Individualized Decision Making in Transperineal Prostate Biopsy: Should All Men Undergo an Additional Systematic Biopsy?

SIMPLE SUMMARY: In the last few years, multiparametric magnetic resonance imaging (mpMRI) has been implemented in the diagnostic prostate cancer pathway for the identification of cancerous lesions, and consecutively, targeted fusion biopsy was implemented. In some cases, aggressive prostate cancer is missed by a targeted biopsy. To address this imperfection, additional systematic biopsy is recommended but may be harmful in terms of the additional diagnosis of indolent cancer, and the higher frequency of adverse events and resource expenditures. This study investigates whether all men should undergo an additional systematic biopsy within this clinically relevant trade-off. As a key finding, men with an mpMRI-lesion classified as PI-RADS 5 may obviate additional systematic biopsy. This was confirmed when we analyzed histopathological reclassification rates between biopsy and a subsequent radical prostatectomy. ABSTRACT: Background: In prostate cancer (PC) diagnosis, additional systematic biopsy (SB) is recommended to complement MRI-targeted biopsy (TB) to address the limited sensitivity of TB alone. The combination of TB+SB is beneficial for diagnosing additional significant PC (sPC) but harmful in terms of the additional diagnosis of indolent PC (iPC), morbidity, and resource expenditures. We aimed to investigate the benefit of additional SB and to identify predictors for this outcome. Methods: We analyzed the frequency of upgrading to sPC by additional SB in a retrospective single-center cohort of 1043 men. Regression analysis (RA) was performed to identify predictors for this outcome. Reclassification rates of ISUP grade groups between prostate biopsy and a subsequent radical prostatectomy were assessed. Results: Additional SB led to upgrading to sPC in 98/1043 men (9.4%) and to the additional diagnosis of iPC in 71/1043 (6.8%). In RA, men harboring a PI-RADS 2-4 lesion were more likely to have TB results upgraded by SB (p < 0.01) compared to PI-RADS 5 men. When analyzing reclassification rates, additional SB reduced the upgrading to sPC from 43/214 (20.1%) to 8/214 (3.7%). In the PI-RADS 5 subgroup, this difference decreased: 4/87 (4.7%) with TB only vs. 1/87 (1.2%) with TB+SB. Conclusion: Men with a PI-RADS 5 lesion may obviate additional SB.