Targeted Prostate Biopsy: How, When, and Why? A Systematic Review.

OBJECTIVE: Prostate cancer, the second most diagnosed cancer among men, requires precise diagnostic techniques to ensure effective treatment. This review explores the technological advancements, optimal application conditions, and benefits of targeted prostate biopsies facilitated by multiparametric magnetic resonance imaging (mpMRI). METHODS: A systematic literature review was conducted to compare traditional 12-core systematic biopsies guided by transrectal ultrasound with targeted biopsy techniques using mpMRI. We searched electronic databases including PubMed, Scopus, and Web of Science from January 2015 to December 2024 using keywords such as "targeted prostate biopsy", "fusion prostate biopsy", "cognitive prostate biopsy", "MRI-guided biopsy", and "transrectal ultrasound prostate biopsy". Studies comparing various biopsy methods were included, and data extraction focused on study characteristics, patient demographics, biopsy techniques, diagnostic outcomes, and complications. CONCLUSION: mpMRI-guided targeted biopsies enhance the detection of clinically significant prostate cancer while reducing unnecessary biopsies and the detection of insignificant cancers. These targeted approaches preserve or improve diagnostic accuracy and patient outcomes, minimizing the risks associated with overdiagnosis and overtreatment. By utilizing mpMRI, targeted biopsies allow for precise targeting of suspicious regions within the prostate, providing a cost-effective method that reduces the number of biopsies performed. This review highlights the importance of integrating advanced imaging techniques into prostate cancer diagnosis to improve patient outcomes and quality of life.

Cognitive Targeted Prostate Biopsy Alone for Diagnosing Clinically Significant Prostate Cancer in Selected Biopsy-Naïve Patients: Results from a Retrospective Pilot Study.

(1) Background: To identify a particular setting of biopsy-naïve patients in which it would be reasonable to offer only cognitive targeted prostate biopsy (PBx) with a transrectal approach. (2) Methods: We designed an observational retrospective pilot study. Patients with a prostatic specific antigen (PSA) level > 10 ng/mL, either a normal or suspicious digital rectal examination (DRE), and a lesion with a PI-RADS score ≥ 4 in the postero-medial or postero-lateral peripheral zone were included. All patients underwent a transrectal PBx, including both systematic and targeted samples. The detection rate of clinically significant prostate cancer (csPCa) (Gleason Score ≥ 7) was chosen as the primary outcome. We described the detection rate of csPCa in systematic PBx, targeted PBx, and overall PBx. (3) A total of 92 patients were included. Prostate cancer was detected in 84 patients (91.30%) with combined biopsies. A csPCa was diagnosed in all positive cases (100%) with combined biopsies. Systematic PBxs were positive in 80 patients (86.96%), while targeted PBxs were positive in 84 men (91.30%). Targeted PBx alone would have allowed the diagnosis of csPCa in all positive cases; systematic PBx alone would have missed the diagnosis of 8/84 (9.52%) csPCa cases (4 negative patients and 4 not csPCa) (p = 0.011). (4) Conclusions: Cognitive targeted PBx with a transrectal approach could be offered alone to diagnose csPCa in biopsy-naïve patients with PSA ≥ 10 ng/mL, either normal or suspicious DRE, and a lesion with PI-RADS score ≥ 4 in the postero-medial or postero-lateral peripheral zone.

Ex Vivo Fluorescence Confocal Microscopy of MRI-Guided Targeted Prostate Biopsies for Rapid Detection of Clinically Significant Carcinomas-A Feasibility Study.

BACKGROUND: MRI-guided prostate biopsies from visible tumor-specific lesions (TBx) can be used to diagnose clinically significant carcinomas (csPCa) requiring treatment more selectively than conventional systematic biopsies (SBx). Ex vivo fluorescence confocal microscopy (FCM) is a novel technique that can be used to examine TBx prior to conventional histologic workup. METHODS: TBx from 150 patients were examined with FCM on the day of collection. Preliminary findings were reported within 2 h of collection. The results were statistically compared with the final histology. RESULTS: 27/40 (68%) of the csPCa were already recognized in the intraday FCM in accordance with the results of conventional histology. Even non-significant carcinomas (cisPCa) of the intermediate and high-risk groups (serum prostate-specific antigen (PSA) > 10 or 20 ng/mL) according to conventional risk stratifications were reliably detectable. In contrast, small foci of cisPCa were often not detected or were difficult to distinguish from reactive changes. CONCLUSION: The rapid reporting of preliminary FCM findings helps to reduce the psychological stress on patients, and can improve the clinical management of csPCa. Additional SBx can be avoided in individual cases, leading to lower rates of complications and scarring in the future surgical area. Additional staging examinations can be arranged without losing time. FCM represents a promising basis for future AI-based diagnostic algorithms.

