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Article of the week: Ultrasound characteristics of regions identified as suspicious by MRI predict the likelihood of clinically significant cancer on MRI–ultrasound fusion‐targeted biopsy

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community, and a video made by the authors. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

 

The ultrasound characteristics of regions identified as suspicious by magnetic resonance imaging (MRI) predict the likelihood of clinically significant cancer on MRI–ultrasound fusion‐targeted biopsy

Benjamin Press*, Andrew B. Rosenkrantz, Richard Huang and Samir S. Taneja§ 
 
*Rutgers New Jersey Medical School, Newark, NJ, Department of Radiology, Department of Urology, and §Departments of Urology and Radiology, NYU Langone Health, New York, NY, USA
 

Abstract

Objective

To determine whether the presence of an ultrasound hypoechoic region at the site of a region of interest (ROI) on magnetic resonance imaging (MRI) results in improved prostate cancer (PCa) detection and predicts clinically significant PCa on MRI–ultrasonography fusion‐targeted prostate biopsy (MRF‐TB).

Materials and Methods

Between July 2011 and June 2017, 1058 men who underwent MRF‐TB, with or without systematic biopsy, by a single surgeon were prospectively entered into an institutional review board‐approved database. Each MRI ROI was identified and scored for suspicion by a single radiologist, and was prospectively evaluated for presence of a hypoechoic region at the site by the surgeon and graded as 0, 1 or 2, representing none, a poorly demarcated ROI‐HyR, or a well demarcated ROI‐HyR, respectively. The interaction of MRI suspicion score (mSS) and ultrasonography grade (USG), and the prediction of cancer detection rate by USG, were evaluated through univariate and multivariate analysis.

Results

For 672 men, the overall and Gleason score (GS) ≥7 cancer detection rates were 61.2% and 39.6%, respectively. The cancer detection rates for USGs 0, 1 and 2 were 46.2%, 58.6% and 76.0% (P < 0.001) for any cancer, and 18.7%, 35.2% and 61.1% (P < 0.001) for GS ≥7 cancer, respectively. For MRF‐TB only, the GS ≥7 cancer detection rates for USG 0, 1 and 2 were 12.8%, 25.7% and 52.0%, respectively (P < 0.001). On univariate analysis, in men with mSS 2–4, USG was predictive of GS ≥7 cancer detection rate. Multivariable regression analysis showed that USG, prostate‐specific antigen density and mSS were predictive of GS ≥7 PCa on MRF‐TB.

Conclusions

Ultrasonography findings at the site of an MRI ROI independently predict the likelihood of GS ≥7 PCa, as men with a well‐demarcated ROI‐HyR at the time of MRF‐TB have a higher risk than men without.

Editorial: Is transrectal ultrasonography of the prostate obsolete in the MRI era?

Sampling of prostate tissue to confirm pathologically a clinical suspicion of cancer has undergone an exponential change. The random systematic prostate biopsy technique was the only method used for many decades, initially guided by the finger but, since 1989, performed with TRUS guidance. Now, within the space of only a few years, we have entered the era of performing prostate biopsies on the basis of high‐tech three‐dimensional multiparametric MRI images, including software that can track the exact course of the biopsy needle [1]. While new technical developments in general lead to better, more individually directed healthcare, there is always the risk of abandoning ‘old’ but well developed and extensively tested techniques too soon. In this issue of the BJUI, Press et al. [2] looked at the added value of the presence of an ‘old‐fashioned’ TRUS‐detected lesion in cancer‐suspicious regions on MRI to better predict the presence of clinically significant prostate cancer (csPCa) defined as Gleason score ≥7. In their study comprising 1058 men, it was shown that a well‐demarcated abnormal TRUS finding noted at the time of MRI‐TRUS fusion‐guided prostate biopsy coincides with an increased risk of csPCa detection, independent of MRI suspicion (Prostate Imaging Reporting and Data System [PI‐RADS] score).

Increasing PI‐RADS score is correlated with an increased percentage of csPCa after targeted biopsy, both at initial and repeat biopsy. In a review based on data from 8252 men, it was shown that there is a gradual increase in the detection of csPCa from PI‐RADS 3 to PI‐RADS 4 to PI‐RADS 5 index lesions. For example, at first biopsy, the overall rate of PCa detection and the percentage of csPCa were 39%, 62% and 92% and 54%, 63% and 76% for PI‐RADS 3, 4 and 5 lesions, respectively. This means that in men with PI‐RADS 3 lesions, representing approximately one‐third of men deemed eligible for further assessment, only 39% will be diagnosed with PCa and half of the PCa detected will be potentially indolent Gleason 6 PCa [3]. This makes this group of men extremely interesting for further risk stratification before biopsy. Multivariable risk stratification in which PSA density plays an important role has been shown to be of value in these men [4] but further refinement could potentially be made by including suspicious lesions identified at TRUS.

