI in the detection of csPC. RECENT FINDINGS In diagnosing clinically significant prostate cancer pre-biopsy, advances include our understanding of MRI-targeted biopsy, the role of biparametric MRI (non-contrast) and changing indications, for example the role of MRI in screening for prostate cancer. Furthermore, the role of MRI in identifying csPC is maturing, with emphasis on standardization of MRI reporting in active surveillance (PRECISE), clinical staging (EPE grading, MET-RADS-P) and recurrent disease (PI-RR, PI-FAB). Future directions of prostate MRI in detecting csPC include quality improvement, artificial intelligence and radiomics, positron emission tomography (PET)/MRI and MRI-directed therapy. SUMMARY The utility of MRI in detecting csPC has been demonstrated in many clinical scenarios, initially from simply diagnosing csPC pre-biopsy, now to screening, active surveillance, clinical staging, and detection of recurrent disease. Continued efforts should be undertaken not only to emphasize the reporting of prostate MRI quality, but to standardize reporting according to the appropriate clinical setting.
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Affiliation(s)
- Shaun Trecarten
- Department of Urology, UT Health San Antonio, San Antonio, TX, United States
| | - Abhijit G Sunnapwar
- Department of Radiology, UT Health San Antonio, San Antonio, TX, United States
| | - Geoffrey D Clarke
- Department of Radiology, UT Health San Antonio, San Antonio, TX, United States
| | - Michael A Liss
- Department of Urology, UT Health San Antonio, San Antonio, TX, United States.
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8
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Lang J, McClure TD, Margolis DJA. MRI-Ultrasound Fused Approach for Prostate Biopsy-How It Is Performed. Cancers (Basel) 2024; 16:1424. [PMID: 38611102 PMCID: PMC11010881 DOI: 10.3390/cancers16071424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
The use of MRI-ultrasound image fusion targeted biopsy of the prostate in the face of an elevated serum PSA is now recommended by multiple societies, and results in improved detection of clinically significant cancer and, potentially, decreased detection of indolent disease. This combines the excellent sensitivity of MRI for clinically significant prostate cancer and the real-time biopsy guidance and confirmation of ultrasound. Both transperineal and transrectal approaches can be implemented using cognitive fusion, mechanical fusion with an articulated arm and electromagnetic registration, or pure software registration. The performance has been shown comparable to in-bore MRI biopsy performance. However, a number of factors influence the performance of this technique, including the quality and interpretation of the MRI, the approach used for biopsy, and experience of the practitioner, with most studies showing comparable performance of MRI-ultrasound fusion to in-bore targeted biopsy. Future improvements including artificial intelligence promise to refine the performance of all approaches.
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Affiliation(s)
- Jacob Lang
- Department of Urology, Weill Cornell Medicine, New York, NY 10068, USA
| | - Timothy Dale McClure
- Department of Urology, Weill Cornell Medicine, New York, NY 10068, USA
- Department of Radiology, Weill Cornell Medicine, New York, NY 10068, USA
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9
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Diamand R, Guenzel K, Mjaess G, Lefebvre Y, Ferriero M, Simone G, Fourcade A, Fournier G, Bui AP, Taha F, Oderda M, Gontero P, Rysankova K, Bernal-Gomez A, Mastrorosa A, Roche JB, Fiard G, Abou Zahr R, Ploussard G, Windisch O, Novello Q, Benamran D, Delavar G, Anract J, Barry Delongchamps N, Halinski A, Dariane C, Benijts J, Assenmacher G, Roumeguère T, Peltier A. Transperineal or Transrectal Magnetic Resonance Imaging-targeted Biopsy for Prostate Cancer Detection. Eur Urol Focus 2024:S2405-4569(24)00047-6. [PMID: 38508895 DOI: 10.1016/j.euf.