Utility of positive core number on MRI-ultrasound fusion targeted biopsy in combination with PI-RADS scores for predicting unexpected extracapsular extension of clinically localized prostate cancer.

OBJECTIVES: To evaluate the utility of magnetic resonance imaging (MRI) and MRI-ultrasound fusion targeted biopsy (TB) for predicting unexpected extracapsular extension (ECE) in clinically localized prostate cancer (CLPC). METHODS: This study enrolled 89 prostate cancer patients with one or more lesions showing a Prostate Imaging-Reporting and Data System (PI-RADS) score ≥3 but without morphological abnormality in the prostatic capsule on pre-biopsy MRI. All patients underwent TB and systematic biopsy followed by radical prostatectomy (RP). Each lesion was examined by 3-core TB, taking cores from each third of the lesion. The preoperative variables predictive of ECE were explored by referring to RP specimens in the lesion-based analysis. RESULTS: Overall, 186 lesions, including 81 (43.5%), 73 (39.2%), and 32 (17.2%) with PI-RADS 3, 4, and 5, respectively, were analyzed. One hundred and twenty-two lesions (65.6%) were diagnosed as cancer on TB, and ECE was identified in 33 (17.7%) on the RP specimens. The positive TB core number was ≤2 in 129 lesions (69.4%) and three in 57 lesions (30.6%). On the multivariate analysis, PI-RADS ≥4 (p = 0.049, odds ratio [OR] = 2.39) and three positive cores on TB (p = 0.005, OR = 3.07) were independent predictors of ECE. Lesions with PI-RADS ≥4 and a positive TB core number of 3 had a significantly higher rate of ECE than those with PI-RADS 3 and a positive TB core number ≤2 (37.5% vs. 7.8%, p < 0.001). CONCLUSIONS: Positive TB core number in combination with PI-RADS scores is helpful to predict unexpected ECE in CLPC.

Application of Magnetic Resonance Imaging and Transrectal Ultrasound Image Fusion Targeted Transperineal Biopsy Technique Using Electromagnetic Needle Tracking Under Local Anaesthesia / 肿瘤防治研究

Objective To explore the effect and safety of magnetic resonance imaging and transrectal ultrasound (mpMRI-TRUS) image fusion targeted transperineal biopsy technique using electromagnetic needle tracking under local anesthesia. Methods We retrospectively analyzed the clinical and pathological data of 81 patients with mpMRI-TRUS image fusion targeted transperineal prostate biopsy using electromagnetic needle tracking under local anesthesia. Visual analog scale (VAS) and visual numeric scale (VNS) were used to evaluate the pain level and satisfaction of patients during prostate biopsy (VAS-1 and VNS-1), one hour after puncture (VAS-2 and VNS-2), and one day after surgery (VAS-3 and VNS-3). The perioperative clinical data and tumor positive rate of postoperative biopsy were recorded. Results The average prostate volume of 81 patients was 53.39±29.46 cm3. The PSA values of patients with PI-RADS scores of 2, 3, 4, and 5 were 9.14±2.31, 9.95±4.10, 14.77±6.36, and 32.17±24.39 ng/ml, respectively. The scores of VAS-1, VAS-2, and VAS-3 were 1.70±0.73, 1.16±0.58, and 0.53±0.55, respectively; the scores of VNS-1, VNS-2, and VNS-3 were 2.74±0.44, 3.69±0.46, and 3.84±0.37, respectively. The average surgical time was 17.47±3.44 minutes. Postoperative pathological results showed that the tumor positive rate of targeted prostate biopsy was 64.20%. According to the PI-RADS score for subgroup analysis, the tumor positive rates of patients with PI-RADS scores of 2, 3, 4, and 5 were 21.43%, 44.44%, 61.11%, and 96.77%, respectively. After transperineal prostate biopsy, gross hematuria occurred in 19.75% patients, and urinary retention occurred in 3.70%. The latter were relieved after symptomatic treatment. All patients did not experience complications, such as perineal puncture area hematoma, urinary tract infection, hematospermia, hematoma in perineal puncture area, urinary tract infection, hematospermia, vagus nerve reaction, or septic shock. Conclusion For suspected prostate cancer patients, mpMRI-TRUS image fusion targeted transperineal biopsy technique using electromagnetic needle tracking under local anesthesia is a feasible and easily tolerated surgical procedure. It has good safety and high tumor positive-detection rate, indicating that this technique is worthy of further clinical promotion and application.

