The added value of systematic biopsy in men with suspicion of prostate cancer undergoing multiparametric MRI-targeted biopsy

Value of cognitive fusion targeted and standard systematic transrectal prostate biopsy for prostate cancer diagnosis

ABSTRACT

The aim of this study was to compare the accuracies of cognitive fusion-guided targeted biopsy (TB), systematic biopsy (SB), and combined TB+SB for the detection of prostate cancer (PCa) and clinically significant PCa (csPCa) in males with lesions detected by magnetic resonance imaging (MRI). We conducted a retrospective analysis of individuals who underwent prostate biopsy at Peking University People's Hospital (Beijing, China), with an emphasis on patients with both transrectal TB and SB. The main objective was to determine the precisions of SB, TB, and TB+SB for diagnosing PCa and csPCa. We also evaluated the detection rates of TB, SB, TB+ipsilateral-SB (ipsi-SB), TB+contralateral-SB (contra-SB), and TB+SB for PCa and csPCa in patients with unilateral MRI lesions. We compared the diagnostic yields of the various biopsy schemes using the McNemar's test. A total of 180 patients were enrolled. The rates of PCa detection using TB, SB, and TB+SB were 52.8%, 62.2%, and 66.7%, respectively, and the corresponding rates for csPCa were 46.1%, 56.7%, and 58.3%, respectively. Among patients with unilateral MRI lesions, the PCa detection rates for TB, SB, TB+ipsi-SB, TB+contra-SB, and TB+SB were 53.3%, 64.8%, 65.6%, 61.5%, and 68.0%, respectively. TB+ipsi-SB detected 96.4% of PCa and 95.9% of csPCa cases. These findings suggest that the combination of TB+SB has better diagnostic accuracy compared with SB or TB alone. For patients with unilateral MRI lesions, the combination of TB+ipsi-SB may be suitable in clinical settings.

Does experience change the role of systematic biopsy during MRI-fusion biopsy of the prostate?

PURPOSE

To determine the role of biopsy experience regarding a potential benefit of additional systematic biopsies and fusion failures during MRI-targeted biopsy of the prostate.

SUBJECTS/PATIENTS AND METHODS

We retrospectively evaluated 576 men undergoing transrectal (MRI)-targeted biopsy of the prostate by seven residents in urology between November 2019 and March 2022. Benefit of systematic biopsies (detection of ISUP ≥ 2 PCa (clinically significant PCa (csPCa)) solely in systematic biopsies) and fusion failure (detection of csPCa during systematic biopsies in the area of a reported MRI-lesion and no detection of csPCa in targeted biopsy) were compared by growing biopsy experience levels. Multivariable regression analyses were calculated to investigate the association with benefit of systematic biopsies and fusion failure.

RESULTS

The overall PCa detection rate was 72% (413/576). A benefit of systematic biopsies was observed in 11% (63/576); of those, fusion failure was seen in 76% (48/63). Benefit of systematic biopsies and fusion failure were more common among residents with very low experience compared to highly experienced residents (18% versus 4%, p = 0.026; 13% versus 3%, p = 0.015, respectively). Increasing biopsy experience was associated with less benefit from systematic biopsies (OR: 0.98, 95% CI 0.97-0.99) and less fusion failure (OR: 0.98, 95% CI 0.97-0.99).

CONCLUSIONS

The benefit of systematic biopsies following targeted biopsy decreases with growing biopsy experience. The higher risk of fusion failure among inexperienced residents necessitates systematic biopsies to ensure the detection of csPCa. Further prospective trials are warranted before a targeted only approach can be recommended in routine clinical practice.

A Matched-pair Analysis Comparing Systematic Prostate Biopsy by Conventional Transrectal Ultrasound-guidance Versus Software-based Predefined 3D-Guidance

OBJECTIVE

To compare software-based three-dimensional-guided systematic prostate biopsy (3D-GSB) with conventional transrectal ultrasound-guided systematic biopsy (TGSB) regarding prostate cancer (PCa) detection rates (CDR).

METHODS

In total, 956 patients (200 TGSB patients and 756 3D-GSB patients) without prior positive biopsies and with a prostate-specific antigen value ≤20 ng/ml were eligible for analysis. TGSB and 3D-GSB cases were matched in a 1:1 ratio using propensity score matching with age, prostate-specific antigen, prostate volume, previous biopsy status, and suspicious palpatory finding as confounders. 3D-GSB was conducted with the semi-robotic prostate fusion-biopsy system Artemis. For each patient in both groups, SB was conducted in a similar pattern with 12 cores. All cores in 3D-GSB were automatically planned and mapped on a 3D-model as well as on the real-time transrectal ultrasound imaging. Primary end points were the clinically significant (cs) and overall CDR. Secondary end point was the cancer-positive core rate.

RESULTS

After matching, the csCDR was not significantly different between the 3D-GSB and the TGSB groups (33.3% vs 28.8%, P = .385). Overall CDR was significantly higher for 3D-GSB compared to TGSB (55.6% vs 39.9%, P = .002). 3D-GSB detected significantly more non-significant PCa than TGSB (22.2% vs 11.1%, P = .004). In patients with PCa, the number of cancer-positive SB cores was significantly higher by TGSB (42% vs 25%, P < .001).

CONCLUSION

3D-GSB was associated with a higher CDR than TGSB. However, no significant difference was shown in detection of csPCa between both techniques. Therefore, currently, 3D-GSB does not appear to add value to conventional TGSB.

