Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy

Dominik Deniffel^{1

2

3}, Nathan Perlis⁴, Sangeet Ghai³, Stephanie Girgis⁵, Gerard M Healy^{2

3}, Neil Fleshner⁴, Robert Hamilton⁴, Girish Kulkarni⁴, Ants Toi³, Theodorus van der Kwast⁶, Alexandre Zlotta^{4

7}, Antonio Finelli⁴, Masoom A Haider^{8

9}

Affiliations

¹ Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
² Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, M5G 1X5, Toronto, ON, Canada.
³ Joint Department of Medical Imaging, University Health Network, Sinai Health System and University of Toronto, Toronto, ON, Canada.
⁴ Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
⁵ University of Liverpool School of Medicine, Liverpool, UK.
⁶ Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.
⁷ Department of Surgery, Division of Urology, Mount Sinai Hospital, Toronto, ON, Canada.
⁸ Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, M5G 1X5, Toronto, ON, Canada. mahaider@radfiler.com.
⁹ Joint Department of Medical Imaging, University Health Network, Sinai Health System and University of Toronto, Toronto, ON, Canada. mahaider@radfiler.com.

PMID: 35507051
DOI: 10.1007/s00330-022-08822-3

Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy

Dominik Deniffel et al. Eur Radiol. 2022 Nov.

. 2022 Nov;32(11):7544-7554.

doi: 10.1007/s00330-022-08822-3. Epub 2022 May 4.

Authors

Affiliations

¹ Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
² Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, M5G 1X5, Toronto, ON, Canada.
³ Joint Department of Medical Imaging, University Health Network, Sinai Health System and University of Toronto, Toronto, ON, Canada.
⁴ Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
⁵ University of Liverpool School of Medicine, Liverpool, UK.
⁶ Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.
⁷ Department of Surgery, Division of Urology, Mount Sinai Hospital, Toronto, ON, Canada.
⁸ Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, M5G 1X5, Toronto, ON, Canada. mahaider@radfiler.com.
⁹ Joint Department of Medical Imaging, University Health Network, Sinai Health System and University of Toronto, Toronto, ON, Canada. mahaider@radfiler.com.

PMID: 35507051
DOI: 10.1007/s00330-022-08822-3

Abstract

Objectives: We aimed to develop and compare strategies that help optimize current prostate biopsy practice by identifying patients who may forgo concurrent systematic biopsy (SBx) in favor of MRI-targeted (TBx) alone.

Methods: Retrospective study on 745 patients who underwent combined MRI-TBx plus SBx. Primary outcome was the upgrade to clinically significant prostate cancer (csPCa; grade group ≥ 2) on SBx versus MRI-TBx. Variables (age, previous biopsy status, Prostate Imaging Reporting and Data System (PI-RADS) score, index lesion size/location, number of lesions, PSA, PSA density, prostate volume) associated with the primary outcome were identified by logistic regression and used for biopsy strategies. Clinical utility was assessed by decision curve analysis (DCA).

Results: SBx detected 47 (6%) additional men with csPCa. The risk of detecting csPCa uniquely on SBx was significantly lower in men with PI-RADS 5 (versus PI-RADS 3: OR 0.30, p = 0.03; versus PI-RADS 4: OR 0.33, p = 0.01), and previous negative biopsy (versus previous positive biopsy: OR 0.40, p = 0.007), and increased with age (per 10 years: OR 1.64, p = 0.016). No significant association was observed for other variables. DCA identified the following strategies as most useful: (a) avoid SBx in men with PI-RADS 5 and (b) additionally in those with previous negative biopsy, resulting in avoiding SBx in 201 (27%) and 429 (58%), while missing csPCa in 5 (1%) and 15 (2%) patients, respectively.

Conclusion: Not all men benefit equally from the combination of SBx and MRI-TBx. SBx avoidance in men with PI-RADS 5 and/or previous negative biopsy may reduce the risk of excess biopsies with a low risk of missing csPCa.

Key points: • In men undergoing MRI-targeted biopsy, the risk of detecting clinically significant prostate cancer (csPCa) only on additional systematic biopsy (SBx) decreased in men with PI-RADS 5, previous negative biopsy, and younger age. • Using these variables may help select men who could avoid the risk of excess SBx. • If missing csPCa in 5% was acceptable, forgoing SBx in men with PI-RADS 5 and/or previous negative biopsy enabled the highest net reduction in SBx.

Keywords: Decision analysis; Image-guided biopsy; Magnetic resonance imaging; Prostatic neoplasms; Risk assessment.

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Comment in

Towards a judicious use of perilesional biopsy in the era of MRI-targeting, parting of the ways from systematic prostate biopsy.
Padhani AR, Raman SS, Schoots IG. Padhani AR, et al. Eur Radiol. 2022 Nov;32(11):7491-7493. doi: 10.1007/s00330-022-09097-4. Epub 2022 Sep 8. Eur Radiol. 2022. PMID: 36074267 No abstract available.
Should we combine systematic with MRI-targeted biopsy? Implications for the management of patients with prostate cancer.
Gandaglia G, Giannarini G, Stabile A, Montorsi F, Briganti A. Gandaglia G, et al. Eur Radiol. 2022 Nov;32(11):7488-7490. doi: 10.1007/s00330-022-09096-5. Epub 2022 Sep 15. Eur Radiol. 2022. PMID: 36107203 No abstract available.

References

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1. Ahmed HU, El-Shater Bosaily A, Brown LC et al (2017) Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet 389:815–822. https://doi.org/10.1016/S0140-6736(16)32401-1 - DOI
1. Drost F-JHJH, Osses DF, Nieboer D et al (2019) Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev 2019:CD012663. https://doi.org/10.1002/14651858.CD012663.pub2 - DOI
1. van der Leest M, Cornel E, Israël B et al (2019) Head-to-head comparison of transrectal ultrasound-guided prostate biopsy versus multiparametric prostate resonance imaging with subsequent magnetic resonance-guided biopsy in biopsy-naïve men with elevated prostate-specific antigen: a large prospective multicenter clinical study. Eur Urol 75:570–578. https://doi.org/10.1016/j.eururo.2018.11.023 - DOI
1. Rouvière O, Puech P, Renard-Penna R et al (2019) Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol 20:100–109. https://doi.org/10.1016/S1470-2045(18)30569-2 - DOI

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Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy

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Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy

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