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.

Targeted Biopsy in Men High Risk for Prostate Cancer: 68Ga-PSMA PET/CT Versus mpMRI.

INTRODUCTION/BACKGROUND: To evaluate the accuracy of 68Ga-PSMA PET/CT versus mpMRI targeted biopsy (TPBx) in the diagnosis of clinically significant prostate cancer (csPCa) in men high risk for PCa. MATERIALS AND METHODS: From January 2021 to March 2023, 125 men with clinical parameters high risk for PCa were evaluated by mpMRI and 68Ga-PSMA PET/CT; median PSA was 32.5 ng/mL (range: 12-160 ng/mL) and 60/125 (48%) had abnormal digital rectal examination. The mpMRI lesions with PI-RADS scores ≥ 3 and/or 68Ga-PSMA areas characterized by a standardized uptake value (SUVmax) values ≥ 8 were submitted to TPBx (4 cores); in addition, all the patients underwent systematic transperineal prostate biopsy (18 cores) under sedation and antibiotic prophylaxis. RESULTS: In 80 of 125 men (64%) a csPCa was found: 10 (12.5%) had a ISUP Grade Group 3 (GG), 45 (56.2%) a ISUP GG4 and 25 (31.2%) ISUP GG5. The median intraprostatic 68Ga-PSMA SUVmax was 42.3 (range:10.5-164) and 72 of 80 (90%) had a PI-RADS score ≥ 3. 68GaPSMA PET/CT showed the presence of metastases in 20 of 80 (25%) men: the median SUVmax in bone (15 cases) and nodes (40 cases) metastases was 55 and 47, respectively. Accuracy of 68Ga PSMA PET/CT (SUVmax cut-off ≥ 8) versus mpMRI PI-RADS score ≥ 3 in the diagnosis of csPCa was 92 versus 86.2%. CONCLUSION: 68GaPSMA PET/CT demonstrated a good diagnostic accuracy as a single procedure for the diagnosis and staging of high-risk PCa.

MRI-Targeted, Systematic, or Combined Biopsy for Detecting Clinically Significant Prostate Cancer.

PURPOSE: The aim of this study was to assess MRI-targeted, systematic, or combined prostate biopsy for diagnosing prostate cancer to identify opportunities for diagnostic accuracy improvement. METHODS: This institutional review board-approved, retrospective study, performed at a large, quaternary hospital, included all men undergoing prostate multiparametric MRI (mpMRI) from January 1, 2015, to December 31, 2019, with prostate-specific antigen ≥ 4 ng/mL, biopsy target on mpMRI (Prostate Imaging Reporting and Data System [PI-RADS] 3-5 lesion), and combined targeted and systematic biopsy ≤6 months after MRI. Analysis included the highest grade lesion per patient. The primary outcome was prostate cancer diagnosis by grade group (GG; 1, 2, and ≥3). Secondary outcomes were rates of cancer upgrading by biopsy type and cancer proximity to the targeted biopsy site in patients upgraded by systematic biopsy. RESULTS: Two hundred sixty-seven biopsies (267 patients) were included; 94.4% (252 of 267) were biopsy naive. The most suspicious mpMRI lesion was PI-RADS 3 in 18.7% (50 of 267), PI-RADS 4 in 52.4% (140 of 267), and PI-RADS 5 in 28.8% (77 of 267). Prostate cancer was diagnosed in 68.5% (183 of 267): 22.1% (59 of 267) GG 1, 16.1% (43 of 267) GG 2, and 30.3% (81 of 267) GG ≥ 3. Combined biopsy (124 of 267) yielded more GG ≥ 2 prostate cancer diagnoses than systematic (87 of 267) or targeted (110 of 267) biopsy alone. More GG ≥ 2 cancers were upgraded by targeted biopsy than by systematic biopsy (P = .0062). Systematic biopsy upgrades were in close proximity to the targeted biopsy site in 42.1% (24 of 57); GG ≥ 3 cancers 62.5% (15 of 24) constituted most proximal misses. CONCLUSIONS: In men with prostate-specific antigen ≥ 4 ng/mL and PI-RADS 3, 4, or 5 lesion on mpMRI, combined biopsy led to more prostate cancer diagnoses than targeted or systematic biopsy alone. Cancers upgraded by systematic biopsy proximal and distant from the targeted biopsy site may indicate opportunities for biopsy and mpMRI improvement, respectively.