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/13/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND AND OBJECTIVE A notable paradigm shift has emerged in the choice of prostate biopsy approach, with a transition from transrectal biopsy (TRBx) to transperineal biopsy (TPBx) driven by the lower risk of severe urinary tract infections. The impact of this change on detection of clinically significant prostate cancer (csPCa) remains a subject of debate. Our aim was to compare the csPCa detection rate of TRBx and TPBx. METHODS Patients who underwent magnetic resonance imaging (MRI)-targeted and systematic biopsies for clinically localized PCa at 15 European referral centers from 2016 to 2023 were included. A propensity score matching (PSM) analysis was performed to minimize selection biases. Logistic regression models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). KEY FINDINGS AND LIMITATIONS Of 3949 patients who met the study criteria, 2187 underwent TRBx and 1762 underwent TPBx. PSM resulted in 1301 matched pairs for analysis. Patient demographics and tumor characteristics were comparable in the matched cohorts. TPBx versus TRBx was associated with greater detection of csPCa, whether defined as International Society of Urological Pathology grade group ≥2 (51% vs 45%; OR 1.37, 95% CI 1.15-1.63; p = 0.001) or grade group ≥3 (29% vs 23%; OR 1.38, 95% CI 1.13-1.67; p = 0.001). Similar results were found when considering MRI-targeted biopsy alone and after stratifying patients according to tumor location, Prostate Imaging-Reporting and Data System score, and clinical features. Limitations include the retrospective nature of the study and the absence of centralized MRI review. CONCLUSIONS Our findings bolster existing understanding of the additional advantages offered by TPBx. Further randomized trials to fully validate these findings are awaited. PATIENT SUMMARY We compared the rate of detection of clinically significant prostate cancer with magnetic resonance imaging (MRI)-guided biopsies in which the sample needle is passed through the perineum or the rectum. Our results suggest that the perineal approach is associated with better detection of aggressive prostate cancer.
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Affiliation(s)
- Romain Diamand
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium.
| | - Karsten Guenzel
- Department of Urology, Vivantes Klinikum am Urban, Berlin, Germany
| | - Georges Mjaess
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Yolène Lefebvre
- Department of Radiology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Giuseppe Simone
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alexandre Fourcade
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | - Georges Fournier
- Department of Urology, Hôpital Cavale Blanche, CHRU Brest, Brest, France
| | | | - Fayek Taha
- Department of Urology, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Marco Oderda
- Department of Urology, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Katerina Rysankova
- Department of Urology, University Hospital Ostrava, Ostrava, Czechia; Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava, Czechia
| | | | | | | | - Gaelle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, Grenoble, France
| | - Rawad Abou Zahr
- Department of Urology, La Croix du Sud Hospital, Quint Fonsegrives, France
| | | | - Olivier Windisch
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Quentin Novello
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Daniel Benamran
- Department of Urology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Gina Delavar
- Departement of Urology, Hôpital Cochin, Paris, France
| | - Julien Anract
- Departement of Urology, Hôpital Cochin, Paris, France
| | | | - Adam Halinski
- Department of Urology, Klinika Wisniowa, Zielona Góra, Poland
| | - Charles Dariane
- Department of Urology, Hôpital Européen Georges-Pompidou, Université de Paris, Paris, France
| | - Jan Benijts
- Department of Urology, Cliniques de l'Europe-Saint Elisabeth, Brussels, Belgium
| | | | - Thierry Roumeguère
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Peltier
- Department of Urology, Jules Bordet Institute-Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
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10
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Ploussard G, Barret E, Fiard G, Lenfant L, Malavaud B, Giannarini G, Almeras C, Aziza R, Renard-Penna R, Descotes JL, Rozet F, Beauval JB, Salin A, Rouprêt M. Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Biopsies for Prostate Cancer Diagnosis: Final Results of the Randomized PERFECT trial (CCAFU-PR1). Eur Urol Oncol 2024:S2588-9311(24)00049-X. [PMID: 38403523 DOI: 10.1016/j.euo.