The combination of targeted and systematic prostate biopsies is the best protocol for the detection of clinically significant prostate cancer

MRI software and cognitive fusion biopsies in people with suspected prostate cancer: a systematic review, network meta-analysis and cost-effectiveness analysis

Background

Magnetic resonance imaging localises cancer in the prostate, allowing for a targeted biopsy with or without transrectal ultrasound-guided systematic biopsy. Targeted biopsy methods include cognitive fusion, where prostate lesions suspicious on magnetic resonance imaging are targeted visually during live ultrasound, and software fusion, where computer software overlays the magnetic resonance imaging image onto the ultrasound in real time. The effectiveness and cost-effectiveness of software fusion technologies compared with cognitive fusion biopsy are uncertain.

Objectives

To assess the clinical and cost-effectiveness of software fusion biopsy technologies in people with suspected localised and locally advanced prostate cancer. A systematic review was conducted to evaluate the diagnostic accuracy, clinical efficacy and practical implementation of nine software fusion devices compared to cognitive fusion biopsies, and with each other, in people with suspected prostate cancer. Comprehensive searches including MEDLINE, and Embase were conducted up to August 2022 to identify studies which compared software fusion and cognitive fusion biopsies in people with suspected prostate cancer. Risk of bias was assessed with quality assessment of diagnostic accuracy studies-comparative tool. A network meta-analysis comparing software and cognitive fusion with or without concomitant systematic biopsy, and systematic biopsy alone was conducted. Additional outcomes, including safety and usability, were synthesised narratively. A de novo decision model was developed to estimate the cost-effectiveness of targeted software fusion biopsy relative to cognitive fusion biopsy with or without concomitant systematic biopsy for prostate cancer identification in biopsy-naive people. Scenario analyses were undertaken to explore the robustness of the results to variation in the model data sources and alternative assumptions.

Results

Twenty-three studies (3773 patients with software fusion, 2154 cognitive fusion) were included, of which 13 informed the main meta-analyses. Evidence was available for seven of the nine fusion devices specified in the protocol and at high risk of bias. The meta-analyses show that patients undergoing software fusion biopsy may have: (1) a lower probability of being classified as not having cancer, (2) similar probability of being classified as having non-clinically significant cancer (International Society of Urological Pathology grade 1) and (3) higher probability of being classified at higher International Society of Urological Pathology grades, particularly International Society of Urological Pathology 2. Similar results were obtained when comparing between same biopsy methods where both were combined with systematic biopsy. Evidence was insufficient to conclude whether any individual devices were superior to cognitive fusion, or whether some software fusion technologies were superior to others. Uncertainty in the relative diagnostic accuracy of software fusion versus cognitive fusion reduce the strength of any statements on its cost-effectiveness. The economic analysis suggests incremental cost-effectiveness ratios for software fusion biopsy versus cognitive fusion are within the bounds of cost-effectiveness (£1826 and £5623 per additional quality-adjusted life-year with or with concomitant systematic biopsy, respectively), but this finding needs cautious interpretation.

Limitations

There was insufficient evidence to explore the impact of effect modifiers.

Conclusions

Software fusion biopsies may be associated with increased cancer detection in relation to cognitive fusion biopsies, but the evidence is at high risk of bias. Sufficiently powered, high-quality studies are required. Cost-effectiveness results should be interpreted with caution given the limitations of the diagnostic accuracy evidence.

Study registration

This trial is registered as PROSPERO CRD42022329259.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: 135477) and is published in full in Health Technology Assessment; Vol. 28, No. 61. See the NIHR Funding and Awards website for further information.

Do we need MRI in all biopsy naïve patients? A multicenter cohort analysis

PURPOSE

The combined approach (CB) of magnetic resonance imaging (MRI)-guided biopsy (TB) and systematic biopsy (SB) is strongly recommended based on numerous studies in biopsy naïve men with suspicion of clinically significant prostate cancer (csPCA). However, the unbalanced accessibility of MRI, challenges related to reimbursement and the scarcity of specialized medical practitioners continue to impede a widespread implementation. Therefore, our objective was to determine a subset of men that could undergo SB without an increased risk of underdiagnosis at reduced expenses.

METHODS

A multicenter analysis of 2714 men with confirmed PCA and suspicious MRI who underwent CB were enrolled. Cancer detection rates were compared between the different biopsy routes SB, TB and CB using McNemar paired test. Additionally, Gleason grade up- and down-grading was determined.