Apart from the added value of TRUS findings in terms of risk stratification, the performance of the MRI‐targeted biopsy itself could be improved by visual guidance of hypoechoic lesions. In the present study by Press et al [2], a hypoechoic TRUS lesion was present at or near the location of two‐thirds of cancer‐suspicious lesions on MRI. The authors more or less advise to direct the targeted biopsy cores not only to the MRI suspicious lesion, but also the TRUS suspicious lesion, both of which often do not fully overlay in a software‐assisted MRI‐TRUS fusion model. The extent to which this ‘correction for misregistration’ is already included during targeted biopsy in current clinical practice is unknown. Although feasible and seemingly important during software‐assisted fusion targeted biopsy, TRUS lesions in cancer‐suspicious MRI regions might be more frequently targeted during cognitive fusion‐targeted biopsy. Two recent studies underline the important message of the present study, and show that a considerable proportion of csPCa is missed in and around MRI‐suspicious lesions by targeted biopsies, as a result of sampling errors related to both misregistration and intra‐tumour heterogeneity [56]. As suggested by these studies, visual guidance by hypoechoic lesions and ‘focal saturation’ biopsy by additional (peri‐)lesional cores might improve the detection of csPCa.

In summary, ‘good old’ TRUS could be of value in those patients who are virtually always present in scenarios in which a grading system is being used, i.e. patients belonging to the so‐called grey zone. The challenge of risk stratification (i.e. personalized medicine) is to nibble at both sides of the grey zone by implementing new techniques or, more likely by implementing a combination of all available and relevant knowledge.

by Monique J. Roobol, Frank-Jan H. Drost and Arnout R. Alberts

References

  1. Verma, SChoyke, PLEberhardt, SC et al. The current state of MR imaging‐targeted biopsy techniques for detection of prostate cancer. Radiology 201728534356
  2. Press, BRosenkrantz, ABHuang, RTaneja, SSThe ultrasound characteristics of MRI suspicious regions predict the likelihood of clinically significant cancer on MRI‐ultrasound fusion targeted biopsy. BJUI 201912343946.
  3. Schoots, IGMRI in early prostate cancer detection: how to manage indeterminate or equivocal PI‐RADS 3 lesions? Transl Androl Urol 201877082
  4. Alberts, ARSchoots, IGBokhorst, LPLeenders, GJBangma, CHRoobol, MJRisk‐based patient selection for magnetic resonance imaging‐targeted prostate biopsy after negative transrectal ultrasound‐guided random biopsy avoids unnecessary magnetic resonance imaging scans. Eur Urol 201669112934
  5. Simmons, LAMKanthabalan, AArya, M et al. Accuracy of transperineal targeted prostate biopsies, visual estimation and image fusion in men needing repeat biopsy in the PICTURE trial. J Urol 2018200122734
  6. Leest, M, Cornel, EIsrael, B et al. Head‐to‐head comparison of transrectal ultrasound‐guided prostate biopsy versus multiparametric prostate resonance imaging with subsequent magnetic resonance‐guided biopsy in biopsy‐naive men with elevated prostate‐specific antigen: a large prospective multicenter clinical study. Eur Urol 2018; [Epub ahead of print]. https://doi.org/10.1016/j.eururo.2018.11.023.

 

EAU 2016 Congress Day 3

Das bringt mich weiter! While the sun was shining in Munich, the 3rd day of the 31st EAU Annual Congress continued with very well attended plenary and poster sessions. And that is no wonder because the EAU Scientific Committee had created such an attractive program, including amazing plenary sessions during the morning and a plethora of informative poster sessions in the afternoon.

 

Professor Hendrik Borgmann (@HendrikBorgmann) has already covered highlights of the opening days 1 and 2 of this year’s Congress in his BJUI blog. We will give you some highlights of Day 3 and highly recommend you to take a look on EAU congress website, Day 3, which has archived a huge amount of material to allow you to catch up on sessions you may have missed. Indeed, lots of webcasts are available!