Systematic Review and Meta-Analysis of Free-Hand and Fixed-Arm Spatial Tracking Methodologies in Software-Guided MRI-TRUS Fusion Prostate Biopsy Platforms

OBJECTIVE

To evaluate the cancer detection rate (CDR) between the 2 dominant spatial tracking methodologies in software-guided MRI-transrectal ultrasound fusion prostate biopsy (SGF-Bx) platforms: fixed-arm and free-hand.

METHODS

We conducted a systematic review and meta-analysis on published primary analyses of prospective trials and cohort studies that enrolled biopsy-naïve patients for SFG-Bx. Inclusion criteria included the use of the Prostate Imaging Reporting & Data System (PI-RADS) v2.0 or later and the targeting of lesions graded as PI-RADS 3 or higher. Random effects models were used to assess the overall prostate cancer (PCa) CDR and the clinically significant prostate cancer (csPCa) CDR for both platforms. csPCa was standardized to a definition of Gleason Grade Group 2 or higher when possible. Subgroup analysis was performed by stratifying studies into the average number of cores taken per lesion.

RESULTS

The PCa CDR was 0.674 for free-hand systems and 0.681 for fixed-arm systems. The csPCa CDR was 0.492 for free-hand systems and 0.500 for fixed-hand systems. There was no significant difference between free-hand and fixed-arm cancer detection rates for both overall PCa (P = .88) and csPCa (P = .90). Subgroup analyses revealed significant PCa CDR and csPCa CDR differences (P < .001) between free-hand and fixed-arm platforms only when 2 cores per lesion were taken, in favor of fixed-arm platforms.

CONCLUSIONS

Fixed-arm platforms performed similarly in cancer detection to free-hand platforms but show a minor benefit on fewer samples. While tracking methodology differences appear subtle, further investigation into the clinical impact of platform-specific features are warranted.

Performance of multiparametric prostate magnetic resonance imaging validated by targeted and systematic transperineal biopsies

Objective

To measure the performance of multiparametric (mp) magnetic resonance imaging (MRI) to identify intraprostatic tumour deposits using a systematic and targeted MR-guided transperineal prostate biopsy technique.

Materials and Methods

Patients underwent a combined systematic and targeted MR-guided transperineal biopsy procedure in the dorsal lithotomy position under general anaesthesia. Systematic biopsies were spaced 10 mm or less apart and additional biopsies targeted any Prostate Imaging-Reporting and Data System (PI-RADS) 3, 4 or 5 lesions identified on mpMRI. Cancer detection rates were calculated on a per patient and per lesion basis.

Results

A total of 125 patients underwent the biopsy procedure. The positive predictive value (PPV) of mpMRI per patient was 59% for any cancer and 49% for Gleason score (GS) ≥ 7 cancer. The negative predictive value (NPV) of mpMRI per patient was 67% for any cancer and 88% for GS ≥ 7 cancer. On a per lesion basis, the PPV of PI-RADS 3 lesions for any and GS ≥ 7 cancer was 24% and 10%. For PI-RADS 4 lesions it was 42% and 32%. For PI-RADS 5 lesions, it was 76% and 70%. MpMRI failed to identify GS ≥ 7 cancer found on systematic biopsy in 22% of patients.

Conclusion

Based on a combination of systematic and targeted transperineal prostate biopsies, mpMRI showed a high NPV and low PPV for GS ≥ 7 cancer on a per patient basis. The PPV of mpMRI on a per lesion basis increased with increasing PI-RADS score. However, there were a significant number of both false positive as well as false negative (mpMRI invisible) areas within the prostate that contained GS ≥ 7 cancer. Therefore, pathologic confirmation using both targeted and systematic mapping biopsy is necessary to accurately identify all intraprostatic tumour deposits.

Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications

Transrectal ultrasound (TRUS) has been an invaluable tool in the assessment of prostate size, anatomy and aiding in prostate cancer (PCa) diagnosis for decades. Emerging techniques warrant an investigation into the efficacy of TRUS, how it compares to new techniques, and options to increase the accuracy of prostate cancer diagnosis. Currently, TRUS is used to guide both transrectal and transperineal biopsy approaches with similar cancer detection rates, but lower rates of infection have been reported with the transperineal approach, while lower rates of urinary retention are often reported with the transrectal approach. Multiparametric MRI has substantial benefits for prostate cancer diagnosis and triage such as lesion location, grading, and can be combined with TRUS to perform fusion biopsies targeting specific lesions. Micro-ultrasound generates higher resolution images that traditional ultrasound and has been shown effective at diagnosing PCa, giving it the potential to become a future standard of care. Finally, high-intensity focused ultrasound focal therapy administered via TRUS has been shown to offer safe and effective short-term oncological control for localized disease with low morbidity, and the precise nature makes it a viable option for salvage and repeat therapy.

Evidence-based guideline recommendations on multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer: A Cancer Care Ontario updated clinical practice guideline

INTRODUCTION

This clinical practice guideline is based on a systematic review to assess the use of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis of clinically significant prostate cancer (csPCa) for biopsy-naive men and men with a prior negative transrectal ultrasound-guided systematic biopsy (TRUS-SB) at elevated risk.

METHODS

The methods of the clinical practice guideline included searches to September of 2020 of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Internal and external reviews were conducted.