RESULTS

CB detected more csPCA than TB and SB (p < 0.001), irrespective of MRI findings or biopsy route (transperineal vs. transrectal). Thereby, single biopsy approaches misgraded > 50% of csPCA. TB showed higher diagnostic efficiency, defined as csPCA detection per biopsy core than CB and SB (p < 0.001). For patients with abnormal DRE and PSA levels > 12.5 ng/ml, PSAD > 0.35 ng/ml/cm3, or > 75 years, SB and CB showed similar csPCA detection rates.

CONCLUSION

Conducting CB provides the highest level of diagnostic certainty and minimizes the risk of underdiagnosis in almost all biopsy-naive men. However, in patients with suspicious DRE and high PSA levels, PSAD, or advanced age solely using SB leads to similar csPCA detection rates. Thus, a reduced biopsy protocol may be considered for these men in case resources are limited.

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 Diagnostic Accuracy Study of Targeted and Systematic Biopsies to Detect Clinically Significant Prostate Cancer, including a Model for the Partial Omission of Systematic Biopsies

The primary objective of this study was to analyse the current accuracy of targeted and systematic prostate biopsies in detecting csPCa. A secondary objective was to determine whether there are factors predicting the finding of csPCa in targeted biopsies and, if so, to explore the utility of a predictive model for csPCa detection only in targeted biopsies. We analysed 2122 men with suspected PCa, serum PSA > 3 ng/mL, and/or a suspicious digital rectal examination (DRE), who underwent targeted and systematic biopsies between 2021 and 2022. CsPCa (grade group 2 or higher) was detected in 1026 men (48.4%). Discrepancies in csPCa detection in targeted and systematic biopsies were observed in 49.6%, with 13.9% of csPCa cases being detected only in systematic biopsies and 35.7% only in targeted biopsies. A predictive model for csPCa detection only in targeted biopsies was developed from the independent predictors age (years), prostate volume (mL), PI-RADS score (3 to 5), mpMRI Tesla (1.5 vs. 3.0), TRUS-MRI fusion image technique (cognitive vs. software), and prostate biopsy route (transrectal vs. transperineal). The csPCa discrimination ability of targeted biopsies showed an AUC of 0.741 (95% CI 0.721-0.762). The avoidance rate of systematic prostate biopsies went from 0.5% without missing csPCa to 18.3% missing 4.6% of csPCa cases. We conclude that the csPCa diagnostic accuracy of targeted biopsies is higher than that of systematic biopsies. However, a significant rate of csPCa remains detected only in systematic biopsies. A predictive model for the partial omission of systematic biopsies was developed.

Direct comparison between Grade Group assessed on systematic and MRI/ultrasound fusion targeted biopsies correlated to the radical prostatectomy specimens in patients with prostate cancer

OBJECTIVES

To compare the correlation of Gleason score (GS) and ISUP grade determined by prostate biopsies (PBx) and radical prostatectomy (RP) specimens according to the biopsy technique: ultrasound randomised (RBx) vs. MRI/ultrasound fusion targeted (TBx).

MATERIALS AND METHODS

Between March 2013 and June 2018, we retrospectively included patients who underwent RP for prostate cancer (PCa) histopathologically proven by RBx and/or TBx. All patients had a prebiopsy MRI by a single radiologist (using PI-RADS score), then transrectal RBx (12cores, blinded to MRI lesions) and TBx (2-4 cores/target) with elastic MRI/ultrasound fusion (UroStation™, Koelis, Grenoble, France). Histological findings were compared: PBx vs. RP.

RESULTS

One hundred and four patients underwent RP after RBx and/or TBx. ISUP concordance rate was better with the association RBx+TBx 49% (51/104) vs. 43.3% with TBx (P=0.07) and 43.3% with RBx (P=0.13). With RBx, 50% of the patients were downgraded (52/104) against 42.3% (44/104) with TBx (P=0.088). The association RBx+TBx significantly decreased the rate of downgrading of the ISUP score compared to the ISUP score of RP 35.6% (37/104) vs. RBx (50%, P=0.0001) and vs. TBx (42.3%, P=0.016).

CONCLUSION

In half of cases, the ISUP score was underestimated in RBx compared to RP specimens. Adding TBx to RBx significantly reduced downgrading. The combination of both biopsy techniques appeared to be the best protocol to get closer to ISUP score and GS of the RP specimens.

LEVEL OF EVIDENCE

C.

