Magnetic resonance imaging-ultrasound fusion-targeted biopsy combined with systematic 12-core ultrasound-guided biopsy improves the detection of clinically significant prostate cancer: Are we ready to abandon the systematic approach?

Background: Multiparametric (mp) magnetic resonance imaging (MRI)-ultrasound fusion-targeted biopsy (TB) has improved the detection of clinically significant prostate cancer (csCaP) using the Prostate Imaging Reporting and Data System (PI-RADS) reporting system, leading some authors to conclude that TB can replace the 12-core systematic biopsy (SB). We compared the diagnostic performance of TB with SB at our institution.

Methods: Eighty-three men with elevated prostate-specific antigen levels (6.6 ng/mL, interquartile range [IQR] 4.5-9.2) and abnormal mp-MRI (127 lesions, PI-RADS ≥3, median size: 1.1 cm, IQR 0.8-1.6) underwent simultaneous TB and SB. Diagnosis of any CaP (Gleason score, [GS] ≥6) and csCaP (GS ≥7) was compared using the McNemar's exact test.

Results: SB showed higher, but not statistically significant, detection rates of any CaP and csCaP (51.8% and 34.9%) versus TB (44.6% and 28.9%) ( = 0.286 and = 0.359, respectively). TB outperformed SB in the quantification of 56.6% CaP and detecting cancer in anterior sectors (7.2%). Compared to SB, TB missed twice the amount of any CaP and csCaP. SB alone detected 22.2% of all csCaPs and upgraded 20.6% of TB-detected CaP. SB identified cancer invisible on mp-MRI (13.7% of all CaP) or missed by TB due to a small size (<1 cm) and sampling error (7% of lesions).

Conclusion: A combination of SB with TB remained necessary for achieving the highest cancer detection rates. Limiting prostate biopsy to TB alone can miss csCaP due to the presence of synchronous high-grade cancer invisible on MRI or failure to hit the target. TB is the best approach for anterior lesions and tumor quantification.