Impact of Magnetic Resonance Imaging Targeting on Pathologic Upgrading and Downgrading at Prostatectomy: A Systematic Review and Meta-analysis.

CONTEXT: The evidence supporting multiparametric magnetic resonance imaging (MRI) targeting for biopsy is nearly exclusively based on biopsy pathologic outcomes. This is problematic, as targeting likely allows preferential identification of small high-grade areas of questionable oncologic significance, raising the likelihood of overdiagnosis and overtreatment. OBJECTIVE: To estimate the impact of MRI-targeted, systematic, and combined biopsies on radical prostatectomy (RP) grade group concordance. EVIDENCE ACQUISITION: PubMed MEDLINE and Cochrane Library were searched from July 2018 to January 2022. Studies that conducted systematic and MRI-targeted prostate biopsies and compared biopsy results with pathology after RP were included. We performed a meta-analysis to assess whether pathologic upgrading and downgrading were influenced by biopsy type and a net-benefit analysis using pooled risk difference estimates. EVIDENCE SYNTHESIS: Both targeted only and combined biopsies were less likely to result in upgrading (odds ratio [OR] vs systematic of 0.70, 95% confidence interval [CI] 0.63-0.77, p < 0.001, and 0.50, 95% CI 0.45-0.55, p < 0.001), respectively). Targeted only and combined biopsies increased the odds of downgrading (1.24 (95% CI 1.05-1.46), p = 0.012, and 1.96 (95% CI 1.68-2.27, p < 0.001) compared with systematic biopsies, respectively. The net benefit of targeted and combined biopsies is 8 and 7 per 100 if harms of up- and downgrading are considered equal, but 7 and -1 per 100 if the harm of downgrading is considered twice that of upgrading. CONCLUSIONS: The addition of MRI-targeting results in lower rates of upgrading as compared to systematic biopsy at RP (27% vs 42%). However, combined MRI-targeted and systematic biopsies are associated with more downgrading at RP (19% v 11% for combined vs systematic). Strong heterogeneity suggests further research into factors that influence the rates of up- and downgrading and that distinguishes clinically relevant from irrelevant grade changes is needed. Until then, the benefits and harms of combined MRI-targeted and systematic biopsies cannot be fully assessed. PATIENT SUMMARY: We reviewed the ability of magnetic resonance imaging (MRI)-targeted biopsies to predict cancer grade at prostatectomy. We found that combined MRI-targeted and systematic biopsies result in more cancers being downgraded than systematic biopsies.

The role of tumor density in predicting significant cancer on targeted biopsy of the prostate.

OBJECTIVE: Multiparametric magnetic resonance imaging (mpMRI) is central to diagnosing prostate cancer; however, not all imaged lesions represent clinically significant tumors. We aimed to evaluate the association between the relative tumor volume on mpMRI and clinically significant prostate cancer on biopsy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 340 patients who underwent combined transperineal targeted and systematic prostate biopsies between 2017 and 2021. Tumor volume was estimated based on the mpMRI diameter of suspected lesions. Relative tumor volume (tumor density) was calculated by dividing the tumor and prostate volumes. The study outcome was clinically significant cancer on biopsy. Logistic regression analyses were used to evaluate the association between tumor density and the outcome. The cutoff for tumor density was determined with ROC curves. RESULTS: Median estimated prostate and peripheral zone tumor volumes were 55cm3 and 0.61cm3, respectively. Median PSA density was 0.13 and peripheral zone tumor density was 0.01. Overall, 231 patients (68%) had any cancer and 130 (38%) had clinically significant cancer. On multivariable logistic regression age, PSA, previous biopsy, maximal PI-RADS score, prostate volume, and peripheral zone tumor density were significant predictors of outcome. Using a threshold of 0.006, the sensitivity, specificity, positive and negative predictive values of peripheral zone tumor density were 0.9, 0.51, 0.57, and 0.88, respectively. CONCLUSION: Peripheral zone tumor density is associated with clinically significant prostate cancer in patients with PI-RADS 4 and 5 mpMRI lesions. Future studies are required to validate our findings and evaluate the role of tumor density in avoiding unnecessary biopsies.