Current role of systematic biopsy in diagnosis of clinically significant prostate cancer in primary combined MRI-targeted biopsy: a high-volume single-center study

PURPOSE

Additive systematic biopsy (SB) contributes to prostate cancer (PCA) detection in MRI-targeted biopsy (TB). However, the reasons for this are not yet clear. We compared the performance of TB, SB and the combined approach (CB) in biopsy-naive men to determine the added value of SB for tumor grading and spatial tumor distribution.

METHODS

Two hundred and fifty-nine men with PI-RADS 3-5 graded lesions who underwent CB were enrolled. Data were prospectively collected, and cancer detection rates (CDR) were compared at patient and lesion level. Gleason grade up- and down-grading from biopsy to prostatectomy specimens (n = 56; 21.6%) were determined. Clinically significant cancer (csPCA) was defined as Gleason grade ≥ 2.

RESULTS

CDR by CB based on PI-RADS categories 3, 4 and 5 for PCA were 24%, 72% and 98% and 17%, 64% and 96% for csPCA. CB detected more PCA and csPCA than TB (p < 0.001). However, TB showed higher efficiency, defined as CDR per biopsy core, for PCA and csPCA in PI-RADS 4-5 rated patients (p < 0.001). Concordance between biopsy and prostatectomy grading was highest in CB with misdiagnosis of csPCA in 25% of men. TB missed cancer attributed to the index lesion in 10.2% and underestimated csPCA in 7%. In these cases, 76% of csPCA were detected and 85% were upgraded to csPCA by SB in adjacent sectors.

CONCLUSION

SB cannot be safely abundant without increased diagnostic uncertainty. When TB missed csPCA, SB detected it close to the MRI-target lesion. Therefore, perifocal biopsies could potentially replace 12-core SB with increased efficiency in taking manageable risks.

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.

Prostate cancer: diagnostic yield of modified transrectal ultrasound-guided twelve-core combined biopsy (targeted plus systematic biopsies) using prebiopsy magnetic resonance imaging

PURPOSE

This study aimed to analyze the diagnostic yield of modified transrectal ultrasound (TRUS)-guided 12-core combined biopsy (CB) using prebiopsy magnetic resonance imaging (MRI) for detecting clinically significant prostate cancer (csPCa).

METHODS

This retrospective study included 130 consecutive patients who underwent modified TRUS-guided 12-core CB using cognitive fusion for lesions of Prostate Imaging-Reporting and Data System (PI-RADS) category ≥ 3. The 12-core CB comprised 3-6-core targeted biopsy (TB) and systematic biopsy (SB). For SB, tissue sampling in TB regions was omitted, and 3-core sampling (i.e., apex, mid, and base) in the contralateral peripheral zone of TB was mandatory. csPCa was defined as International Society of Urological Pathology (ISUP) grade ≥ 2 cancer. The per-patient cancer detection rates (CDRs) according to biopsy type or PI-RADS category were investigated.

RESULTS

The CDRs of TB, SB, and CB for csPCa were 47.7% (62/130 patients), 29.2% (38/130), and 52.3% (68/130), respectively. For csPCa, the CDRs of TB and CB according to PI-RADS categories of 3, 4, or 5 were 25.0% (8/32) and 31.3% (10/32), 41.2% (28/68) and 45.6% (31/68), or 86.7% (26/30) and 90.0% (27/30), respectively. In 6 (4.6%) patients, csPCa was detected only by SB. In 18 (13.8%) patients, SB detected PCa of a higher ISUP grade than TB. In 11 (8.5%) patients, SB detected csPCa at contralateral peripheral zone of TB.

CONCLUSION

Modified TRUS-guided 12-core CB using prebiopsy MRI seems to be feasible. It may reduce total biopsy cores in patients who are suitable for CB based on prebiopsy MRI findings.

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.

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.

Should we perform systematic biopsies in case of suspicious MRI for prostate cancer in 2020? A review of literature

CONTEXT

Multiparametric magnetic resonance imaging (MRI) is now recommended before performing prostate biopsies, looking for suspicious lesions to perform targeted biopsies (TB). However, the association or exclusive performance of systematic biopsies (SB), criticized for its morbidity and for the detection of insignificant cancers, remains debated.

OBJECTIVE

To perform a literature review to answer three questions: (1) In the presence of a suspicious MRI lesion, should we always perform SB in addition to TB? (2) Can we avoid SB when considering focal treatment? (3) Is there an increase in adverse events when associating SB with TB?

SOURCES

A non-systematic literature review was carried out on Medline in April 2020 using the keywords "MRI", "PROSTATE CANCER", "SYSTEMATIC BIOPSY", "TARGETED BIOPSY", "ADVERSE EVENTS". The references of the selected articles were analyzed for additional articles. Selection of Studies published in the last five years were analyzed and retained if the available data made it possible to answer one of the three questions asked.

