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

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An Editorial Comment to this article was published on 15 September 2022

An Editorial Comment to this article was published on 08 September 2022

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.

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Abbreviations

CBx:

Combined biopsy

csPCa:

Clinically significant prostate cancer

DCA:

Decision curve analysis

GG:

Grade group

mpMRI:

Multiparametric magnetic resonance imaging

OR:

Odds ratio

PCa:

Prostate cancer

PI-RADS:

Prostate Imaging Reporting and Data System

PSA:

Prostate-specific antigen

SBx:

Systematic biopsy

TBx:

Targeted biopsy

TRUS:

Transrectal ultrasound

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Funding

This study has received funding from the Ontario Institute for Cancer Research (M.A.H.), Deutsche Forschungsgemeinschaft (DFG) fellowship [DE 3207/1-1] (D.D.), and Clinical Research Scholarship from the Faculty of Radiologists, Royal College of Surgeons in Ireland (G.M.H).

Author information

Authors and Affiliations

  1. Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany

    Dominik Deniffel

  2. Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Avenue, M5G 1X5, Toronto, ON, Canada

    Dominik Deniffel, Gerard M. Healy & Masoom A. Haider

  3. Joint Department of Medical Imaging, University Health Network, Sinai Health System and University of Toronto, Toronto, ON, Canada

    Dominik Deniffel, Sangeet Ghai, Gerard M. Healy, Ants Toi & Masoom A. Haider

  4. Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

    Nathan Perlis, Neil Fleshner, Robert Hamilton, Girish Kulkarni, Alexandre Zlotta & Antonio Finelli

  5. University of Liverpool School of Medicine, Liverpool, UK

    Stephanie Girgis

  6. Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada

    Theodorus van der Kwast

  7. Department of Surgery, Division of Urology, Mount Sinai Hospital, Toronto, ON, Canada

    Alexandre Zlotta

Authors
  1. Dominik Deniffel
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  2. Nathan Perlis
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  3. Sangeet Ghai
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  13. Masoom A. Haider
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Contributions

Guarantors of integrity of entire study: Deniffel D., Haider M.A.

Study concept and design: Deniffel D., Perlis N., Haider M.A.

Data acquisition: Deniffel D., Perlis N., Ghai S., Girgis S., Toi A., Haider M.A.

Data analysis/interpretation: Deniffel D., Perlis N., Ghai S., Haider M.A.

Manuscript drafting: Deniffel D., Perlis N., Healy G.M., Haider M.A.

Critical revision of the manuscript for important intellectual content: all authors

Statistical analysis: Deniffel D.

Supervision: Haider M.A.

Corresponding author

Correspondence to Masoom A. Haider.

Ethics declarations

Parts of this work were presented at the Radiological Society of North America (RSNA) 2021 Scientific Assembly and Annual Meeting (Abstract GU04-A2).

Guarantor

The scientific guarantor of this publication is Masoom A. Haider.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Dr. Dominik Deniffel has extensive expertise in statistics.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

Three hundred twenty-two of the 745 patients were included in previous reports: a multi-institutional study on the positive predictive value of PI-RADS [1] and a study comparing risk stratification strategies prior to biopsy referral [2].

References:

1.Westphalen AC, McCulloch CE, Anaokar JM, et al (2020) Variability of the positive predictive value of PI-RADS for prostate MRI across 26 centers: experience of the Society of Abdominal Radiology prostate cancer disease-focused panel. Radiology 296:76–84. https://doi.org/10.1148/radiol.2020190646

2.Deniffel D, Healy GM, Dong X, et al (2021) Avoiding unnecessary biopsy: MRI-based risk models versus a PI-RADS and PSA density strategy for clinically significant prostate cancer. Radiology 204112. https://doi.org/10.1148/radiol.2021204112

Methodology

• retrospective

• diagnostic or prognostic study

• performed at one institution

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Deniffel, D., Perlis, N., Ghai, S. et al. Prostate biopsy in the era of MRI-targeting: towards a judicious use of additional systematic biopsy. Eur Radiol 32, 7544–7554 (2022). https://doi.org/10.1007/s00330-022-08822-3

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