Feasibility and preliminary clinical tolerability of low-field MRI-guided prostate biopsy.

OBJECTIVE: We evaluate the clinical feasibility of a portable, low-field magnetic resonance imaging (MRI) system for prostate cancer (PCa) biopsy. METHODS: A retrospective analysis of men who underwent a 12-core systematic transrectal ultrasound-guided prostate biopsy (SB) and a low-field MRI guided transperineal targeted biopsy (MRI-TB). Comparison of the detection of clinically significant PCa (csPCa) (Gleason Grade [GG] ≥ 2) by SB and low field MRI-TB, stratified by Prostate Imaging Reporting & Data System (PI-RADS) score, prostate volume, and prostate serum antigen (PSA) was performed. RESULTS: A total of 39 men underwent both the MRI-TB and SB biopsy. Median (interquartile range [IQR]) age was 69.0 (61.5-73) years, body mass index (BMI) was 28.9 kg/m2 (25.3-34.3), prostate volume was 46.5 cc (32-72.7), and PSA was 9.5 ng/ml (5.5-13.2). The majority (64.4%) of patients had PI-RADS ≥ 4 lesions and 25% of lesions were anterior on pre-biopsy MRII. Cancer detection rate (CDR) was greatest when combining SB and MRI-TB (64.1%). MRI-TB detected 74.3% (29/39) cancers. Of which, 53.8% (21/39) were csPCa while SB detected 42.5% (17/39) csPCa (p = 0.21). In 32.5% (13/39) of cases, MRI-TB upstaged the final diagnosis, compared to 15% (6/39) of cases in which SB upstaged the final diagnosis (p = 0.11). CONCLUSION: Low-field MRI-TB is clinically feasible. Although future studies on the accuracy of MRI-TB system are needed, the initial CDR is comparable to those seen with fusion-based prostate biopsies. A transperineal and targeted approach may be beneficial in patients with higher BMI and anterior lesions.

Routine Systematic Prostate Biopsies not Replaced by Magnetic Resonance Imaging-Targeted Biopsy

ABSTRACT Background: Multiparametric magnetic resonance imaging improves the performance of prostate cancer (PCa) diagnostics through a better selection of patients. Objectives: The aim of the study was to study the detection rate (DR) of systematic and targeted cognitive biopsies in a cohort with the previous negative systematic biopsies. A secondary objective was to describe the value of prostate-specific antigen density (PSAd) in the detection of clinically significant PCa (CSPCa). Methods: We designed a prospective, single-center, and comparative study to determine the DR of systematic and targeted cognitive biopsies. The clinical and pathological characteristics of each patient were described. Results: A total of 111 patients with Prostate Imaging Reporting and Data System lesions > 3 were included in the study. PCa was detected in 41.4% (46 of 111 patients); 42 (91.3%) were detected by systematic biopsy and 30 (65.2%) by targeted biopsy. CSPCa was detected in 26 (23.4%), 23 (88.5%) by systematic biopsy, and 21 (76.9%) by targeted biopsy. PSAd > 0.15 was directly associated with CSPCa. Conclusion: The detection of PCa by systematic biopsy in this series was higher than 80%; hence, its routine use should not be replaced by targeted biopsy, since it continues to be the cornerstone of the diagnosis in patients with prior negative biopsies.

Prostate Cancer Detection Rate of Manually Operated and Robot-assisted In-bore Magnetic Resonance Imaging Targeted Biopsy.

