The decision of targeted, systematic or combined biopsy in a biopsy naïve patient for the diagnosis of prostate cancer, can be made on the basis of multiparametric magnetic resonance imaging

Abstract

Introduction: The current trend to implement multiparametric magnetic resonance imaging (mpMRI)-guided targeted biopsy (TB) as primary biopsy for the diagnosis of suspected prostate cancer and to avoid systematic biopsy (SB) is growing. However, concern remains regarding missing clinically significant (Cs) cancer on the normal mpMRI areas of the prostate. Therefore, we compared the normal and abnormal areas from mpMRI at the same prostate biopsy, using simultaneous SB and TB technique. Methods: A prospective, comparative effectiveness study included 134 patients initially referred for primary biopsy (from October 2017 to June 2018); 100 men were selected, mean age 68 years, with a median level of prostate specific antigen of 7.6, with average prostate volume of 52 cm3 (T3 disease and prostate imaging reporting and data system (PI-RADS) score < 3 were excluded). All underwent six cores TB (median), from an average of two lesions on mpMRI and also eight cores SB (median) from normal mpMRI areas of the prostate after informed consent. Results: The combined (SB + TB) biopsy cancer detection rate was 67%, 51% having Cs disease. For Cs cancer, 35 patients were detected by both techniques. TB missed four Cs cancer (95% confidence interval (CI), p < 0.0001). Fewer men in the TB group than in the SB group were found to have clinically insignificant (Ci) cancer (95% CI, p < 0.0001). No Cs cancer diagnosis was missed on TB from PI-RADS 5 lesion. Overall, 4% Cs cancers were missed on TB and avoided over diagnosis of 9% Ci cancer. Conclusions: Cognitive TB didn’t miss any Cs cancer from PI-RADS 5 lesion found on mpMRI. Only doing Cognitive TB on PI-RADS 5 lesion would save time, reduce workload and will be cost effective both for Urology and Pathology. PI-RADS 3 and 4 lesions on mpMRI will benefit from adding systematic samples. Level of evidence: 4 Oxford Centre for Evidence-Based Medicine (CEBM).

Evidence-based guideline recommendations on multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer: A Cancer Care Ontario updated clinical practice guideline

“…A change has been made to the target population definition as follows: "Patients with an elevated risk of csPCa (defined as International -In total, 16 cohort studies and the two RCTs mentioned above presented detection rates comparing mpMRI-TB to TRUS-SB. 7,9,11,12,14,16,[22][23][24][31][32][33]40,[42][43][44] Estimates for csPCa showed increased detection favoring mpMRI-TB by 3% (95% CI 0-7, p=0.03).…”

“…Twenty-three trials (all full-text publications) compared mpMRI with a reference standard (n=5, all cohort studies) or with TRUS-SB (n=18: 2 randomized controlled trials [RCTs] and 16 cohort studies) for biopsy-naive men. The certainty of the aggregate study evidence for each comparison showed 14 of the 21 cohort studies to be at either low 6,32,40 or moderate 7,9,11,2,14,16,18,22,25,33,44 risk of bias based on a GRADE approach. 48 One of the RCTs was assessed to be at low risks of bias 20 and the other was assessed at being at unclear risk.…”

“…40 Overall estimates for the studies comparing mpMRI-TB plus TRUS-SB to targeted biopsy alone showed 6% increased csPCa detection when combining the systematic and targeted biopsy (95% CI 4-8, p<0.00001) and 8% increased detection of cis-PCa (95% CI 6-10, p<0.00001). 9,11,12,14,16,[31][32][33]39,40,[42][43][44] Justification for recommendation 1…”