 

We focused on non-oncology plenary morning sessions and oncology poster sessions afternoon. Here are some of our highlights:

SURGERY IN THE ELDERLY – As our urological patients become older and older, surgery for octogenarians, or even nonagenarians, is increasingly common. The morning session covered various aspects on diagnosis and treatment of benign prostatic hyperplasia and other urological conditions in the ageing patient.

Professor Cosimo De Nunzio began the morning with “Highlights” on lower urinary tract symptoms and prostatic disease presented during this year’s EAU congress. Also this year, as many as every third abstract was on either prostate cancer or prostatic hyperplasia.

EAU 3-1

Indeed, the plenary session on Day 3 also covered prostatic disease.

Professor Alexander Bachmann talked about surgery for BPO in the elderly. He pointed out that in elderly (high-risk) patients we do not need a complete anatomical tissue removal, we do not need a (very) long-term follow-up and that we do not need tissue for prostate cancer diagnosis. Instead, we need a safe and efficient operation with individual adaptation of the technique and preferably feasibility in an ambulatory setting or local anaesthesia.

EAU 3-2

Professor Bachmann further emphasized that it would be preferable if surgery for the elderly would be performed by experienced surgeons, and that age per se is not a reason to not operate. There are several new minimally invasive operations available, and especially for elderly less is often more.

HOW AND WHEN TO STOP ANTICOAGULATION – Managing perioperative thromboprophylaxis for patients who already receive anticoagulants remains a challenge. Associate professor Daniel Eberli and Professor Per Morten Sandset covered many of these aspects in their helpful presentations.

EAU 3-3

Dr. Eberli told us that bridging therapy (options for stopping or not stopping anticoagulation in the above figure) is eminence-based, as no papers exist showing benefits. He also presented data from the recent NEJM trial (BRIDGE study; see Table below), which showed that stopping anticoagulation without bridging was non-inferior to perioperative bridging for the prevention of arterial thromboembolism and decreased the risk of major bleeding.

EAU 3-4

Dr. Eberli gave us all a take home message to discuss and question our local bridging guidelines as new evidence is very likely not supporting them (concluding slide below).

EAU 3-5

Professor Sandset recommended that during the perioperative period only use aspirin in high-risk patients, that is, those with recent thrombotic event or extensive coronary heart disease. He also informed us that stopping antiplatelet therapy 5 days before surgery (figure below) is often the way to go, and agreed with Dr. Eberli regarding bridging therapy statements.

EAU 3-6

Professor Sandset also gave helpful information regarding use of direct oral anticoagulants (DOACs) in urological surgery:

EAU 3-7

There were numerous poster sessions available on Day 3, as usual, many of them on prostate cancer. We have selected some of the highlight abstracts presented.

PROSTATE CANCER – On Day 3, prostate cancer presentations dominated once again in a number of poster, abstract and thematic sessions but also kidney, bladder, testicular and penile cancer sessions, which provided new interesting data.

Molecular markers, genomic profiling and individualized risk and treatment assessments were presented and discussed in poster session 58, and summarized by Stacy Loeb (@LoebStacy). Further advances in prostate cancer biomarkers in prostate cancer were presented in poster session 84. These new tools are moving from bench to bedside and urologists can hopefully incorporate these new tools to cancer care sooner rather than later.

In sessions on prostate cancer diagnostics, more advanced risk profiling tools were highlighted. For instance, STHLM3 test combines history of the patient, clinical parameters, biochemical markers and genetic markers. It was presented earlier in the congress and on Day 3 further health, economic and clinical evaluations were presented in Thematic session 12. It is one example of the tests showing promising results to potentially decrease the number of prostate biopsies needed. Other similar risk profiling tools were also presented during the congress. In addition to PSA only, evaluation of the smart use of already available clinical and biochemical parameters and the combination of genetic markers may bring individualized risk assessment of prostate cancer to the next level.

In poster session 62 on Day 3, diagnostic proceedings in prostate cancer with co-morbidity evaluation, biopsy strategies and MRI imaging were presented.  A combination of molecular markers and imaging may be the way to proceed in future. These aspects were covered nicely in Thematic session 12.

MRIs have been heavily integrated in prostate cancer diagnostics during recent years. Image guidance in prostate biopsies seem to be making a breakthrough in prostate cancer diagnostics. Targeted biopsies with cognitive or MRI-TRUS fusion imaging were shown to be the way to enhance the results and reliability of biopsies and cut down the number of biopsies. However, as biopsies are still needed in prostate cancer diagnostics, use of the pre-biopsy MRI protocols were suggested to be done only in clinical trial setting. Many aspects of MRI diagnostics of prostate cancer were elegantly summarized in Thematic session 11.

