Optimal Prostate Biopsy Research Articles

Magnetic Resonance Imaging, Clinical, and Biopsy Findings in Suspected Prostate Cancer

Multiple strategies integrating magnetic resonance imaging (MRI) and clinical data have been proposed to determine the need for a prostate biopsy in men with suspected clinically significant prostate cancer (csPCa) (Gleason score ≥3 + 4). However, inconsistencies across different strategies create challenges for drawing a definitive conclusion. To determine the optimal prostate biopsy decision-making strategy for avoiding unnecessary biopsies and minimizing the risk of missing csPCa by combining MRI Prostate Imaging Reporting & Data System (PI-RADS) and clinical data. PubMed, Ovid MEDLINE, Embase, Web of Science, and Cochrane Library from inception to July 1, 2022. English-language studies that evaluated men with suspected but not confirmed csPCa who underwent MRI PI-RADS followed by prostate biopsy were included. Each study had proposed a biopsy plan by combining PI-RADS and clinical data. Studies were independently assessed for eligibility for inclusion. Quality of studies was appraised using the Quality Assessment of Diagnostic Accuracy Studies 2 tool and the Newcastle-Ottawa Scale. Mixed-effects meta-analyses and meta-regression models with multimodel inference were performed. Reporting of this study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Independent risk factors of csPCa were determined by performing meta-regression between the rate of csPCa and PI-RADS and clinical parameters. Yields of different biopsy strategies were assessed by performing diagnostic meta-analysis. The analyses included 72 studies comprising 36 366 patients. Univariable meta-regression showed that PI-RADS 4 (β-coefficient [SE], 7.82 [3.85]; P = .045) and PI-RADS 5 (β-coefficient [SE], 23.18 [4.46]; P < .001) lesions, but not PI-RADS 3 lesions (β-coefficient [SE], -4.08 [3.06]; P = .19), were significantly associated with a higher risk of csPCa. When considered jointly in a multivariable model, prostate-specific antigen density (PSAD) was the only clinical variable significantly associated with csPCa (β-coefficient [SE], 15.50 [5.14]; P < .001) besides PI-RADS 5 (β-coefficient [SE], 9.19 [3.33]; P < .001). Avoiding biopsy in patients with lesions with PI-RADS category of 3 or less and PSAD less than 0.10 (vs <0.15) ng/mL2 resulted in reducing 30% (vs 48%) of unnecessary biopsies (compared with performing biopsy in all suspected patients), with an estimated sensitivity of 97% (vs 95%) and number needed to harm of 17 (vs 15). These findings suggest that in patients with suspected csPCa, patient-tailored prostate biopsy decisions based on PI-RADS and PSAD could prevent unnecessary procedures while maintaining high sensitivity.

Prostate Cancer Imaging: What We Already Know and What Is on the Horizon.

Prostate Cancer Imaging: What We Already Know and What Is on the Horizon.

An optimized prostate biopsy strategy in patients with a unilateral lesion on prostate magnetic resonance imaging avoids unnecessary biopsies.

Purpose:The introduction of magnetic resonance imaging (MRI)-targeted biopsy (TBx) besides systematic prostate biopsies has resulted in a discussion on what the optimal prostate biopsy strategy is. The ideal template has high sensitivity for clinically significant prostate cancer (csPCa), while reducing the detection rate of clinically insignificant prostate cancer (iPCa). This study evaluates different biopsy strategies in patients with a unilateral prostate MRI lesion.Methods:Retrospective subgroup analysis of a prospectively managed database consisting of patients undergoing prostate biopsy in two academic centres. Patients with a unilateral lesion (PI-RADS ⩾ 3) on MRI were included for analysis. The primary objective was to evaluate the diagnostic performance for different biopsy approaches compared with bilateral systematic prostate biopsy (SBx) and TBx. Detection rates for csPCa (ISUP ⩾ 2), adjusted csPCa (ISUP ⩾ 3) and iPCa (ISUP = 1) were determined for SBx alone, TBx alone, contralateral SBx combined with TBx and ipsilateral SBx combined with TBx. A subgroup analysis was performed for biopsy-naive patients.Results:A total of 228 patients were included from October 2015 to September 2021. Prostate cancer (PCa) detection rate of combined SBx and TBx was 63.5% for csPCa, 35.5% for adjusted csPCa, and 14% for iPCa. The best performing alternative biopsy strategy was TBx and ipsilateral SBx, which reached a sensitivity of 98.6% (95% CI: 95.1–99.6) for csPCa and 98.8% (95% CI: 96.3–99.9) for adjusted csPCa, missing only 1.4% of csPCa, while reducing iPCa detection by 15.6% compared with SBx and TBx. TBx or SBx alone missed a significant amount of csPCa, with sensitivities of 90.3% (95% CI: 84.4–94.2) and 86.8% (95% CI: 80.4–91.4) for csPCa. Subgroup analysis on biopsy-naive patients showed similar results as the overall group.Conclusion:This study shows that performing TBx with ipsilateral SBx and omitting contralateral SBx is the optimal biopsy strategy in patients with a unilateral MRI lesion. With this strategy, a very limited amount of csPCa is missed and iPCa detection is reduced.