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Recent guidelines favor transperineal (TP) prostate biopsies over the transrectal (TR) approach due to a reduced sepsis risk. Yet, evidence from controlled trial comparing both approaches within the MRI-targeted pathway for significant prostate cancer (PCa) detection is lacking. OBJECTIVE To compare the significant PCa detection rate between magnetic resonance imaging (MRI)-targeted TR and TP approaches in biopsy-naïve patients. DESIGN, SETTING, AND PARTICIPANTS In this noninferiority controlled trial, we randomized (ratio 1:1) 270 MRI-positive biopsy-naïve patients. INTERVENTION MRI-targeted TP versus TR biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES The primary outcome was the detection rate of significant PCa (International Society of Urological Pathology [ISUP] ≥2) in MRI-targeted biopsies. Secondary outcomes were any-grade PCa detection, detection on concomitant systematic biopsy, complications, and functional outcomes. RESULTS AND LIMITATIONS Targeted biopsies identified significant PCa in 47.2% of TP and 54.2% of TR participants (-7%, p = 0.6235). On a per-lesion analysis, posterior lesions yielded higher detection rates via TR (59.0% vs 44.3%, p = 0.0443), while anterior lesions were more frequently detected via TP (40.6% vs 26.5%, p = 0.2228). The overall (any grade) cancer detection rate in targeted biopsies was comparable between groups: 71.3% (TP) versus 64.1% (TR; p = 0.2209) with significantly more ISUP 1 cases detected in the TP arm. Adverse events of grade ≥2 were not different between TP (35.7%) and TR (40.5%, p = 0.4256). One TR patient (0.8%) experienced grade 3 sepsis. Quality of life, and urinary and sexual function, as well as pain scores, were comparable between groups. CONCLUSIONS Despite a comparable overall detection rate for any-grade PCa, noninferiority of TP over TR for MRI-targeted biopsies for significant PCa detection was not demonstrated. However, MRI lesion location influenced biopsy route performance, suggesting that a pragmatic approach based on lesion location might enhance significant PCa assessment. PATIENT SUMMARY This trial compared the efficacy and safety of two biopsy approaches for prostate cancer diagnosis. Both approaches seem complementary according to the lesion location.
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Affiliation(s)
| | - Eric Barret
- Institut Mutualiste Montsouris, Paris, France
| | - Gaëlle Fiard
- Grenoble Alpes University Hospital, University Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble, France
| | - Louis Lenfant
- AP-HP - Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | | | | | - Christophe Almeras
- Clinique Capio La Croix du Sud Cabinet d'Urologie, Quint-Fonsegrives, France
| | - Richard Aziza
- Comprehensive Cancer Cancer IUCT-Oncopole, Toulouse, France
| | | | | | | | | | | | - Morgan Rouprêt
- AP-HP - Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
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11
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Turchi B, Lombardo R, Franco A, Tema G, Nacchia A, Cicione A, Pastore AL, Carbone A, Fuschi A, Franco G, Tubaro A, De Nunzio C. Residents and Consultants Have Equal Outcomes When Performing Transrectal Fusion Biopsies: A Randomized Clinical Trial. Curr Oncol 2024; 31:747-758. [PMID: 38392049 PMCID: PMC10887997 DOI: 10.3390/curroncol31020055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/24/2024] Open
Abstract
The aim of our study was to compare the performance of residents vs. consultants in transrectal fusion prostate biopsies (FUS-PBs), as well as patient-reported comfort. Between January 2021 and October 2022, a consecutive series of patients undergoing FUS-PBs were randomized into two groups: (A) FUS-PBs performed by a consultant; (B) FUS-PBs performed by trained residents (>50 procedures). All patients underwent FUS-PBs with 12 systematic cores and 3/6 target cores. The detection rate and number of positive cores in the target lesion were compared between groups, and the patient's discomfort after the procedure was evaluated using the VAS scale. Overall, 140 patients with a median age of 72 years were enrolled. Overall, 69/140 (49.3%) presented prostate cancer and 53/69 (76.8%) presented a clinically significant cancer (Grade Group ≥ 2). Consultants presented a detection rate of 37/70 (52.9%) and residents a detection rate of 32/70 (45.7%) (p > 0.2); the mean number of positive cores in the index lesion was similar in both groups (1.5 vs. 1.1; p > 0.10). In terms of the patients' experiences, the procedure was well tolerated, with a median VAS score of 2 in both groups, with no statistically significant differences. Residents showed satisfactory outcomes in terms of detection rate, procedural time, and patient comfort when performing prostate biopsies. Residents, after adequate training, can safely perform prostate biopsies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Cosimo De Nunzio
- Department of Urology, Sapienza University of Rome, 00100 Rome, Italy; (B.T.); (R.L.); (A.F.); (G.T.); (A.N.); (A.C.); (A.L.P.); (A.C.); (A.F.); (G.F.); (A.T.)