RESULTS

In biopsy-naive patients, the added value of SB to TB for detection of significative cancer varied from +5 to+7% and was reduced to +1 to +3% in the case of a previous series of negative biopsies. For patients under active surveillance, this added value was higher, ranging from +8% to +17%. MRI has a negative predictive value of 85 to 95%, but this value drops to 55% for the detection of secondary or tertiary foci. The use of SB is necessary if focal treatment is considered. Serious complications from biopsies requiring hospitalization range from 1.4 to 6.9% and are increased by the number of previous biopsy series performed more than by the number of biopsies per series.

CONCLUSION

In the presence of a suspicious MRI lesion, SB is indicated in addition to TB but can be discussed in patients with previous negative biopsies. They are necessary if focal treatment is considered to aid surgical planning. Severe complications from biopsies do not seem to increase when SB are associated to TB, but rather with the number of biopsy series performed.

Magnetic resonance imaging/transrectal ultrasonography fusion guided seed placement in a phantom: Accuracy between 2-seed versus 1-seed strategies

PURPOSE

To investigate whether the 2-seed placement per Magnetic Resonance Imaging (MRI) suspicious lesion yields a higher seed placement accuracy than a 1-seed strategy on a phantom.

METHODS

Eight olives embedded in gelatin, each simulating a prostate, underwent MRI. Three virtual spherical lesions (3, 5, and 8 mm diameters) were marked in each olive on the MRI images and co-registered to the MRI/Transrectal Ultrasonography (TRUS) fusion biopsy system. Two radiologists placed 0.5 mm fiducials, targeting the center of each virtual lesion under fusion image guidance. Half of the 8 olives in each phantom were assigned either to the 1-seed or 2-seeds per lesion strategy. Post-procedure Computed Tomography (CT) images identified each seed and were fused with MR to localize each virtual lesion and collected the seed placement error - distance between the virtual target and the corresponding seed (using the closer seed for the 2-seed strategy). Seed placement success is defined as fiducial placement within a lesion boundary.

RESULTS

Each operator repeated the procedure on three different phantoms, and data from 209 seeds placed for 137 lesions were analyzed, with an overall error of 3.03 ± 1.52 mm. The operator skill, operator phantom procedural experience, lesion size, and number of seeds, were independently associated with the seed placement error. Seed placement success rate was higher for the 2-seed group compared to 1-seed, although the difference was not statistically significant.

CONCLUSIONS

Placing 2 seeds per MRI lesion yielded a significantly lower error compared to 1-seed strategy, although seed placement success rate was not significantly different.

What is the ideal number of biopsy cores per lesion in targeted prostate biopsy?

Background

The number of cores to be obtained in targeted biopsy (TB) is important. This study aimed to evaluate the TB outcomes in suspicious prostate lesions classified according to the Prostate Imaging Reporting and Data System (PI-RADS) and to determine the ideal number of biopsy cores per lesion.

Methods

This retrospective study included patients who underwent multiparametric magnetic resonance imaging–guided fusion prostate biopsy owing to increased serum prostate-specific antigen (PSA) levels and suspicious digital rectal examination outcomes in our institute. Patients with PI-RADS <3 lesions, PSA levels >10 ng/ml, and a prior diagnosis of prostate cancer (PCa) (active surveillance) were excluded from the study. The number of biopsy cores to be obtained from each lesion was determined by the clinician.

Results

The study included a total of 418 patients and 684 lesions. Among PI-RADS 3 lesions, clinically significant PCa (sPCa) detection rate was similar in the lesions from which 2 and 3 cores were obtained (9.1% and 10.0%, respectively), whereas it was relatively higher in the lesions from which 4 biopsy cores were obtained (18.5%). Among PI-RADS 4 lesions, sPCa detection rate was similar in the lesions from which 3 and 4 cores were obtained (35.6% and 32.3%, respectively), whereas it was relatively lower in the lesions from which 2 biopsy cores were obtained (17.9%). Among PI-RADS 5 lesions, however, sPCa detection rate was similar in the lesions from which 2, 3, or 4 cores were obtained (47.6%, 46.0%, 48.9%, respectively).

Conclusion

The results indicated that the ideal number of cores to be obtained from each suspicious lesion in TB depends on the characteristics of the lesions. Accordingly, while obtaining 2–3 biopsy cores could be adequate in PI-RADS 4 and 5 lesions, which have a serious risk of cancer, a minimum of 4 biopsy cores should be obtained from PI-RADS 3 lesions to ensure accurate histopathological results.