Using Prostate Imaging-Reporting and Data System (PI-RADS) Scores to Select an Optimal Prostate Biopsy Method: A Secondary Analysis of the Trio Study

BackgroundWhile magnetic resonance imaging (MRI)-targeted biopsy (TBx) results in better prostate cancer (PCa) detection relative to systematic biopsy (SBx), the combination of both methods increases clinically significant PCa detection relative to either Bx method alone. However, combined Bx subjects patients to higher number of Bx cores and greater detection of clinically insignificant PCa. ObjectiveTo determine if prebiopsy prostate MRI can identify men who could forgo combined Bx without a substantial risk of missing clinically significant PCa (csPC). Design, setting, and participantsMen with MRI-visible prostate lesions underwent combined TBx plus SBx. Outcome measurements and statistical analysisThe primary outcomes were detection rates for grade group (GG) ≥2 and GG ≥3 PCa by TBx and SBx, stratified by Prostate Imaging-Reporting and Data System (PI-RADS) score. Results and limitationsAmong PI-RADS 5 cases, nearly all csPCs were detected by TBx, as adding SBx resulted in detection of only 2.5% more GG ≥2 cancers. Among PI-RADS 3–4 cases, however, SBx addition resulted in detection of substantially more csPCs than TBx alone (8% vs 7.5%). Conversely, TBx added little to detection of csPC among men with PI-RADS 2 lesions (2%) relative to SBx (7.8%). ConclusionsWhile combined Bx increases the detection of csPC among men with MRI-visible prostate lesions, this benefit was largely restricted to PI-RADS 3–4 lesions. Using a strategy of TBx only for PI-RADS 5 and combined Bx only for PI-RADS 3–4 would avoid excess biopsies for men with PI-RADS 5 lesions while resulting in a low risk of missing csPC (1%). Patient summaryOur study investigated an optimized strategy to diagnose aggressive prostate cancer in men with an abnormal prostate MRI (magnetic resonance imaging) scan while minimizing the risk of excess biopsies. We used a scoring system for MRI scan images called PI-RADS. The results show that MRI-targeted biopsies alone could be used for men with a PI-RADS score of 5, while men with a PI-RADS score of 3 or 4 would benefit from a combination of MRI-targeted biopsy and systematic biopsy.This trial is registered at ClinicalTrials.gov as NCT00102544.

Spatial distribution of biopsy cores and the detection of intra-lesion pathologic heterogeneity.

Objectives:The objective of this study was to determine if spatial distribution of multiparametric magnetic resonance imaging–transrectal ultrasound (mpMRI-TRUS) fusion biopsy cores to the index lesion reveals trends in the detection of intra-lesion Gleason heterogeneity and a more optimal prostate biopsy strategy.Methods:Index lesion was the lesion with longest diameter on T2-weighted (T2W)-MRI. In cohort 1, fusion biopsy cores biopsies were taken in areas in the center of the target as well as 1 cm laterally on each side. For cohort 2, targeted biopsies were taken from the center of the lesion only. Heterogeneity was defined as difference in maximum Gleason score obtained from fusion cores in the center of the index lesion versus cores obtained from the periphery (cohort 1), or any difference in maximum Gleason score obtained from fusion cores targeted to the index lesion (cohort 2) compared with systematic 12 cores TRUS biopsy.Results:Ninety-nine consecutive patients (35 and 64 in cohorts 1 and 2, respectively) with median age (SD) and prostate-specific antigen (PSA) of 66.9 (±5.9) and 9.7 (±8.2) respectively, were included. Age, PSA, Prostate Imaging Reporting and Data System (PI-RADS) score, and preoperative MRI lesion size were not significantly different between cohorts. Gleason heterogeneity was observed at a significantly higher rate in cohort 1 versus cohort 2 (58% versus 24%; p = 0.041). In cohort 1, cores obtained from the center of the lesion had higher Gleason score than cores obtained from the periphery of the targeted lesion in 57% of cases.Conclusions:We demonstrate that there is observable tumor heterogeneity in biopsy specimens, and that increased number of cores, as well as cores focused on the center and periphery of the largest lesion in the prostate, provide more comprehensive diagnostic information about the patient’s clinical risk category than taking nonspecific cores targeted within the tumor.