RESULTS

The recommendations are:Recommendation 1: For biopsy-naive patients at elevated risk of csPCa, mpMRI is recommended prior to biopsy in patients who are candidates for curative management with suspected clinically localized prostate cancer.- If the mpMRI is positive, mpMRI-targeted biopsy (TB) and TRUS-SB should be performed together to maximize detection of csPCa.- If the mpMRI is negative, consider forgoing any biopsy after discussion of the risks and benefits with the patient as part of shared decision-making and ongoing followup.Recommendation 2: In patients who had a prior negative TRUS-SB and demonstrate a high risk of having csPCa in whom curative management is being considered:- mpMRI should be performed.- If the mpMRI is positive, targeted biopsy should be performed. Concomitant TRUS-SB can be considered depending on the patient's risk profile and time since prior TRUS-SB biopsy.- If the mpMRI is negative, consider forgoing a TRUS-SB only after discussion of the risks and benefits with the patient as part of shared decision-making and ongoing followup.Recommendation 3: mpMRI should be performed and interpreted in compliance with the current Prostate Imaging Reporting & Data System (PI-RADS) guidelines.

An optimized prostate biopsy strategy in patients with a unilateral lesion on prostate magnetic resonance imaging avoids unnecessary biopsies

Purpose:

The introduction of magnetic resonance imaging (MRI)-targeted biopsy (TBx) besides systematic prostate biopsies has resulted in a discussion on what the optimal prostate biopsy strategy is. The ideal template has high sensitivity for clinically significant prostate cancer (csPCa), while reducing the detection rate of clinically insignificant prostate cancer (iPCa). This study evaluates different biopsy strategies in patients with a unilateral prostate MRI lesion.

Methods:

Retrospective subgroup analysis of a prospectively managed database consisting of patients undergoing prostate biopsy in two academic centres. Patients with a unilateral lesion (PI-RADS ⩾ 3) on MRI were included for analysis. The primary objective was to evaluate the diagnostic performance for different biopsy approaches compared with bilateral systematic prostate biopsy (SBx) and TBx. Detection rates for csPCa (ISUP ⩾ 2), adjusted csPCa (ISUP ⩾ 3) and iPCa (ISUP = 1) were determined for SBx alone, TBx alone, contralateral SBx combined with TBx and ipsilateral SBx combined with TBx. A subgroup analysis was performed for biopsy-naive patients.

Results:

A total of 228 patients were included from October 2015 to September 2021. Prostate cancer (PCa) detection rate of combined SBx and TBx was 63.5% for csPCa, 35.5% for adjusted csPCa, and 14% for iPCa. The best performing alternative biopsy strategy was TBx and ipsilateral SBx, which reached a sensitivity of 98.6% (95% CI: 95.1–99.6) for csPCa and 98.8% (95% CI: 96.3–99.9) for adjusted csPCa, missing only 1.4% of csPCa, while reducing iPCa detection by 15.6% compared with SBx and TBx. TBx or SBx alone missed a significant amount of csPCa, with sensitivities of 90.3% (95% CI: 84.4–94.2) and 86.8% (95% CI: 80.4–91.4) for csPCa. Subgroup analysis on biopsy-naive patients showed similar results as the overall group.

Conclusion:

This study shows that performing TBx with ipsilateral SBx and omitting contralateral SBx is the optimal biopsy strategy in patients with a unilateral MRI lesion. With this strategy, a very limited amount of csPCa is missed and iPCa detection is reduced.

A prospective study on inter-operator variability in semi-robotic software-based MRI/TRUS-fusion targeted prostate biopsies

Purpose

Magnetic resonance imaging (MRI)/ultrasound-fusion prostate biopsy (FB) comprises multiple steps each of which can cause alterations in targeted biopsy (TB) accuracy leading to false-negative results. The aim was to assess the inter-operator variability of software-based fusion TB by targeting the same MRI-lesions by different urologists.

Methods

In this prospective study, 142 patients eligible for analysis underwent software-based FB. TB of all lesions (n = 172) were carried out by two different urologists per patient (n = 31 urologists). We analyzed the number of mismatches [overall prostate cancer (PCa), clinically significant PCa (csPCa) and non-significant PCa (nsPCa)] between both performed TB per patient. In addition we evaluated factors contributing to inter-operator variability by uni- and multivariable analyses.

Results

In 11.6% of all MRI-lesions (10.6% of all patients) there was a mismatch between TB1 and TB2 in terms of overall prostate cancer (PCa detection. Regarding csPCa, patient-based mismatch occurred in 14.8% (n = 21). Overall PCa and csPCa detection rate of TB1 and TB2 did not differ significantly on a per-patient and per-lesion level.

Analyses revealed a smaller lesion size as predictive for mismatches (OR 9.19, 95% CI 2.02–41.83, p < 0.001).

Conclusion

Reproducibility and precision of targeting particularly small lesions is still limited although using software-based FB. Further improvements in image-fusion, segmentation, needle-guidance, and automatization are necessary.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03891-3.

Effectiveness of magnetic resonance imaging-targeted biopsy for detection of prostate cancer in comparison with systematic biopsy in our countries with low prevalence of prostate cancer: our first experience after 3 years

Background

Some men are subjected to multiple repeated biopsies because of ongoing suspicion of prostate cancer, which might subject them to complications. The aim of the study was to determine the diagnostic accuracy of magnetic resonance imaging (MRI)/target fusion-guided biopsy in comparison with systematic biopsy in our low prevalence prostate cancer population, in terms of validity measure, case detection rate, and detection of clinically significant cancer.

Methods

This is a retrospective cohort study. All consecutive patients who met the inclusion criteria (all men with persistent high prostate-specific antigen levels >4 ng/ml and/or subnormal finding in direct rectal examination, with suspicious regions identified on prebiopsy MRI) were subjected to transrectal MRI/ultrasound fusion-guided biopsy.