Background: The diagnostic efficacy regarding prostate cancer (PC) detection by manually operated in-bore magnetic resonance imaging (MRI) targeted prostate biopsy (MO-MRGB) versus robot-assisted in-bore MRI targeted prostate biopsy (RA-MRGB) is lacking evidence. Objective: We hypothesized that the detection rates (DRs) for PC of MO-MRGB and RA-MRGB were similar and aimed to compare these. Design setting and participants: We prospectively included all patients who received in-bore MRI targeted prostate biopsy (MRGB) of the prostate in the Central Denmark Region from August 2014 to February 2020. From August 2014, MO-MRGB was used, and from March 2018, RA-MRGB was preferred. Referral to in-bore MRGB was based on multiparametric MRI (mpMRI). Outcome measurements and statistical analysis: We compared PC DRs of MO-MRGB and RA-MRGB with Pearson's chi-square test. We made three binary regression models and calculated the risk difference (RD) of PC between the in-bore MRGB systems. Results and limitations: A total of 3107 patients were referred to mpMRI, and 884 (28%) patients went on to receive in-bore MRGB. The MO-MRGB and RA-MRGB systems were used in 505 (57%) and 379 (43%) patients, respectively. Taking clinically relevant covariates into account, we found no statistically significant difference in PC DRs between MO-MRGB and RA-MRGB (72% vs 73%, RD 1%, 95% confidence interval -4% to 7%, p = 0.6). The main limitation was a shift in population characteristics. Conclusions: We did not see evidence of an effect on the DR or the RD for PC when we compared MO-MRGB with RA-MRGB. Cost effectiveness should be considered carefully when choosing the MRGB system. Patient summary: We compared two magnetic resonance imaging guided prostate tissue sampling systems regarding prostate cancer (PC) detection. One system was manually operated, and the other system was robot assisted. Comparing the systems, we found no evidence of a difference in their ability to detect PC.

Routine systematic prostate biopsies not replaced by magnetic resonance imaging-targeted biopsy.

Background: Multiparametric magnetic resonance imaging improves the performance of prostate cancer (PCa) diagnostics through a better selection of patients. Objectives: The aim of the study was to study the detection rate (DR) of systematic and targeted cognitive biopsies in a cohort with the previous negative systematic biopsies. A secondary objective was to describe the value of prostate-specific antigen density (PSAd) in the detection of clinically significant PCa (CSPCa). Methods: We designed a prospective, single-center, and comparative study to determine the DR of systematic and targeted cognitive biopsies. The clinical and pathological characteristics of each patient were described. Results: A total of 111 patients with Prostate Imaging Reporting and Data System lesions > 3 were included in the study. PCa was detected in 41.4% (46 of 111 patients); 42 (91.3%) were detected by systematic biopsy and 30 (65.2%) by targeted biopsy. CSPCa was detected in 26 (23.4%), 23 (88.5%) by systematic biopsy, and 21 (76.9%) by targeted biopsy. PSAd > 0.15 was directly associated with CSPCa. Conclusion: The detection of PCa by systematic biopsy in this series was higher than 80%; hence, its routine use should not be replaced by targeted biopsy, since it continues to be the cornerstone of the diagnosis in patients with prior negative biopsies.

Office-Based, Single-Sided, Low-Field MRI-Guided Prostate Biopsy.

This paper describes the workflow of transperineal prostate biopsy (TBx) using the single-sided, low-field Promaxo MRI system (Promaxo Inc., Oakland, California, United States) operating at a field strength ranging between 58 and 74 millitesla (mT). Prostate cancer (PCa) is the leading cause of cancer-related death and the second most frequently diagnosed cancer in men. Systematic biopsy (SBx) with 12-14 cores is the preferred standard of care procedure. The blinded approach of SBx, however, results in several shortcomings, including high rates of false negatives and increased infection rates due to the transrectal approach. The evolution of clinical use and scientific research using different prostate biopsy modalities is discussed, including the potential for the Promaxo MRI system to mitigate logistical constraints often associated with standard magnetic resonance (MR)-guided biopsy through the utilization of an office-based, low-field MRI.

Could 68Ga-PSMA PET/CT Evaluation Reduce the Number of Scheduled Prostate Biopsies in Men Enrolled in Active Surveillance Protocols?