A review of optimal prostate biopsy: indications and techniques.

Prostate biopsy is the gold standard diagnostic technique for the detection of prostate cancer. Patient selection for prostate biopsy is complex and is influenced by emerging use of prebiopsy imaging. The introduction of the magnetic resonance imaging (MRI)–transrectal ultrasound (TRUS) fusion prostate biopsy has clear advantages over the historical standard of care. There are several biopsy techniques currently utilized with unique advantages and disadvantages. We review and summarize the current body of literature pertaining to when and how a prostate biopsy should be performed. We discuss current recommendations regarding patient selection for biopsy and discuss future directions regarding prebiopsy imaging. We offer a description of the MRI–TRUS fusion biopsy technique and a comparison of many of the currently available fusion software platforms. Articles pertaining to the title were obtained via PubMed index search with relevant keywords supplemented with personal collection of related publications. Prostate biopsy should be considered for patients with gross digital rectal exam (DRE) abnormality, patients with a prostate-specific antigen (PSA) greater than 4 ng/ml, and concomitant risk factors for prostate cancer or patients with lesions identified on multiparametric MRI (mpMRI) with Prostate Imaging Reporting and Data System 2 (PI-RADS2) score of 4 or 5. MRI–TRUS fusion biopsy has demonstrated advantages in cancer detection when compared with TRUS-guided biopsy. There are currently several fusion software platforms available with a variety of biopsy approaches. Future efforts should detail the role of prebiopsy imaging as a triage tool for prostate biopsy. Consensus should be sought regarding the preferred modality of fusion biopsy. Additional data describing each fusion software platform would enable a more rigorous comparison of platform sensitivities.

TOP: Prospective Evaluation of a Volume Based, Computer Assisted Method for Transperineal Optimized Prostate Biopsy

Objective: This study is a prospective evaluation of a volume-based, computer-assisted method for transperineal optimized prostate (TOP) biopsy. The TOP algorithm automates core planning for systematic prostate biopsies using the 3-dimensional organ contour and an alterable volume for tumors to be excluded. Subjects and Methods: MRI-transrectal ultrasound fusion biopsy with MRI-targeted biopsies (TBs) and systematic-TOP biopsies were performed on 172 men between October 2013 and March 2014. Systematic biopsies were placed according to TOP for detection of tumor volumes >0.5 mL with a minimum of 80% organ coverage in prostates up to 50 mL (70% in larger organs). Results: Median 24 TOP cores and 3 MRI-TBs have been placed. Prostate cancer (PCa) was detected in 112 of 172 (65%) of men; TOP detected 109 (97%) and TB 62 (55%). Significant cancer (Gleason score ≥7) was detected in 75 (44%) of men and of these TOP detected 73 of 75 (97%) and TB 51 of 75 (68%). Overall, systematic-TOP sampling significantly outperformed TB for the detection of both, all PCa as well as significant PCa (p < 0.0001, p = 0.0005). Conclusion: The TOP method is innovative by integrating the individual prostate volume and PCa volume detection thresholds. In the present cohort, it diagnosed more significant tumors than TB alone. However, at the same time, more low-risk tumors are detected.

Repeated biopsy in the detection of prostate cancer: when and how many cores.

We performed an analysis of the literature about the optimal prostate biopsy (PBX) scheme in the repeated setting We performed a clinical and critical literature review by searching Medline Database from January 2005 up to January 2014. Electronic searches were limited to the English language. The keywords were: prostate cancer, prostate biopsy, transrectal ultrasound, transperineal prostate biopsy. The recommended approach in repeated setting is still the extended scheme (EPBx) (12 cores). An approach with more than 12 cores according to the clinical characteristics of the patients may optimize cancer detection. Saturation PBx (> 20 cores) clearly improves cancer detection if clinical suspicion persists after previous negative biopsy. Nevertheless international guidelines do not strongly recommended SPBx in all situations of repeated setting. EPBx or SPBX may be, in the future, substituted by multiparametric MRI-targeted biopsies. Since the scenario in which a PBx is changing, the issue about the number and location of the cores in PBx is still a matter of debate in repeated setting. At present, EPBx are still the gold standard even if SPBx seems to be necessary in many cases. However, random PBx does not represent the approach of the future, but rather imaging targeted biopsy.