Results

A total of 165 cases met the inclusion criteria and were included in the study. The cancer detection rate (CDR) of target biopsy was significantly higher than that of standard biopsy (27.9% vs 14%, respectively), and 25 cases (52%) were missed by standard strategy and correctly classified by multiparametric MRI with targeted biopsy (MRI-TB). On the other hand, only 2 cases (4.3%) were misclassified by MRI-TB, and one of them was clinically significant. There was an exact agreement between the 2 strategies in 15 (31%) cases. Targeted biopsy diagnosed 41.5% more high-risk cancers vs systematic biopsy (41.6% vs 6.2%, P < .001). The difference between sensitivity, specificity, and negative predictive value of MRI-TG varies between 80% and 98%.

Conclusion

The CDR of prostate cancer in general and clinically significant cancer, in specific, is significantly higher with MRI-TG modality than with systematic modality. Yet, MRI-TG biopsy still misses some men with clinically significant prostate cancer. Hence, the addition of a 12-core biopsy is required to evade missing cases of clinically significant and insignificant cancer.

Diagnostic accuracy of magnetic resonance imaging targeted biopsy techniques compared to transrectal ultrasound guided biopsy of the prostate: a systematic review and meta-analysis

Background

Multiparametric MRI localizes cancer in the prostate, allowing for MRI guided biopsy (MRI-GB) 43 alongside transrectal ultrasound-guided systematic biopsy (TRUS-GB). Three MRI-GB approaches exist; visual estimation (COG-TB); fusion software-assisted (FUS-TB) and MRI ‘in-bore’ biopsy (IB-TB). It is unknown whether any of these are superior.

We conducted a systematic review and meta-analysis to address three questions. First, whether MRI-GB is superior to TRUS-GB at detecting clinically significant PCa (csPCa). Second, whether MRI-GB is superior to TRUS-GB at avoiding detection of insignificant PCa. Third, whether any MRI-GB strategy is superior at detecting csPCa.

Methods

A systematic literature review from 2015 to 2019 was performed in accordance with the START recommendations. Studies reporting PCa detection rates, employing MRI-GB and TRUS-GB were included and evaluated using the QUADAS-2 checklist. 1553 studies were found, of which 43 were included in the meta-analysis.

Results

For csPCa, MRI-GB was superior in detection to TRUS-GB (0.83 vs. 0.63 [p = 0.02]). MRI-GB was superior in detection to TRUS-GB at avoiding detection of insignificant PCa. No MRI-GB technique was superior at detecting csPCa (IB-TB 0.87; COG TB 0.81; FUS-TB 0.81, [p = 0.55]). There was significant heterogeneity observed between the included studies.

Conclusions

In patients with suspected PCa on MRI, MRI-GB offers superior rates of csPCa detection and reduces detection of insignificant PCa compared to TRUS-GB. No individual MRI-GB technique was found to be better in csPCa detection. Prospective adequately powered randomized controlled trials are required.

The accuracy of prostate cancer diagnosis in biopsy-naive patients using combined magnetic resonance imaging and transrectal ultrasound fusion-targeted prostate biopsy

Background

This study aimed to estimate whether multiparametric magnetic resonance imaging (mpMRI)-transrectal ultrasound (TRUS) fusion biopsy (FUS-TB) increases the detection rates of clinically significant prostate cancer (csPCa) compared with TRUS-guided systematic biopsy (TRUS-GB).

Methods

This retrospective study focused on patients who underwent mpMRI before prostate biopsy (PB) with Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) scores ≥3 and prostate-specific antigen (PSA) level between 2.5 and 20 ng/mL. Before FUS-TB, the biopsy needle position was checked virtually using three-dimensional mapping. After confirming the position of the target within the prostate, biopsy needle was inserted and PB was performed. Suspicious lesions were generally targeted with 2 to 4 cores. Subsequently, 10–12 cores were biopsied for TRUS-GB. The primary endpoint was the PCa detection rate (PCDR) for patients with PCa who underwent combined FUS-TB and TRUS-GB.

Results

According to PI-RADS v2, 76.7% of the patients with PI-RADS v2 score ≥3 were diagnosed with PCa. The PCDRs in patients with PI-RADS v2 score of 4 or 5 were significantly higher than those in patients with PI-RADS v2 score of 3 (3 vs. 4, P<0.001; 3 vs. 5, P<0.001; 4 vs. 5, P=0.073). According to PCDR, the detection rates of PCa and csPCa in the FUS-TB were significantly higher than that in the TRUS-GB.

Conclusions

Following detection of suspicious tumor lesions on mpMRI, FUS-TB use detects a higher number of PCa cases compared with TRUS-GB.

Multiparametric Magnetic Resonance Imaging in the Diagnosis of Clinically Significant Prostate Cancer: an Updated Systematic Review