Background: To evaluate the accuracy of 68Ga-prostate specific membrane antigen (PSMA) PET/CT in the diagnosis of clinically significant prostate cancer (csPCa) (Grade Group > 2) in men enrolled in Active Surveillance (AS) protocol. Methods: From May 2013 to May 2021, 173 men with very low-risk PCa were enrolled in an AS protocol study. During the follow-up, 38/173 (22%) men were upgraded and 8/173 (4.6%) decided to leave the AS protocol. After four years from confirmatory biopsy (range: 48−52 months), 30/127 (23.6%) consecutive patients were submitted to mpMRI and 68Ga-PSMA PET/CT scan before scheduled repeated biopsy. All the mpMRI (PI-RADS > 3) and 68Ga-PET/TC standardised uptake value (SUVmax) > 5 g/mL index lesions underwent targeted cores (mpMRI-TPBx and PSMA-TPBx) combined with transperineal saturation prostate biopsy (SPBx: median 20 cores). Results: mpMRI and 68Ga-PSMA PET/CT showed 14/30 (46.6%) and 6/30 (20%) lesions suspicious for PCa. In 2/30 (6.6%) men, a csPCa was found; 68Ga-PSMA-TPBx vs. mpMRI-TPBx vs. SPBx diagnosed 1/2 (50%) vs. 1/2 (50%) vs. 2/2 (100%) csPCa, respectively. In detail, mpMRI and 68Ga-PSMA PET/TC demonstrated 13/30 (43.3%) vs. 5/30 (16.7%) false positive and 1 (50%) vs. 1 (50%) false negative results. Conclusion: 68Ga-PSMA PET/CT did not improve the detection for csPCa of SPBx but would have spared 24/30 (80%) scheduled biopsies showing a lower false positive rate in comparison with mpMRI (20% vs. 43.3%) and a negative predictive value of 85.7% vs. 57.1%, respectively.

Detection Rate of 68Ga-PSMA PET/CT vs. mpMRI Targeted Biopsy for Clinically Significant Prostate Cancer.

BACKGROUND/AIM: To evaluate the diagnostic accuracy of 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) vs. multiparametric magnetic resonance imaging (mpMRI) targeted biopsy (TPBx) in the diagnosis of clinically significant prostate cancer (csPCa: Grade Group ≥2). PATIENTS AND METHODS: From January 2021 to January 2022, 45 patients (median age: 67 years) with negative digital rectal examination underwent transperineal prostate biopsy for abnormal PSA values (median 7.3 ng/ml). Before prostate biopsy, all patients underwent mpMRI and 68Ga-PET/CT examinations, which included mpMRI (PI-RADS version 2 ≥3), and 68Ga-PET/CT index lesions suspicious for cancer (SUVmax ≥5 g/ml) underwent cognitive targeted cores (mpMRI-TPBx and PSMA-TPBx: four cores) combined with extended systematic prostate biopsy (eSPBx: median 18 cores). The procedure was performed transperineally using a tru-cut 18-gauge needle under sedation and antibiotic prophylaxis. RESULTS: PCa was found in 29/45 (64.4%) men; in detail, 22/45 (48.9%) were csPCa. 68Ga-PSMA-TPBx vs. mpMRI-TPBx vs. eSPBx missed one (4.5%) vs. four (18.1%) vs. seven (31.8%) csPCa, respectively; mpMRI-TPBx vs. 68Ga-PSMA-TPBx for csPCa showed a diagnostic accuracy of 73.7 vs. 77.5%. CONCLUSION: 68Ga-PSMA PET/CT TPBx demonstrated good accuracy in the diagnosis of csPCa, which was not inferior to mpMRI-TPBx (77.5 vs. 73.7%), improving the detection rate for cancer in systematic biopsy.

Analysis of the cause of missed diagnosis in mpMRI/TRUS fusion-guided targeted prostate biopsy.

OBJECTIVES: To investigate the causes of missed diagnosis in mpMRI/TRUS fusion-guided targeted prostate biopsy. METHODS: The clinical data of 759 patients who underwent transperineal prostate biopsy from March 2021 to June 2021 at Nanjing DrumTower Hospital were retrospectively analyzed. Twenty-one patients had MRI contraindications. Ultimately, 738 patients completed mpMRI/TRUS fusion-guided targeted prostate biopsy + 12-core transperineal systematic biopsy after mpMRI and PI-RADS scoring. The pathological diagnoses from targeted and systematic biopsy were compared to evaluate and analyze the reasons for missed diagnoses in targeted biopsy. RESULTS: A total of 388 prostate cancer patients were identified, including 37 (9%) missed diagnoses with targeted biopsy and 44 (11.34%) with systematic biopsy. Between the target biopsy missed diagnosis group and not missed diagnosis group, there was no significant difference in age (71.08 ± 7.11 vs. 71.80 ± 7.94), but PSA (13.63 ± 12.41 vs. 54.54 ± 177.25 ng/ml), prostate volume (61.82 ± 40.64 vs. 44.34 ± 25.07 cm3), PSAD (0.27 ± 0.28 vs. 1.07 ± 2.91), and ISUP grade [1(1) vs. 3(2)] were significantly different. The pathological results of the 37 targeted biopsy missed diagnoses were recompared with MRI: 21 prostate cancers were normal on MRI; 9 cancer areas were abnormal on MRI; and 7 cancer areas on MRI were PI-RADS 3. CONCLUSIONS: Early prostate cancer, large prostate, effect of local anesthesia, doctor-patient cooperation, MRI diagnosis, and operator technology were possible factors for missed diagnosis in targeted biopsy. Improvements imaging technology, greater experience, and personalized biopsy may lead to an accurate pathological diagnosis.