New sophisticated imaging technologies in addition to MRI were present in several sessions during the meeting. Diagnostic enhancement has been seen also in metastatic prostate cancer. PSMA-PET seems to be replacing choline-PET-TT in evaluation of relapsing and metastatic prostate cancer (e.g. Thematic session 10). More reliable diagnostics and imaging of prostate cancer are also enhancing the treatment decision and treatment choice of patients with local prostate cancer. Finding the right patients for the active surveillance protocols is also being helped with advanced diagnostics. Indeed, finding only patients who need treatment for prostate cancer should be the ultimate goal for enhanced diagnostics as discussed in poster sessions 66 and 75 on Day 3. There are also high expectations on focal therapy (e.g. poster session 66), which at the moment is still experimental but will likely be a real option for patients with low volume prostate cancer verified by imaging.

The role of quality of life evaluations and patient reported outcomes measured were heavily discussed during the congress in all treatment modalities of both local and advanced prostate cancer. Survivorship issues are an increasingly important issue when more effective treatments both in local and advanced prostate cancer are available.

In metastatic disease, the use of early chemotherapy in combination with hormonal treatment has been implemented very rapidly to clinical use after the results of the CHAARTED and STAMPEED studies. Further evaluation of early chemo in metastatic disease is still needed and the patient selection needs still clarification. Hormonal therapy still has a very marked role in metastatic prostate cancer and new advances can also be found in new strategies of using castration therapy as presented in poster session 67. Urologists should actively follow the changing landscape of the medical treatment of metastatic prostate cancer and be active in treatment planning and treatment of these patients. At the same time with poster session 62 novel drugs and new forms of isotope radiation therapy in castration resistant prostate cancer were discussed in poster session 61. These open new possibilities for potential treatments.

The clinical and scientific content of the program of the Day 3 was of a very high standard, and reflective of the breadth of contemporary research in many areas within urology. Besides this session, it was our pleasure to meet old and new urological friends worldwide. The annual EAU meeting remains a highly effective method of knowledge translation and provides the opportunity for collaboration between surgeon scientists and other researchers in the field. As always in big congresses, there are so many interesting sessions going on at the same time, that it is hard to pick up and follow everything you would like to. We hope that this report provides some memories and take home messages of the Day 3 to the readers of the BJUI and BJUI blogs.

We look forward to future BJUI and EAU happenings!

 

Kari Tikkinen

Urology resident, adjunct professor of clinical epidemiology

Helsinki University Hospital, Helsinki, Finland

@KariTikkinen

 

Mika Matikainen

Chief of urology, adjunct professor of urology

Helsinki University Hospital, Helsinki, Finland

 

 

Article of the Week: Comparison of systematic transrectal biopsy to transperineal MRI/(US)-fusion biopsy for the diagnosis of prostate cancer

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Angelika Borkowetz, discussing her paper. 

If you only have time to read one article this week, it should be this one.

Comparison of systematic transrectal biopsy to transperineal MRI/ultrasound-fusion biopsy for the diagnosis of prostate cancer

Angelika Borkowetz, Ivan Platzek*, Marieta Toma, Michael Laniado*, Gustavo Baretton†, Michael Froehner, Rainer Koch, Manfred Wirth and Stefan Zastrow

 

Department of Urology, *Department of Radiology and Interventional Radiology, Department of Pathology, and Institution of Medical Statistics and Epidemiology, Technische Universitat, Dresden, Germany

 

Read the full article

OBJECTIVES

To compare targeted, transperineal magnetic resonance imaging (MRI)/ultrasound (US)-fusion biopsy to systematic transrectal biopsy in patients with previous negative or first prostate biopsy and to evaluate the gain in diagnostic information with systematic biopsies in addition to targeted MRI/US-fusion biopsies.

PATIENTS AND METHODS

In all, 263 consecutive patients with suspicion of prostate cancer were investigated. All patients were evaluated by 3-T multiparametric MRI (mpMRI) applying the European Society of Urogenital Radiology criteria. All patients underwent MRI/US-fusion biopsy transperineally (mean nine cores) and additionally a systematic transrectal biopsy (mean 12 cores).