There has been growing utilisation of multiparametric magnetic resonance imaging (MPMRI) as a non-invasive tool to diagnose and localise clinically significant prostate cancer (CSPCa). This updated systematic review examines the use of MPMRI in patients with an elevated risk of CSPCa who have had a prior negative transrectal ultrasound systematic biopsy (TRUS-SB) and who were biopsy naïve. MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews were searched for existing systematic reviews published up to September 2020. The literature search of the electronic databases combined disease-specific terms (prostate cancer, prostate carcinoma, etc.) and treatment-specific terms (magnetic resonance, etc.). Studies were included if they were randomised controlled trials (RCTs) comparing MPMRI to template transperineal mapping biopsy (TPMB) or to TRUS-SB. Thirty-six RCTs were eligible. For biopsy-naïve men, accuracy of diagnosis of CSPCa showed sensitivities from 87 to 96% and specificities ranging from 29 to 45%. Meta-analyses for CSPCa showed increased detection favouring MPMRI-targeted biopsy over TRUS-SB by 3% (95% confidence interval 0-7%, P = 0.03) and decreased detection of clinically insignificant prostate cancer (CISPCa) favouring MPMRI by 8% (95% confidence interval -11 to 5%, P < 0.00001). Accuracy of MPMRI for men with prior negative biopsy showed sensitivities of 78-100% and specificities of 30-100%. Meta-analyses comparing MPMRI to TRUS-SB showed increased detection of 5% (95% confidence interval 3-7%, P < 0.0001) with a reduction of CISPCa detection of 7% (95% confidence interval 4-9%, P < 0.00001). The growing acceptance of MPMRI utilisation internationally and the recent publication of several RCTs regarding MPMRI in reducing CISPCa detection rates, particularly in biopsy-naïve men, without loss of sensitivity for CSPCa necessitates the synthesis of updated evidence examining MPMRI in the diagnosis of CSPCa.

Does PSA level affect the choice of prostate puncture methods among MRI-ultrasound fusion targeted biopsy, transrectal ultrasound systematic biopsy or the combination of both?

OBJECTIVES

To explore whether prostate-specific antigen (PSA) affects the choice of prostate puncture methods by comparing MRI-ultrasound fusion targeted biopsy (MRI-TBx) with transrectal ultrasound systematic biopsy (TRUS-SBx) in the detection of prostate cancer (PCa), clinically significant prostate cancer (csPCa) and non-clinically significant prostate cancer (nsPCa) in different PSA groups (<10.0,10.0-20.0 and>20.0 ng ml-1).

METHODS

A total of 190 patients with 215 lesions who underwent both MRI-TBx and TRUS-SBx were included in this retrospective study. PSA was measured pre-operatively and stratified to three levels. The detection rates of PCa, csPCa and nsPCa through different methods (MRI-TBx, TRUS-SBx, or MRI-TBx +TRUS SBx) were compared with stratification by PSA.

RESULTS

Among the 190 patients, the histopathological results revealed PCa in 126 cases, including 119 csPCa. In PSA <10.0 ng ml-1 group, although the detection rates of PCa and csPCa by MRI-TBx were higher than those of TRUS-SBx, no significant differences were observed (p = 0.741; p = 0.400). In PSA 10.0-20.0 ng ml-1 group, difference between the detection rate of csPCa with TRUS-SBx and the combined method was statistically significant (p = 0.044). As for PSA >20.0 ng ml-1, MRI-TBx had a higher csPCa rate than TRUS-SBx with no statistical significance noted (p = 0.600).

CONCLUSION

MRI-TBx combined with TRUS-SBx could be suitable as a standard detection approach for csPCa in patients with PSA 10.0-20.0 ng ml-1. As for PSA >20.0 and <10.0 ng ml-1, both MRI-TBx and TRUS-SBx might provide effective solutions for tumor detection.

ADVANCES IN KNOWLEDGE

This study gives an account of choosing appropriate prostate puncture methods through PSA level.

The Utility of Combined Target and Systematic Prostate Biopsies in the Diagnosis of Clinically Significant Prostate Cancer Using Prostate Imaging Reporting and Data System Version 2 Based on Biparametric Magnetic Resonance Imaging

This study aimed to determine the predictive value of the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) based on biparametric magnetic resonance imaging (bpMRI) with combined target biopsy (TBx) and systematic biopsy (SBx) in patients with suspicion of having clinically significant prostate cancer (csPCa). In this retrospective study, we reviewed the clinical and pathological records of 184 consecutive patients who underwent bpMRI before prostate biopsy. We focused on patients with PI-RADS v2 scores ≥ 3. MRI was performed using a 3-Tesla clinical scanner with a 32-channel phased-array receiver coil. PI-RADS v2 was used to describe bpMRI findings based on T2-weighted imaging and diffusion-weighted imaging scores. The primary endpoint was the diagnostic accuracy rate of PI-RADS v2 based on bpMRI for patients with prostate cancer (PCa) who underwent combined TBx and SBx. A total of 104 patients were enrolled in this study. Combined TBx and SBx was significantly superior to either method alone for PCa detection in patients with suspicious lesions according to PI-RADS v2. TBx and SBx detected concordant csPCa in only 24.1% of the patients. In addition, the rate of increase in the Gleason score was similar between SBx (41.5%) and TBx (34.1%). The diagnostic accuracy of bpMRI is comparable to that of standard multiparametric MRI for the detection of csPCa. Moreover, combined TBx and SBx may be optimal for the accurate determination of csPCa diagnosis, the International Society of Urological Pathology grade, and risk classification.

Comparison of pain levels in fusion prostate biopsy and standard TRUS-Guided biopsy

Objectives

Fusion prostate biopsy (FPB) has recently emerged as a popular and successful biopsy technique on diagnosis of prostate cancer. The aim of this study was to compare the pain levels in TRUS-guided standard 12-core prostate biopsy (SPB) and MpMRI-guided FPB.

Materials and Methods

Patients detected with a PI-RADS (Prostate Imaging Reporting and Data System) ≥3 lesion on MpMRI underwent MpMRI-guided FPB (Group I) and the patients who had no suspected lesions or had a PI-RADS <3 lesion on MpMRI underwent TRUS-guided SPB (Group II). Pain assessment was performed using Visual Analog Scale (VAS) five minutes after the procedure. Following the procedure, the patients were asked to indicate the most painful biopsy step among the three steps.

