MRI/US fusion prostate biopsy in men on active surveillance: Our experience

Abstract

Aim: The upgrading or staging in men with prostate cancer (PCA) undergoing active surveillance (AS), defined as Gleason score (GS) ≥ 3+4 or more than 2 area with cancer, was investigated in our experience using the software-based fusion biopsy (FB). Methods: We selected from our database, composed of 620 biopsies, only men on AS according to criteria of John Hopkins Protocol (T1c, < 3 positive cores, GS = 3+3 = 6). Monitoring consisted of PSA measurement every 3 months, a clinical examination every 6 months, confirmatory FB within 6 months and then annual FB in all men. The suspicious MRI lesions were scored according to the Prostate Imaging Reporting and Data System (PI-RADS) classification version 2. FB were performed with a transrectal elastic free-hand fusion platform. The overall and clinically significant cancer detection rate was reported. Secondary, the diagnostic role of systematic biopsies was evaluated. Results: We selected 56 patients on AS with mean age 67.4 years, mean PSA 6.7 ng/ml and at least one follow-up MRI-US fusion biopsy (10 had 2 or 3 follow-up biopsies). Lesions detected by MRI were: PIRADS-2 in 5, PIRADS-3 in 28, PIRADS-4 in 18 pts and PIRADS-5 in 5 patients. In each MRI lesion, FB with 2.1 ± 1.1 cores were taken with a mean total cores of 13 ± 2.4 including the systematic cores. The overall cancer detection rate was 71% (40/56): 62% (25/40) in target core and 28% (15/40) in systematic core. The overall significant cancer detection rate was 46% (26/56): 69% (18/26) in target vs 31% (8/26) in random cores. Conclusions: The incidence of clinical significant cancer was 46% in men starting active surveillance, but it was more than doubled using MRI/US Target Biopsy 69% (18/26) rather than random cores (31%, 8/26). However, 1/3 of disease upgrades would have been missed if only the targeted biopsies were performed. Based on our experience, MRI/US fusion target biopsy must be associated to systematic biopsies to improve detection of significant cancer, reducing the risks of misclassification.

Evaluating the diagnostic role of in‐bore magnetic resonance imaging guided prostate biopsy: a single‐centre study

“…Our results may be due to the 73 patients with prior negative biopsies or on AS. This subset had 18 patients with PI‐RADS 5 lesions, of which 10 had csPCa, which is similar to reported data 26 . Furthermore, Hambrock et al .…”

“…This subset had 18 patients with PI-RADS 5 lesions, of which 10 had csPCa, which is similar to reported data. 26 Furthermore, Hambrock et al also demonstrated 31 of 46 tumours were anterior in a series of men with repeated negative biopsies, 27 suggesting that anterior lesions may account for missed diagnosis in men with previous biopsies. If we only assessed biopsy-naïve men with PI-RADS 5 lesions, 85% (6 out of 7) demonstrate csPCa which is in line with expectations.…”

Confirmatory transperineal saturation prostate biopsy combined with mpMRI decrease the reclassification rate in men enrolled in Active Surveillance: Our experience in 100 men submitted to eight-years scheduled biopsy

“…At the same time, an adequate number of needle cores allows to select patients with high volume GG1 PCa at risk of reclassification during follow up (33.4% of the cases) (30). In this respect, the number of systematic and/or targeted biopsy cores is an independent predictor for selection of patients with unfavourable characteristics for AS (31)(32)(33)(34)(35). On the other hand, a relevant critical point remain the adherence of patients to scheduled AS follow up; in fact, the estimated drop out to the execution of repeated prostate biopsy at 1 vs. 4 vs. 7 years from initial diagnosis is equal to 11 vs. 30 vs. 29%, respectively (3); therefore, the European Association of Urology (EAU) guidelines strongly recommend to perform repeat biopsy in the presence of clinical suspicion of PCa progression (i,e., PSAD evaluation, progression on mpMRI) instead to repeat biopsies at scheduled times that, anyway, are suggested every three years (36,37).…”

A contemporary analysis of disease upstaging of Gleason 3 + 3 prostate cancer patients after robot‐assisted laparoscopic prostatectomy

“…4,20 Lacetera et al found that using an MRI/US fusion biopsy technique more than doubled the detection of clinically significant disease in men on AS. 21 We defined a post-operative Gleason grade of ≥7 as being clinically significant as this would have resulted in patients being classified as having a higher risk disease pre-operatively using both the CPG and EAU models. AS is a well-established management option in the context of CPG 1 and EAU low-risk disease.…”