The Optimal Prostate Biopsy Regime: Can We Restrict Biopsy to MRI-Targeted Cores Only? – Beyond the Abstract
Our study in 255 men undergoing both mpMRI-targeted biopsy and a systematic biopsy confirms the larger body of research demonstrating that mpMRI-targeted biopsy detects high Gleason score PCa while reducing detection of insignificant PCa as compared to systematic biopsy.2 Both procedures as stand-alone, however, missed clinically significant PCa or misclassified PCa as insignificant: 10% for the mpMRI-targeted biopsy approach and 13% for systematic biopsy approach. Furthermore, a combination of both approaches provided the most accurate assessment of Gleason grading, tumour core involvement and localization (multifocality) of PCa; all relevant factors for adequate risk stratification, prognosis, and treatment selection, especially for novel focal therapy techniques aiming at selectively ablating clinically significant PCa tumours.
In the recent weeks, two multicenter, paired, diagnostic studies in biopsy-naïve men explored and compared the clinical performance of mpMRI-targeted biopsy and systematic biopsy pathway and as such these study designs also provided valuable information in search for the optimal biopsy approach in men with a prebiopsy positive mpMRI. The Dutch 4M study with high-quality MRI standards recommends a ‘no systematic biopsy approach’ after a non-suspicious mpMRI but also demonstrated that 7% (21/317) of all men with a suspicious mpMRI scan had clinically significant PCa only on systematic biopsy.3 The French MRI-FIRST group reported improved detection of clinically significant PCa by combining both techniques as systematic biopsy detected 4% (8/206) of clinically significant PCa missed by the mpMRI-targeted biopsy.4 In line with our study, a combination of lesion targeting and zonal biopsy leads to higher rates of clinically significant PCa.
Both sampling errors and inadequate mpMRI visualization contributed to missed significant PCa in a mpMRI-targeted biopsy only approach. On top of that, a substantial portion of the mpMRI-targeted biopsy results are false positive as demonstrated by the 42-60% benign and insignificant PCa tissue results in targeted biopsy sessions in these studies with comparable selection criteria of patients.
With the adoption of mpMRI and mpMRI-targeted biopsy in the community setting, the need for high-quality expertise of mpMRI in prostate diagnostics seems essential. Both radiologists and urologists need to be adequately trained to achieve reproducible and consistent results in the reporting of mpMRI and targeting of suspicious lesions. Meanwhile, systematic biopsy should not be considered as redundant for the time being and should be performed, just as mpMRI reading and targeted biopsy, by dedicated operators with experience in TRUS as the imperative need to reduce the number of biopsies, by means of omitting systematic biopsy, will currently lead to missed clinically significant PCa.
Currently, it seems too ambitious to rely solely on mpMRI findings and mpMRI-targeted biopsy. In the future, the decision to perform a prostate biopsy should be based on all relevant PCa diagnostics including the patient’s demographics, clinical findings and mpMRI findings. We should rely not only on our eyes but use our mind when deciding on whether a patient should undergo biopsy, mpMRI-targeted biopsy and/or systematic biopsy, or not.5,6
Written by: Christophe Mannaerts, MD1, Theo M de Reijke, PhD, MD1 and Harrie P Beerlage, PhD, MD1
1. Department of Urology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
References:
1. Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2017;71(4):618-629. doi:10.1016/j.eururo.2016.08.003
2. Mannaerts CK, Kajtazovic A, Lodeizen OAP, et al. The added value of systematic biopsy in men with suspicion of prostate cancer undergoing multiparametric MRI-targeted biopsy. Urol Oncol Semin Orig Investig. 2019;000. doi:10.1016/j.urolonc.2019.01.005
3. van der Leest M, Cornel E, Israël B, et al. 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 Mu. Eur Urol. 2018. doi:10.1016/j.eururo.2018.11.023
4. Rouvière O, Puech P, Renard-Penna R, et al. 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. 2018;2045(18):1-10. doi:10.1016/S1470-2045(18)30569-2
5. Alberts AR, Roobol MJ, Verbeek JFM, et al. Prediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators. Eur Urol. 2018. doi:10.1016/j.eururo.2018.07.031
6. Radtke JP, Wiesenfarth M, Kesch C, et al. Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for Advanced Risk Modeling of Prostate Cancer-Patient-tailored Risk Stratification Can Reduce Unnecessary Biopsies. Eur Urol. 2017:1-9. doi:10.1016/j.eururo.2017.03.039
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