Results

252 patients were included in this study (Group I=159, Group II=93). The mean number of cores and the malignancy detection rate were significantly higher in Group I compared to Group II (p <0.001, p=0.043, respectively). No significant difference was found between the two groups with regard to VAS scores (p=0.070). The most painful part of the whole procedure was revealed to be the insertion of the probe into the rectum. However, no significant difference was found between the two groups with regard to the most painful biopsy step (p=0.140).

Conclusion

FPB, with a relatively higher cancer detection rate, leads to the same pain level as SPB although it increases the number of biopsy cores and involves a more complex procedure compared to SPB. Further prospective studies with larger patient series are needed to substantiate our findings.

Magnetic resonance imaging-ultrasound fusion-targeted biopsy combined with systematic 12-core ultrasound-guided biopsy improves the detection of clinically significant prostate cancer: Are we ready to abandon the systematic approach?

Background:

Multiparametric (mp) magnetic resonance imaging (MRI)–ultrasound fusion-targeted biopsy (TB) has improved the detection of clinically significant prostate cancer (csCaP) using the Prostate Imaging Reporting and Data System (PI-RADS) reporting system, leading some authors to conclude that TB can replace the 12-core systematic biopsy (SB). We compared the diagnostic performance of TB with SB at our institution.

Methods:

Eighty-three men with elevated prostate-specific antigen levels (6.6 ng/mL, interquartile range [IQR] 4.5–9.2) and abnormal mp-MRI (127 lesions, PI-RADS ≥3, median size: 1.1 cm, IQR 0.8–1.6) underwent simultaneous TB and SB. Diagnosis of any CaP (Gleason score, [GS] ≥6) and csCaP (GS ≥7) was compared using the McNemar's exact test.

Results:

SB showed higher, but not statistically significant, detection rates of any CaP and csCaP (51.8% and 34.9%) versus TB (44.6% and 28.9%) (P = 0.286 and P = 0.359, respectively). TB outperformed SB in the quantification of 56.6% CaP and detecting cancer in anterior sectors (7.2%). Compared to SB, TB missed twice the amount of any CaP and csCaP. SB alone detected 22.2% of all csCaPs and upgraded 20.6% of TB-detected CaP. SB identified cancer invisible on mp-MRI (13.7% of all CaP) or missed by TB due to a small size (<1 cm) and sampling error (7% of lesions).

Conclusion:

A combination of SB with TB remained necessary for achieving the highest cancer detection rates. Limiting prostate biopsy to TB alone can miss csCaP due to the presence of synchronous high-grade cancer invisible on MRI or failure to hit the target. TB is the best approach for anterior lesions and tumor quantification.

Yield of concurrent systemic biopsy during MRI-targeted biopsy according to Prostate Imaging Reporting and Data System version 2 in patients with suspected prostate cancer

OBJECTIVES

To investigate the yield of concurrent systemic biopsy (SB) during MRI-targeted biopsy (MRTB) as Prostate Imaging Reporting and Data System (PI-RADS) version 2 (v2) interpretations in patients with suspected prostate cancer (PCa).

METHODS

A total of 285 patients with suspected PCa underwent prebiopsy 3-T MRI, followed by MRI-transrectal ultrasound fusion targeted biopsy and concurrent standard SB for lesions with PI-RADS v2 scores 3-5. Detection rates and positive core rates of PCa and clinically significant cancer (CSC) were evaluated.

RESULTS

In concurrent MRTB and SB, PCa and CSC detection rates were 18.9% and 9.4% for PI-RADS score 3, 45.9% and 32.4% for PI-RADS score 4, and 82.1% and 72.6% for PI-RADS score 5, respectively. Overall detection rate of CSCs (40.0%) for concurrent MRTB and SB was significantly higher than that of MRTB (34.4%, p = 0.004) or SB alone (27.7%, p < 0.001): an increase of 5.6% (16 patients) compared with MRTB alone. For patients with PI-RADS score 4 or 5, the CSC detection rate of concurrent MRTB and SB was 47.0%, an increase of 6.1% when compared with MRTB (40.9%) only (p < 0.001). Of the 110 patients with both MRTB- and SB-positive findings, 22 (20.0%) had the highest Gleason score in SB compared with that in MRTB. In 9.5% (27/285) patients including 12 patients with CSCs, only SB was positive, with negative MRTB.

CONCLUSION

Concurrent SB with MRTB based on PI-RADS v2 can yield a higher CSC detection rate compared with MRTB alone in patients with suspected PCa.

KEY POINTS

• Concurrent SB with MRTB yields an increase of 5.6% CSC detection compared with MRTB alone. • Of both MRTB- and SB-positive findings, 20.0% patients have upgraded Gleason score in SB. • In 18.4% patients, only SB was positive, with negative MRTB. Adding MRTB to SB is helpful for adequate risk stratification, reducing diagnostic uncertainty of PCa.

Real life data of MRI-targeted biopsy - experience from a single nonacademic centre using cognitive fusion and 1.5 tesla scanning

OBJECTIVES

To date, it is unknown whether systematic biopsies can be safely omitted in patients with unsuspicious MRI findings or if systematic biopsies should be required when targeting focal lesions (PI-RADS 3-5).

METHODS

A series of 366 patients (249 without a previous biopsy) were examined in a 1.5 Tesla MRI scanner. All patients were submitted to systematic biopsies (12-14 regions) with additional targeted biopsies (by cognitive fusion) of focal PI-RADS lesions (PI-RADS 3-5).