Impact of Surgeon's Experience in Rigid versus Elastic MRI/TRUS-Fusion Biopsy to Detect Significant Prostate Cancer Using Targeted and Systematic Cores.

Multiparametric magnetic resonance imaging (mpMRI) and MRI/ultrasound fusion-targeted prostate biopsy (FB) have excellent sensitivity in detecting significant prostate cancer (sPC). FB platforms can be distinguished by rigid (RTB) or elastic image registration (ETB). We compared RTB and ETB by analyzing sPC detection rates of both RTB and ETB at different stages of the surgeons' learning curve. Patients undergoing RTB between 2015-2017 (n = 502) were compared to patients undergoing ETB from 2017-2019 (n = 437). SPC detection rates were compared by Chi-square-test on patient-basis. Combination of transperineal systematic biopsy and each TB served as reference and sub-analyses were performed for different grades of surgeon's experience. In the RTB subgroup, 233 men (46%) had sPC, compared to 201 (46%) in the ETB subgroup. RTB alone detected 94% of men with sPC and ETB 87% (p = 0.02). However, for at least intermediate-experienced surgeons (>100 FB), no differences occurred between RTB and ETB. In the total cohort, at least intermediate-experienced surgeons detected significantly more sPC (10%, p = 0.008) than novices. Thus, targeted transperineal MRI/TRUS-FB with a RTB registration system showed a similar sPC detection rate to ETB in experienced surgeons but a superior sPC detection rate to ETB in the total cohort. Low-experienced surgeons seem to benefit from RTB.

Integration of Prostate Biopsy Results with Pre-Biopsy Multiparametric Magnetic Resonance Imaging Findings Improves Local Staging of Prostate Cancer.

PURPOSE: To assess the added value of histological information for local staging of prostate cancer (PCa) by comparing the accuracy of multiparametric MRI alone (mpMRI) and mpMRI with biopsy Gleason grade (mpMRI+Bx). METHODS: 133 consecutive patients who underwent preoperative 3T-MRI and subsequent radical prostatectomy for PCa were included in this single-centre retrospective study. mpMRI imaging was reviewed independently by two uroradiologists for the presence of extracapsular extension (ECE) and seminal vesicle invasion (SVI) on a 5-point Likert scale. For second reads, the radiologists received results of targeted fused MR/US biopsy (mpMRI+Bx) prior to re-staging. RESULTS: The median patient age was 63 years (interquartile range (IQR) 58-67 years) and median PSA was 6.5 ng/mL (IQR 5.0-10.0 ng/mL). Extracapsular extension was present in 85/133 (63.9%) patients and SVI was present in 22/133 (16.5%) patients. For ECE prediction, mpMRI showed sensitivity and specificity of 63.5% and 81.3%, respectively, compared to 77.7% and 81.3% achieved by mpMRI+Bx. At an optimal cut-off value of Likert score ≥ 3, areas under the curves (AUCs) was .85 for mpMRI+Bx and .78 for mpMRI, P < .01. For SVI prediction, AUC was .95 for mpMRI+Bx compared to .92 for mpMRI; P = .20. Inter-reader agreement for ECE and SVI prediction was substantial for mpMRI (k range, .78-.79) and mpMRI+Bx (k range, .74-.79). CONCLUSIONS: MpMRI+Bx showed superior diagnostic performance with an increased sensitivity for ECE prediction but no significant difference for SVI prediction. Inter-reader agreement was substantial for both protocols. Integration of biopsy information adds value when staging prostate mpMRI.