RESULTS

In all, 195 patients underwent repeat biopsy and 68 patients underwent first biopsy. The median age was 66 years, median PSA level was 8.3 ng/mL and median prostate volume was 50 mL. Overall, the prostate cancer detection rate was 52% (137/263). MRI/US-fusion biopsy detected significantly more cancer than systematic prostate biopsy (44% [116/263] vs 35% [91/263]; P = 0.002). In repeat biopsy, the detection rate was 44% (85/195) in targeted and 32% (62/195) in systematic biopsy (P = 0.002). In first biopsy, the detection rate was 46% (31/68) in targeted and 43% (29/68) in systematic biopsy (P = 0.527). In all, 80% (110/137) of biopsy confirmed prostate cancers were clinically significant. For the upgrading of Gleason score, 44% (32/72) more clinically significant prostate cancer was detected by using additional targeted biopsy than by systematic biopsy alone. Conversely, 12% (10/94) more clinically significant cancer was found by systematic biopsy additionally to targeted biopsy.

CONCLUSIONS

MRI/US-fusion biopsy was associated with a higher detection rate of clinically significant prostate cancer while taking fewer cores, especially in patients with prior negative biopsy. Due to a high portion of additional tumours with Gleason score ≥7 detected in addition to targeted biopsy, systematic biopsy should still be performed additionally to targeted biopsy.

Read more articles of the week

Editorial: Are men who are biopsied without prior prostate magnetic resonance imaging getting substandard care?

The article by Borkowetz et al. [1], published in this issue, by a multi-disciplinary group from Dresden who have been offering MRI to their patients since 2012, would suggest so. In their hands, an image-guided biopsy resulted in 29 patients with Gleason scores of 7 or 8 being identified, who had been overlooked by an optimised 12-core systematic biopsy taken at the same sitting. Dedicating a minimum of two cores to a ‘target’ conferred an increase in detection of clinically significant prostate cancer, as defined by Gleason pattern ≥4, of 43% compared with systematic biopsy alone.

There is reason to think that, if anything, this might be an underestimate of the utility of sampling a target of high propensity for clinically significant prostate cancer vs a strategy that tries to spread the needle around the posterior limits of the gland. The reason for this is that the operator was aware of the location of the target during the systematic biopsy, as these were done after the targeted biopsy. The resulting incorporation bias should not trouble us too much, as its effect will be to make systematic biopsy ‘better’ and therefore diminish any difference between the two strategies. The fact that the patients had their systematic biopsy under anaesthesia and were in lithotomy (non-standard conditions) might add further to both bias and direction.

This study [1], like many before, incorporates a mixed population that comprises men who were biopsy-naïve (around one-quarter of the population) and those men who had undergone at least one previous biopsy. Again, this probably does not matter for our purposes, as the two groups were identical for overall cancer detection (52%) and very similar in terms of the proportion of patients with Gleason pattern ≥4 (80% for biopsy-naïve men vs 72% for those who had undergone a previous biopsy). The two groups had a similar number of lesions, around two lesions/subject were declared. The two groups did differ in PSA level; men undergoing repeat biopsy had a median PSA level twice that of men having a biopsy for the first time (12.2 vs 6.1 μg/L).

These results appear to be consistent with those summarised in a recent systematic review of studies that compared a targeted sampling strategy with another [2], but they do differ substantially from a recent study of >1000 biopsy-naïve men who were randomised to MRI vs a standard systematic TRUS biopsy approach [3]. In this large randomised controlled trial from Rome, the overall detection rate in MRI-positive individuals who underwent targeted sampling was 93% (410/440) vs the 52% (137/263) achieved in this study [1].

Both studies show higher detection rates compared with a standard systematic approach, and both show that targeting increases the proportion of men with clinically significant disease. However, exploring the differences between the studies might provide us with insight on how best to refine this new intervention. At present, the detection rate of clinically significant cancer (the generally agreed desired outcome of a biopsy when clinically significant disease is indeed present) is contingent on several variables [4]. They comprise the following: the population sampled; the target condition employed (definition of clinical significance); quality of the imaging; quality of the reporting; the threshold used for declaring a ‘lesion’ a target; the accuracy of the needle placement; the number of cores deployed to the target; and the efficiency of tissue capture. All these differed between the two studies, either explicitly or implicitly.

However, it is likely that the one with the greatest influence on the outcome is the level of certainty attributed to the lesion by the radiologist. There are several scales currently in use and this study used the Prostate Imaging Reporting and Data System (PI-RADS), which comprises an ordinal scale, range 1–5, derived from conditions being either met or unmet [5]. Ideally, a risk stratification system should influence clinical practice. A PI-RADS score of 1–2 should result in avoidance of a biopsy, because of the low probability of finding clinically significant disease. A PI-RADS score of 4–5 should result in a targeted biopsy, because of the high probability of underlying clinically significant disease. A PI-RADS 3 score should prompt a repeat assessment after a given interval, reflecting the indeterminate nature of the prediction.