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12
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Zambon A, Nguyen TA, Fourcade A, Segalen T, Saout K, Deruelle C, Joulin V, Tissot V, Doucet L, Fournier G, Valeri A. Which protocol for prostate biopsies in patients with a positive MRI? Interest of systematic biopsies by sectors. Prostate Cancer Prostatic Dis 2023:10.1038/s41391-023-00770-3. [PMID: 38114598 DOI: 10.1038/s41391-023-00770-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Current prostate biopsy (PBx) protocol for prostate cancer (PCa) diagnosis is to perform systematic biopsies (SBx) combined with targeted biopsies (TBx) in case of positive MRI (i.e. PI-RADS ≥ 3). To assess the utility of performing SBx in combination with TBx, we determined the added value of SBx brought to the diagnosis of PCa according to their sextant location and MRI target characteristics. METHODS In our local prospectively collected database, we conducted a single-center retrospective study including all patients with a suspicion of PCa, who underwent transrectal ultrasound-guided (TRUS) prostate biopsies (PBx) with a prior MRI and a single lesion classified as PI-RADS ≥ 3. We have characterized the SBx according to their location on MRI: same sextant (S-SBx), adjacent sextant (A-SBx), ipsilateral side (I-SBx) and contralateral side (C-SBx). The added value of SBx and TBx was defined as any upgrading to significant PCa (csPCa) (ISUP ≥2). RESULTS 371 patients were included in the study. The added value of SBx was 10% overall. Regarding the lesion location and the SBx sextant, the added value of SBx was: 5.1% for S-SBx, 5.4% for A-SBx, 4.9% for I-SBx and 1.9% for C-SBx. The overall added value of SBx was 6.8% for PI-RADS 3 lesions, 14% for PI-RADS 4 lesions and 6.7% for PI-RADS 5 lesions (p = 0.063). The added value of SBx for contralateral side was 1.9% (2/103), 3.1% (5/163) and 0% (0/105) for PI-RADS 3, PI-RADS 4 and PI-RADS 5 lesions, respectively (p = 0,4). The added value of SBx was lower when the number of TBx was higher (OR 0.57; CI 95% 0.37-0.85; p = 0.007). CONCLUSIONS Our results suggest that the utility of performing SBx in the contralateral lobe toward the MRI lesion was very low, supporting that they might be avoided.
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Affiliation(s)
- A Zambon
- Urology Department, Brest University Hospital, Brest, France.
| | - T-A Nguyen
- Urology Department, Brest University Hospital, Brest, France
- LaTIM-UMR 1101, INSERM, EFS, Université de Bretagne Occidentale, Brest, France
| | - A Fourcade
- Urology Department, Brest University Hospital, Brest, France
| | - T Segalen
- Urology Department, Brest University Hospital, Brest, France
| | - K Saout
- Urology Department, Brest University Hospital, Brest, France
| | - C Deruelle
- Urology Department, Brest University Hospital, Brest, France
| | - V Joulin
- Urology Department, Brest University Hospital, Brest, France
| | - V Tissot
- Radiology Department, Brest University Hospital, Brest, France
| | - L Doucet
- Pathology Department, Brest University Hospital, Brest, France
| | - G Fournier
- Urology Department, Brest University Hospital, Brest, France
- LaTIM-UMR 1101, INSERM, EFS, Université de Bretagne Occidentale, Brest, France
- CeRePP, Paris, France
| | - A Valeri
- Urology Department, Brest University Hospital, Brest, France
- LaTIM-UMR 1101, INSERM, EFS, Université de Bretagne Occidentale, Brest, France
- CeRePP, Paris, France
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