Reply

The goal of our analyses was to rationally stratify patients diagnosed with low-risk prostate cancer who were potentially eligible for active surveillance (AS) according to the scheme adopted at prostate biopsy. In this specific context, we demonstrated that patients who fulfilled the inclusion criteria for AS according to the Prostate Cancer Research International: Active Surveillance (PRIAS) study 1 Bul M. Zhu X. Valdagni R. et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013; 63: 597-603 Abstract Full Text Full Text PDF PubMed Scopus (387) Google Scholar with ≤12 cores taken at initial biopsy had a significantly lower probability of having an insignificant cancer confirmed and a higher risk of harboring an unfavorable disease at radical prostatectomy as compared with those patients whose biopsies consisted of 13-18 cores and 13-18 or ≥19 cores, respectively. Editorial CommentUrologyVol. 84Issue 3PreviewIn light of the increased role of prostate cancer risk stratification and wider introduction of active surveillance (AS) protocol for very low and low-risk prostate cancer in clinical practice, this article represents a significant input in development of initial optimal prostate biopsy protocol. In fact, in this manuscript authors used the criteria for AS according to Prostate Cancer Research International: Active Surveillance (PRIAS) study criteria. In fact, recently published short-term data from the PRIAS study comprise the world's largest patient cohort treated with AS protocol (ref.11). Full-Text PDF

Editorial Comment

In light of the increased role of prostate cancer risk stratification and wider introduction of active surveillance (AS) protocol for very low and low-risk prostate cancer in clinical practice, this article represents a significant input in development of initial optimal prostate biopsy protocol. In fact, in this manuscript authors used the criteria for AS according to Prostate Cancer Research International: Active Surveillance (PRIAS) study criteria. In fact, recently published short-term data from the PRIAS study comprise the world's largest patient cohort treated with AS protocol (ref.11).

Optimal Prostate Biopsy Regimen

The prostate-specific antigen (PSA) era has increased the rates of prostate cancer detection and treatment, while reducing the risk of death from prostate cancer in the US. Image-guided prostate biopsy techniques have led to stage migration and the detection and treatment of lower risk prostate cancers. Improved techniques with laterally directed biopsy, office-based saturation biopsy, and transperineal biopsy under anesthesia have increased the detection rates of smaller volume tumors. Improved detection of ever-smaller tumors assists the clinician in determining what treatment is most appropriate for the patient, including the use of active surveillance and focal therapy. Furthermore, the detection of small volume, high grade cancers may widen the latency interval in which a clinically significant tumor may be detectable and curable.

Investigation of Optimal Prostate Biopsy Schemes for Chinese Patients with Different Clinical Characteristics

Purpose: To investigate the optimal schemes of prostate biopsy according to prostate volume (PV), age and transrectal ultrasound (TRUS) status in Chinese men. Methods: 923 consecutive patients who underwent initial TRUS-guided systematic 12-core prostate biopsy (12PBx) were enrolled in this study. The 12PBx was obtained by overlapping of conventional sextant, lateral base, mid-gland of peripheral zone and apex. Each sample was individually marked and inked before fixation. Patients were divided into 8 subgroups on the basis of independent risk factors investigated using logistic regression model. Subsequently, 12PBx was defined as self-control for the analysis of biopsy schemes (6-, 8- and 10PBx) on individual core basis. The prostate cancer detection rates (CDRs) of 6-, 8-, 10- and 12PBx were compared for each individual subgroup. Results: The 12PBx detected 253 (27.4%) cases of prostate cancer (PCa), of which 67.2, 47.1 and 61.3% were located in the base, mid-gland and apex, respectively. Multivariate analysis indicated that age, TRUS status and PV were independent risk factors for PCa detection. CDR increased with increasing biopsy cores. However, for patients with age ≥65 years, positive TRUS and PV <38.5 cm³, CDR of 8PBx (30.6%) was similar to 10PBx (32.2%) and 12PBx (32.2%); for patients with age ≥65 years, negative TRUS and PV <38.5 cm³ or ones with age ≥65 years, positive TRUS and PV ≥38.5 cm³, 10PBx was as effective as 12PBx in detecting PCa (27.8, 27.5 vs. 28.9, 29.3%, respectively). Conclusion: Age, TRUS status and PV were independent risk factors for PCa detection. Traditional sextant biopsy is not recommended. 8-, 10-, or 12PBx as an individual biopsy scheme might be adopted according to these risk factors for Chinese patients.

