Pan-segmental intraprostatic lesions involving mid-gland and apex of prostate (mid-apical lesions): assessing the true value of extreme apical biopsy cores

Abstract

Objective When considering increased morbidity of apical biopsies, the added diagnostic value of separate targeting of mid-gland and apical segment of the pan-segmental mid-apical mpMRI prostate cancer (PCa) suspicious lesions was assessed. Materials and methods A total of 420 patients with a single mpMRI PCa-suspicious PI-RADS ≥ 3 intraprostatic lesion extending from the mid-gland to the apical segment of the gland underwent transrectal MRI-targeted (TBx) and systematic prostate biopsy. Clinically significant PCa (CsPCa) was defined as Gleason Score (GS) ≥ 3 + 4. PCa detection rates of TBx cores were assessed according to targeted anatomical segments. Finally, the diagnostic values of two theoretical TBx protocols utilizing 1-core (A) vs. 2-cores (B) per anatomical segment were compared. Results TBx within the pan-segmental mid-apical lesions yielded 44% of csPCa. After stratification into mid- vs. apical segment of the lesion, csPCa was detected in 36% (mid-gland) and 32% (apex), respectively. Within the patients who had no csPCa detection by mid-gland sampling (64%, n = 270), extreme apical TBx yielded additional 8.1% of csPCa. Comparison of extreme apical TBx strategy B vs. overall PCa detection in our cohort revealed corresponding similar rates of 49 vs.50% and 31 vs.32%, respectively. Conclusion Separate analyses of both segments, mid-gland and apex, clearly revealed the diagnostic contribution of apical TBx. Our findings strongly suggest to perform extreme apical TBx even within pan-segmental lesions. Moreover, our results indicate that a higher number of cores sampled from the mid-gland segment might be avoided if complemented with a two-core extreme apical TBx.

Precision-guidance vs Systematic Sampling: Optimizing Biopsy Assessment of Secondary Prostate Cancer Suspicious Multiparametric Magnetic Resonance Imaging Lesions

“…Challenging diagnostics of multifocal PCa with mpMRI and TBx, as well as ongoing discussion about the prognostic value of IL and SL, [2][3][4][5][6][7] demonstrate an unmet need for further optimization of TBx protocols. For example, previous series examined sparing of the transitional zone, 17 primary TBx-sampling in evasive anatomical regions such as the anterior 18 or apical 19 prostate, reducing the TBx core number to just 2 cores per lesion, 12,20,21 or performing TBx without SBx. 20,22 Despite these efforts, there is a lack of series focusing on SL.…”

PSA-density, DRE, and PI-RADS 5: potential surrogates for omitting biopsy?

“…A minimum of two TBx cores were obtained from each lesion, depending on its location and size. After TBx was completed, a systematic biopsy (SBx) of the residual prostate was performed to achieve whole gland coverage including the complete apex [ 15 ]. All cores were individually sampled, documented, and analyzed.…”