RESULTS

In our series, patients with PI-RADS 1/2 findings had rates of adenocarcinoma of any grade, >GG1 and GG4/5 of 34%, 14% and 3%, respectively. The use of MRI prior to biopsy in our series increased the detection of clinically significant prostate cancer (CSPCa) in 28% of patients with focal lesions, and focal lesions were present in 293/366 (80%) of all patients. For CSPCa (>GG1), targeted biopsies improved the diagnosis in 28% of patients, while systematic biopsies resulted in an additional 19% of cancer cases in the series.

CONCLUSION

Systematic biopsies should still be considered in patients with PI-RADS 1/2 findings. Our findings also suggest a stronger benefit of the combined strategy of targeted and systematic biopsies than the findings of previous studies concerning the detection of CSPCa in biopsy-naïve patients.

Value of extra-target prostate biopsy for the detection of magnetic resonance imaging-missed adverse pathology according to the Prostate Imaging Reporting and Data System scores: Spatial analysis using magnetic resonance-ultrasound fusion images

OBJECTIVES

To clarify who benefits from extra-target sampling of systematic prostate biopsy to detect magnetic resonance imaging-missed significant cancer and upgrading, when concurrently carried out with magnetic resonance imaging-ultrasound fusion targeted biopsy.

METHODS

Targeted biopsy and systematic biopsy were carried out in 301 men with Prostate Imaging Reporting and Data System scores ≥3. All score ≥3 regions were designated as targets. According to patients' highest Prostate Imaging Reporting and Data System scores, spatial relations between targets and biopsy-proven cancer were investigated to identify magnetic resonance imaging-missed pathology.

RESULTS

Overall, targeted biopsy and systematic biopsy detected significant cancer in 56.5% and 46.5%, respectively (P < 0.001). Significant cancer was detected only by systematic biopsy in 7.0%, and only outside targets in 5.0%. Upgrading by systematic biopsy was observed in 16.3%, and occurred outside targets in 11.0%. On multivariate analysis, the highest Prostate Imaging Reporting and Data System 4 was predictive for significant cancer only outside targets (odds ratio 5.81, P = 0.002) and for upgrading derived from outside targets (odds ratio 2.64, P = 0.012). According to the scores of 3, 4 and 5, significant cancer was identified only outside targets in 1.0%, 11.2% and 2.9%, respectively (P = 0.003 for Prostate Imaging Reporting and Data System 3 vs 4; P = 0.019 for Prostate Imaging Reporting and Data System 4 vs 5), and upgrading occurred in 6.1%, 18.4% and 8.6%, respectively (P = 0.009 and 0.040).

CONCLUSIONS

Men with the highest Prostate Imaging Reporting and Data System score 4 receive the largest benefit from extra-target biopsy for magnetic resonance imaging-missed significant cancer detection and upgrading. In men with a score of 3, less adverse pathology is missed without extra-target biopsy. These findings suggest prostate biopsy strategy could be tailored according to Prostate Imaging Reporting and Data System scores.

Value of systematic sampling in an mp-MRI targeted prostate biopsy strategy

The clinical utility of systematic prostate biopsy in addition to multi-parametric magnetic resonance imagining (mp-MRI) targeted biopsy pathways remains unclear. Despite radiological advancements in mp-MRI and utilisation of international standardised reporting systems (i.e., PI-RADS, LIKERT), undetected clinically significant prostate cancer (csPCa) on imaging persists. This has prevented the widespread adoption of an exclusively targeted biopsy approach. The current evidence on csPCa cancer detection rates in mp-MRI targeted alone and combined with a non-targeted systematic sampling is presented. Arguments for and against routine limited systematic sampling as an adjunct to an mp-MRI targeted biopsy are discussed. Our review will report the clinical utility of a combined sampling strategy on csPCa detection rate. The available evidence suggests that we are yet to reach a stage where non-targeted systematic prostate biopsy can be routinely omitted in mp-MRI targeted prostate biopsy pathways. Research should focus on improving the accuracy of mp-MRI, prostate biopsy techniques, and in identifying those men that will most benefit from a combined prostate biopsy. Such strategies may help future urologists reduce the burden of non-targeted cores in modern mp-MRI prostate biopsy pathways.

Targeted and systematic cognitive freehand-guided transperineal biopsy: is there still a role for systematic biopsy?

OBJECTIVES

To assess whether targeted cognitive freehand-assisted transperineal biopsies using a Precisionpoint^TM device still require additional systematic biopsies to avoid missing clinically significant prostate cancer, and to investigate the benefit of a quadrant-only biopsy approach to analyse whether a quadrant or extended target of the quadrant containing the target only would have been equivalent to systematic biopsy.

PATIENTS AND METHODS

Patients underwent combined systematic mapping and targeted transperineal prostate biopsies at a single institution. Biopsies were performed using the Precisionpoint device (Perineologic, Cumberland, MD, USA) under either local anaesthetic (58%, 163/282), i.v. sedation (12%, 34/282) or general anaesthetic (30%, 85/282). A mean (range) of 24 (5-42) systematic and 4.2 (1-11) target cores were obtained. Magnetic resonance imaging (MRI) scans were reported using the Likert scale. Clinically significant cancer was defined as Gleason 7 or above. Histopathological results were correlated with the presence of an MRI abnormality within a spatial quadrant and the other adjoining or non-adjoining (opposite) quadrants. Histological concordance with radical prostatectomy specimens was analysed.