Prostate Biopsies and the Vienna Nomograms

Introduction and objective Discordant data still persists regarding the optimal prostate biopsy scheme to be used, the correct timing for performing repeat biopsy in high risk patients as well as the ability of clinical variables to predict prostate cancer. The aim of this review is to provide a comprehensive assessment of different prostate biopsy approaches and to evaluate the role of clinical variables in predicting the presence of prostate cancer (PCa) at biopsy. Methods Analysis of published full-length papers that were identified through Medline search from January 1980 through January 2006. Abstracts published in peer-reviewed journals from the same period were also considered. Results Several groups have proposed new biopsy strategies, often increasing the number of biopsies and the sectors to be sampled or performing biopsies more laterally. However, controversial data have been reported about the real advantage of these new techniques. Moreover, several studies report that sextant biopsies still do not represent an appropriate tool for PCa detection, especially in large prostates. Our nomogram based on patient age and gland volume provides the minimum number of cores needed to accurately detect cancer and it is associated with a 90% sensistivity of PCa detection. Furthermore, several evidences report that, in case of negative initial biopsy, cancers detected on repeat biopsy have similar stage, grade distribution and total PSA values compared to cancers found on initial biopsy. On the contrary, cancers detected on third and fourth systematic biopsy show characteristics of “insignificant” cancers. Among the available clinical predictors, % free PSA and PSA-Transition Zone showed to be the best markers for repeat prostate biopsy, increasing sensitivity and specificity for prostate cancer detection. Conclusions Traditional sextant biopsies might become obsolete in future designed trials since a body of evidence supports the findings that this technique is far from optimal in patients with large prostates. The combination of prostate size and patient age can help physicians in determining the most appropriate prostate biopsy sampling for PCa detection. Due to the high rate of insignificant prostate cancer detected, a systematic repeat biopsy after the second negative biopsy in a PSA range of 2.5–10 ng/ml is not indicated and PSA based watchful waiting should be advocated. Finally, % free PSA and PSA-Transition Zone should be included in predicting models for prostate cancer detection at repeat biopsy.

Development and evaluation of optimal prostate biopsy protocols for individual groups of patients

We have developed a number of optimal biopsy protocols for the detection of prostate cancer for both general and specific groups of patients. Age, race and prostate volume were considered in the development and optimal protocols were developed for individual patients based on these factors. Experimental results showed that optimal 6-needle protocols outperformed traditional sextant protocol for all age, race and prostate volume groups of patients, and the difference is statistically significant. We did not find significant improvements for developing protocols for age-specific, race-specific or prostate volume-specific patients in this preliminary study. Our results also indicated that more biopsy cores should be used in older men to achieve a targeted detection rate.

Optimized prostate biopsy via a statistical atlas of cancer spatial distribution

A methodology is presented for constructing a statistical atlas of spatial distribution of prostate cancer from a large patient cohort, and it is used for optimizing needle biopsy. An adaptive-focus deformable model is used for the spatial normalization and registration of 100 prostate histological samples, which were provided by the Center for Prostate Disease Research of the US Department of Defense, resulting in a statistical atlas of spatial distribution of prostate cancer. Based on this atlas, a statistical predictive model was developed to optimize the needle biopsy sites, by maximizing the probability of detecting cancer. Experimental results using cross-validation show that the proposed method can detect cancer with a 99% success rate using seven needles, in these samples.

Prostate biopsy: how many cores are enough?

Systematic prostate biopsy has revolutionized our ability to detect prostate cancer. Sextant biopsies were the mainstay of cancer detection since their inception in 1989. Over the past several years more extensive systematic prostate sampling has been introduced and has demonstrated an improved ability to detect prostate cancer. The optimal prostate biopsy scheme should be easy to perform, be able to be done in the clinic without intravenous sedation or general anesthetic, provide a high sensitivity for cancer detection, and have a low complication rate. We review several studies evaluating various biopsy schemes for both initial and repeat biopsy patients and propose an optimal biopsy scheme.