Value of extra-target prostate biopsy for the detection of magnetic resonance imaging-missed adverse pathology according to the Prostate Imaging Reporting and Data System scores: Spatial analysis using magnetic resonance-ultrasound fusion images.

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To clarify who benefits from extra-target sampling of systematic prostate biopsy to detect magnetic resonance imaging-missed significant cancer and upgrading, when concurrently carried out with magnetic resonance imaging-ultrasound fusion targeted biopsy. Targeted biopsy and systematic biopsy were carried out in 301 men with Prostate Imaging Reporting and Data System scores ≥3. All score ≥3 regions were designated as targets. According to patients' highest Prostate Imaging Reporting and Data System scores, spatial relations between targets and biopsy-proven cancer were investigated to identify magnetic resonance imaging-missed pathology. Overall, targeted biopsy and systematic biopsy detected significant cancer in 56.5% and 46.5%, respectively (P<0.001). Significant cancer was detected only by systematic biopsy in 7.0%, and only outside targets in 5.0%. Upgrading by systematic biopsy was observed in 16.3%, and occurred outside targets in 11.0%. On multivariate analysis, the highest Prostate Imaging Reporting and Data System4 was predictive for significant cancer only outside targets (odds ratio 5.81, P=0.002) and for upgrading derived from outside targets (odds ratio 2.64, P=0.012). According to the scores of 3, 4 and 5, significant cancer was identified only outside targets in 1.0%, 11.2% and 2.9%, respectively (P=0.003 for Prostate Imaging Reporting and Data System 3 vs 4; P=0.019 for Prostate Imaging Reporting and Data System 4 vs 5), and upgrading occurred in 6.1%, 18.4% and 8.6%, respectively (P=0.009 and 0.040). Men with the highest Prostate Imaging Reporting and Data System score4 receive the largest benefit from extra-target biopsy for magnetic resonance imaging-missed significant cancer detection and upgrading. In men with a score of 3, less adverse pathology is missed without extra-target biopsy. These findings suggest prostate biopsy strategy could be tailored according to Prostate Imaging Reporting and Data System scores.