Clinical trial number (ClinicalTrials.gov)NCT03936296.

A Comparative Study: Has MRI-guided Fusion Prostate Biopsy Changed the Prostate-specific Antigen Gray-zone Range?

Objective

The gray-zone prostate-specific antigen (PSA) range is accepted to be 4-10 ng/ml and is considered to vary according to age. We aimed to investigate whether fusion prostate biopsy (FPB), which has been reported to have relatively higher cancer detection rates, has an effect on gray-zone PSA cut-off value.

Material and methods

This retrospective study included patients that underwent standard prostate biopsy (SPB) or multiparametric magnetic resonance imaging (MpMRI)-guided FPB (SPB+ targeted biopsy). All the patients included in the study were detected with a Prostate Imaging Reporting and Data System (PI-RADS) ≥3 lesion on MpMRI (the FPB group only). The demographics, clinical characteristics, and histopathological diagnoses were recorded for each patient.

Results

A total of 1,628 patients comprising 1,208 patients in the SPB group and 420 patients in the FPB group were included in the study. The mean PSA level was 9.75±6.68 ng/ml in the FBP group and 10.46±6.46 ng/ml in the SPB group (p=0.053). Prostate cancer (PCa) detection rate was significantly higher in the FPB group as compared to the SPB group (42.4% vs. 36.4%). The PSA cut-off value for PCa was 9.75 ng/ml (sensitivity and specificity, 81%) in the SPB group and was 7.55 ng/ml (sensitivity and specificity, 81% and 84%, respectively) in the FPB group. In the FPB group, the cancer detection rate among the patients with a PSA level of 7.55-10.00 ng/ml was 56.1%.

Conclusion

The results indicated that the introduction of FPB into clinical practice, which has relatively higher cancer detection rates, has further lowered the upper limit for gray-zone PSA.

Comparison of prostate cancer detection rates between magnetic resonance imaging-targeted biopsy and transrectal ultrasound-guided biopsy according to Prostate Imaging Reporting and Data System in patients with PSA ≥4 ng/mL: a systematic review and meta-analysis

Background

Previous studies have investigated magnetic resonance imaging-targeted biopsy (MRI-TBx) on the detection for prostate cancer (PCa). Prostate Imaging Reporting and Data System (PI-RADS), as a standardized MRI reporting system, has widely been used in the management of PCa. However, basing the PI-RADS score, the comparability between MRI-TBx and transrectal ultrasound-guided biopsy (TRUS-Bx) in diagnosing PCa remained inconsistent or even controversial. Thus, this systematic meta-analysis aimed to assess the value of PI-RADS in sifting better prostate biopsy method.

Methods

A meta-analysis including 10 articles was performed. In these included studies, biopsy-naive subjects with concerning PSA levels and/or an abnormal digital rectal examination (DRE) were consecutively enrolled by referral from urologists. All subjects underwent multiparameter MRI (mpMRI) prostate and the results were scored independently by PI-RADS. Subjects with equivocal (PI-RADS 3) and intermediate/high-risk (PI-RADS 4/5) lesions underwent MRI-TBx and followed by TRUS-Bx performed by a urologist. The online databases PubMed, Embase and Web of Science were searched to find all correlated articles until October 1^st, 2019. Data were pooled by odds ratios (ORs) with 95% confidence intervals (CIs) to assess the strength of the associations. Subgroup analyses were conducted based on Gleason score.

Results

Overall, 10 studies were included in this meta-analysis from January, 2015 to June, 2019. In the comparison of the detection of MRI-TBx and TRUS-Bx in PCa patients, TRUS-Bx had a significant advantage in overall PCa detection compared with MRI-TBx (OR =0.78, 95% CI: 0.62-0.98) in PI-RADS 3. Basing subgroup analysis of Gleason score (csPCa: Gleason score ≥7; non-csPCa: Gleason score <7), a summary analysis of the detection rate of csPCa showed that no significant difference was found (OR =0.82, 95% CI: 0.58-1.16); Meanwhile, no significant difference in non-csPCa patients was also detected (OR =0.83, 95% CI: 0.53-1.28). In PI-RADS 4 or 5, no significant results were detected between MRI-TBx and TRUS-Bx (OR =0.96, 95% CI: 0.87-1.06) for overall PCa detection. The stratification analyses by Gleason score found that TRUS-Bx had an advantage over MRI-TBx in non-csPCa patients (OR =0.76, 95% CI: 0.60-0.98); However, there was no significant difference in the detection rate of csPCa (OR =1.05, 95% CI: 0.93-1.20).