In the study by Borkowetz et al. [1], PI-RADS scores of 2 and 3 were both associated with a 10% rate of Gleason pattern ≥4, suggesting poor discriminant ability between the two. On the other hand, PI-RADS scores of 4 and 5 were associated with a 24% and 60% detection rate, respectively, of Gleason pattern ≥4. From this we can say that lesions with PI-RADS scores of 4–5 should be targeted, are positively associated with risk, and will confer a high targeting yield. I think we can also say that more work is needed in relation to the inputs that generate PI-RADS 2–3 scores. This, fortunately, is in hand, as a new version of PI-RADS is soon to replace the one used in this article. Hopefully, it will improve the discriminant quality at the lower limits of PI-RADS and, as a result, should allow us to avoid incorporating a PI-RADS score of 2 into our targeting schedule.

Despite issues with the finessing of PI-RADS and other scoring systems, a task that will never be fully complete, this study adds to the burden of proof. What we can say, quite emphatically (based on this study, the systematic review and other studies published since), is that if patients want to maximise the chances of finding clinically significant prostate cancer, if it is indeed present, they should insist on an MRI before biopsy, so that targeting can be incorporated into the sampling strategy. To do otherwise would, according to this study, just about halve the chances of detecting clinically significant prostate cancer, if it were present.

Read the full article

Mark Emberton
UCL Division of Surgery and Interventional Science, UCL, London, UK

 

References

 

 

Video: Comparison of systematic transrectal biopsy to transperineal MRI/(US)-fusion biopsy for the diagnosis of prostate cancer

Comparison of systematic transrectal biopsy to transperineal MRI/ultrasound-fusion biopsy for the diagnosis of prostate cancer

Angelika Borkowetz, Ivan Platzek*, Marieta Toma, Michael Laniado*, Gustavo Baretton†, Michael Froehner, Rainer Koch, Manfred Wirth and Stefan Zastrow

 

Department of Urology, *Department of Radiology and Interventional Radiology, Department of Pathology, and Institution of Medical Statistics and Epidemiology, Technische Universitat, Dresden, Germany

 

Read the full article

OBJECTIVES

To compare targeted, transperineal magnetic resonance imaging (MRI)/ultrasound (US)-fusion biopsy to systematic transrectal biopsy in patients with previous negative or first prostate biopsy and to evaluate the gain in diagnostic information with systematic biopsies in addition to targeted MRI/US-fusion biopsies.

PATIENTS AND METHODS

In all, 263 consecutive patients with suspicion of prostate cancer were investigated. All patients were evaluated by 3-T multiparametric MRI (mpMRI) applying the European Society of Urogenital Radiology criteria. All patients underwent MRI/US-fusion biopsy transperineally (mean nine cores) and additionally a systematic transrectal biopsy (mean 12 cores).

RESULTS

In all, 195 patients underwent repeat biopsy and 68 patients underwent first biopsy. The median age was 66 years, median PSA level was 8.3 ng/mL and median prostate volume was 50 mL. Overall, the prostate cancer detection rate was 52% (137/263). MRI/US-fusion biopsy detected significantly more cancer than systematic prostate biopsy (44% [116/263] vs 35% [91/263]; P = 0.002). In repeat biopsy, the detection rate was 44% (85/195) in targeted and 32% (62/195) in systematic biopsy (P = 0.002). In first biopsy, the detection rate was 46% (31/68) in targeted and 43% (29/68) in systematic biopsy (P = 0.527). In all, 80% (110/137) of biopsy confirmed prostate cancers were clinically significant. For the upgrading of Gleason score, 44% (32/72) more clinically significant prostate cancer was detected by using additional targeted biopsy than by systematic biopsy alone. Conversely, 12% (10/94) more clinically significant cancer was found by systematic biopsy additionally to targeted biopsy.

CONCLUSIONS

MRI/US-fusion biopsy was associated with a higher detection rate of clinically significant prostate cancer while taking fewer cores, especially in patients with prior negative biopsy. Due to a high portion of additional tumours with Gleason score ≥7 detected in addition to targeted biopsy, systematic biopsy should still be performed additionally to targeted biopsy.

Read more articles of the week

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