RESULTS

A total of 282 patients were included in this study. Their mean (range) age was 66.8 (36-80) years, median (range) prostate-specific antigen level 7.4 (0.91-116) ng/mL and mean prostate volume 45.8 (13-150) mL. In this cohort, 82% of cases (230/282) were primary biopsies and 18% (52/282) were patients on surveillance. In all, 69% of biopsies (195/282) were identified to have clinically significant disease (Gleason ≥3 + 4). Any cancer (Gleason ≥3 + 3) was found in 84% (237/282) of patients. Of patients with clinically significant disease, the target biopsies alone picked up 88% (171/195), with systematic biopsy picking up the additional 12% (24/195) that the target biopsies missed. This altered with Likert score; 73% of Likert score 3 disease was detected by target biopsy, 92% of Likert score 4 and 100% of Likert score 5. Target biopsies with additional same-quadrant-only systematic cores picked up 75% (18/24) of significant cancer that was missed on target only, found in the same quadrant as the target.

CONCLUSION

Systematic biopsy is still an important tool when evaluating all patients referred for prostate biopsy, but the need is decreased with increasing suspicion on MRI. Patients with very high suspicion of prostate cancer (Likert score 5) may not require systematic cores, unless representative surrounding biopsies are required for other specific treatments (e.g. focal therapy, or operative planning). More prospective studies are needed to evaluate this in full.

Detection of clinically significant prostate cancer in biopsy-naïve men: direct comparison of systematic biopsy, multiparametric MRI- and contrast-ultrasound-dispersion imaging-targeted biopsy

OBJECTIVES

To compare and evaluate a multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy (TBx) strategy, contrast-ultrasound-dispersion imaging (CUDI)-TBx strategy and systematic biopsy (SBx) strategy for the detection of clinically significant prostate cancer (csPCa) in biopsy-naïve men.

PATIENTS AND METHODS

A prospective, single-centre paired diagnostic study included 150 biopsy-naïve men, from November 2015 to November 2018. All men underwent pre-biopsy mpMRI and CUDI followed by a 12-core SBx taken by an operator blinded from the imaging results. Men with suspicious lesions on mpMRI and/or CUDI also underwent MRI-TRUS fusion-TBx and/or cognitive CUDI-TBx after SBx by a second operator. A non-inferiority analysis of the mpMRI- and CUDI-TBx strategies in comparison with SBx for International Society of Urological Pathology Grade Group [GG] ≥2 PCa in any core with a non-inferiority margin of 1 percentage point was performed. Additional analyses for GG ≥2 PCa with cribriform growth pattern and/or intraductal carcinoma (CR/IDC), and GG ≥3 PCa were performed. Differences in detection rates were tested using McNemar's test with adjusted Wald confidence intervals.

RESULTS

After enrolment of 150 men, an interim analysis was performed. Both the mpMRI- and CUDI-TBx strategies were inferior to SBx for GG ≥2 PCa detection and the study was stopped. SBx found significantly more GG ≥2 PCa: 39% (56/142), as compared with 29% (41/142) and 28% (40/142) for mpMRI-TBx and CUDI-TBx, respectively (P < 0.05). SBx found significantly more GG = 1 PCa: 14% (20/142) compared to 1% (two of 142) and 3% (four of 142) with mpMRI-TBx and CUDI-TBx, respectively (P < 0.05). Detection of GG ≥2 PCa with CR/IDC and GG ≥3 PCa did not differ significantly between the strategies. The mpMRI- and CUDI-TBx strategies were comparable in detection but the mpMRI-TBx strategy had less false-positive findings (18% vs 53%).

CONCLUSIONS

In our study in biopsy-naïve men, the mpMRI- and CUDI-TBx strategies had comparable PCa detection rates, but the mpMRI-TBX strategy had the least false-positive findings. Both strategies were inferior to SBx for the detection of GG ≥2 PCa, despite reduced detection of insignificant GG = 1 PCa. Both strategies did not significantly differ from SBx for the detection of GG ≥2 PCa with CR/IDC and GG ≥3 PCa.

Focal therapy for localized prostate cancer in the era of routine multi-parametric MRI

BACKGROUND

Prostate cancer focal therapy aims to minimize the side-effects of whole gland treatments, such as radical prostatectomy and radiotherapy without compromising oncological efficacy. However, concerns exist regarding the multifocal nature of prostate cancer and the lack of long-term oncological data for this form of treatment. In recent years, the routine adoption of multi-parametric magnetic resonance imaging (mpMRI) of the prostate has improved our ability to select candidates for focal therapy and to accurately deliver this form of prostate cancer treatment.

METHODS

We performed a review of the literature to provide a summary of the oncological and functional outcomes of men receiving primary prostate focal therapy. Furthermore, we discuss the impact of the routine implementation of mpMRI as part of the initial prostate cancer diagnostic pathway on the selection of candidates and delivery of focal therapy. Finally, we summarize knowledge gaps in the field and highlight active clinical trials in this arena.

RESULTS

Primary focal therapy involves the application of one of a number of energies that ablate tissue, such as cryotherapy and high intensity focused ultrasound (HIFU). Success is principally dependent on highly accurate patient selection and disease localization underpinned in large part by the routine integration of pre-biopsy mpMRI. Prospective medium-term follow-up data for primary HIFU and cryotherapy for men with intermediate-risk disease have shown acceptable cancer control with low risk of side effects and complications. Additional research is needed to clearly define an appropriate follow-up approach and to guide the management of in- and out-of-field recurrences. Multiple comparative trials with randomization against standard care are currently underway in men with intermediate- and high-risk prostate cancer.

CONCLUSION

The widespread adoption of prostate mpMRI has led to improved disease localization, enabling the performance of focal therapy as a viable treatment strategy for men with low volume intermediate-risk prostate cancer.