Conclusions

This meta-analysis indicated that using TRUS-Bx was better than MRI-TBx for the diagnosis of PCa in PI-RADS 3; Besides, TRUS-Bx have an advantage over MRI-TBx in the detection for non-csPCa in PI-RADS 4 or 5. Therefore, PI-RADS could be used as a MRI evaluation system in the selection of prostate biopsy.

Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy

INTRODUCTION

The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone.

METHODS

All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient.

RESULTS

Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001).

CONCLUSIONS

Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.

Targeted and Systematic Prostate Biopsy in Biopsy-naive Men With Positive Multiparameter Magnetic Resonance Imaging Findings: A Meta-analysis

We assessed the difference in the detection rate of prostate cancer, specifically clinically significant prostate cancer, using targeted biopsy (TB), systematic biopsy (SB), and the combination of these 2 (CB) in biopsy-naive men with positive multiparameter magnetic resonance imaging results. We performed a literature review in September 2018 using PubMed and the Web of Science. Relevant studies acquired from specific articles' references were also reviewed. Only those studies that had provided the detection rate of TB, SB, and CB in biopsy-naive men with positive multiparameter magnetic resonance imaging findings were included for a total of 11 studies with 2099 patients. The combined strategy was better than TB or SB alone, with an odds ratio (OR) of 1.47 (95% confidence interval [CI], 1.30-1.67; P < .001) and 1.45 (95% CI, 1.28-1.65; P < .001), respectively, in the overall detection rate. Also, TB was not better than SB, with an OR of 0.99 (95% CI, 0.87-1.12; P = .825). For the clinically significant prostate cancer detection rate, CB was still better than TB or SB alone, with an OR of 1.25 (95% CI, 1.11-1.42; P < .001) and an OR of 1.23 (95% CI, 1.08-1.40; P = .002), respectively. Again, TB was not better than SB, with an OR of 0.98 (95% CI, 0.86-1.12; P = .768). In conclusion, CB resulted in a better detection rate than TB or SB alone for both the overall prostate cancer detection rate and the clinically significant prostate cancer detection rate.

Prostate Imaging Reporting and Data System 3 Category Cases at Multiparametric Magnetic Resonance for Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

The Prostate Imaging Reporting and Data System (PI-RADS) 3 score represents a "grey zone" that need to be further investigated to solve the issue of whether to biopsy these equivocal cases or not.

OBJECTIVE

To critically analyze the current evidence on PI-RADS 3 cases. We evaluated the prevalence of PI-RADS 3 cases in the literature and detection rate of prostate cancer (PC) and clinically significant PC (csPC) at biopsy with regard to factors determining these rates.

EVIDENCE ACQUISITION

We searched in the Medline and Cochrane Library database from the literature from January 2009 to January 2019, following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines.

EVIDENCE SYNTHESIS

A total of 28 studies were included in our analysis (total number of PI-RADS 3 cases: 1759, range 20-187). The prevalence of PI-RADS 3 cases reported in available studies was 17.3% (range 6.4-45.7%). The PC detection rate was 36% (95% confidence interval [CI] 33.8-37.4; range 10.3-55.8%), whereas that of csPC was 18.5% (95% CI 16.6-20.3; range 3.4-46.5%). Detection rates of PC and csPC were found to be similar in men who underwent a target biopsy versus those with a systematic biopsy (23.5% vs 23.9% and 11.4% vs 12.3%, respectively) and lower than the rates achieved with the combined strategy (36.9% and 19.6%, respectively). A prostate-specific antigen density (PSAD) of ≥0.15ng/ml/ml may represent an index to decide whether to submit a PI-RADS 3 case to biopsy.

CONCLUSIONS

In most investigations, PI-RADS 3 cases were not evaluated separately. A PI-RADS 3 lesion remains an equivocal lesion. Evaluation of clinical predictive factors in terms of csPC risk is a main aspect of helping clinicians in the biopsy decision process.

PATIENT SUMMARY

Management of Prostate Imaging Reporting and Data System 3 cases remains an unmet need, and the detection rate of clinically significant prostate cancer (csPC) among this population varies widely. Performing a combined target plus a systematic biopsy yields the highest detection of csPC. A prostate-specific antigen density of lower than 0.15ng/ml/ml may select patients for a follow-up strategy.

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.