Djin - I'm wondering about your last comment there in re targeted biopsies. I hadn't heard that before and would love it if you had time to elaborate as I did indeed have an mpMRI followed by a targeted biopsy!
Be happy to. My comments were directed especially at biopsy-naive men, and not so much men on AS, BTW.
In favor of Targets (only):MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis
(2018, Full Text)
"Fourth, it is possible that clinically significant cancers may have been missed by the omission of standard biopsy cores in men in the MRI-targeted biopsy group. Previous well-designed studies have highlighted that the percentage of cases of clinically significant cancer that are missed by MRI-targeted biopsy but detected by standard transrectal ultrasonography–guided biopsy is low, between 0% and 10%.12,13,23,28 Despite more than one quarter of the men avoiding a biopsy, this trial showed that when clinicians limited themselves to the use of MRI-targeted biopsies only, the rates of detection of clinically significant cancer were higher than those seen with the standard of care. Furthermore, because systematic biopsy was avoided, clinically insignificant cancer was detected in fewer men, which may have a substantial benefit in reducing the overtreatment of men with prostate cancer. If both systematic biopsy and MRI-targeted biopsy were carried out in the same man at the same time, the performance of one test could be influenced by the other, which would make it difficult to evaluate the unbiased performance of each test individually"
On the other side to various degrees:Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging and Fusion Guided Targeted Biopsy Evaluated by Transperineal Template Saturation Prostate Biopsy for the Detection and Characterization of Prostate Cancer
Multiparametric magnetic resonance imaging alone should not be performed as a triage test due to a substantial number of false-negative cases with clinically significant prostate cancer. Systematic biopsy outperformed fusion guided targeted biopsy. Therefore, it will remain crucial in the diagnostic pathway of prostate cancer."Targets missed: predictors of MRI-targeted biopsy failing to accurately localize prostate cancer found on systematic biopsy
Clinically significant PCa is rarely missed utilizing MRI/US fusion-guided biopsy. With the majority of missed tumors representing targeting misregistrations or cases of low-grade cancer in sextants immediately adjacent to MRI suspicious lesions. Lower MRI lesion volumes, lesion density, and PI-RADS are predictors of cases with targeted biopsies missing cancer, for which systematic sampling of the sextants containing MRI targets and adjacent sextants would most optimize PCa detection."How many cores are needed to detect clinically significant prostate cancer on targeted MRI-ultrasound fusion biopsy?
"Conclusions: On a per-lesion basis, sampling two cores of mpMRI-evident lesions at the time of fusion biopsy misses nearly one-quarter of clinically significant PCa that would be detected on additional sampling."A critical comparison of techniques for MRI-targeted biopsy of the prostate
(2017, Full Text)
"The European Association of Urology advise performing a multiparametric magnetic resonance imaging (mpMRI) study when initial standard biopsy results are negative but the suspicion of prostate cancer persists (2). This has been echoed by a joint consortium of the American Urology Association and the Society of Abdominal Radiology, which states that where high quality mpMRI is available, it should be strongly considered for men in whom a repeat biopsy is considered (5). In addition, the National Comprehensive Cancer Network (NCCN) guidelines advise the use of mpMRI prior to repeat biopsy, with mpMRI-targeted cores to be considered in addition to standard cores (6).
[Emphasis mine]There Is No Way to Avoid Systematic Prostate Biopsies in Addition to Multiparametric Magnetic Resonance Imaging Targeted Biopsies
(2020, Full Text)
"Results and limitations
In the European cohort, csPCa detection rate was 55%. The csPCa detection rate for TRUS-Bx was 41%. At MVAs, prostate volume, previous negative biopsy, and Prostate Imaging Reporting and Data System versions 4 and 5 were independent predictors for the presence of csPCa outside the IL. The multivariable model had an AUC of 0.78. Omitting TRUS-Bx in patients with a calculated risk of <15% would have spared 16% of TRUS-Bx at the cost of missing 7% of csPCa. Similar findings were obtained when the same analyses were performed in the North American cohort. No net benefit was observed for low-threshold probabilities (<15%) of the each model relative to the standard of care (performing TRUS-Bx in addition to MRI-TBx to all patients) in both cohorts. The study is limited by its retrospective design.
We failed to identify those patients who might safely benefit from MRI-TBx alone. The combination of MRI-TBx and TRUS-Bx should strongly be considered the best available approach.
Patient summaryIn the presence of positive multiparametric magnetic resonance imaging (mpMRI) of the prostate, physicians should always perform systematic sampling of the prostate in addition to mpMRI targeted biopsy.
[Emphasis mine]Performance of systematic, MRI-targeted biopsies alone or in combination for the prediction of unfavourable disease in MRI-positive low-risk prostate cancer patients eligible for active surveillance
High grade on TB biopsies represented the major predictor of upgrading. Combination of SB and TB better defined the sub-group of patients having the lowest risk of reclassification, compared with TB or SB alone. The risk of non-organ-confined disease remained high, and could not be accurately predicted by MRI or systematic/targeted biopsy features."
(TB = Targeted; SB = Systemic)MRI/Ultrasound Fusion Biopsy Versus Standard 12-Core Biopsy
"Combining targeted and standard biopsy led to the diagnosis of 103 (22%) additional cases, but the vast majority (83%) were Gleason 6 or low-volume Gleason 3 + 4, and only 5% were classified as high-risk. The authors estimated that 200 men would need to undergo standard biopsy in addition to targeted biopsy to find one case of high-risk prostate cancer. Meanwhile, 17 extra low-risk cancers would be detected per each additional high-risk cancer diagnosed"
[However, now we can use genomics to select G6 men who are not good AS candidates because they are high risk for forming higher-grade lesions with met potential]Does the addition of standard systematic biopsies to targeted prostate biopsies influence treatment choices for patients and clinicians?
"Addition of standard systematic prostate biopsy to targeted biopsy in patients with elevated PSA and no prior systematic prostate biopsy within the preceding 3 years detected PCa GS ≥ 7 on the opposite side of the prostate from the target lesions (with no significant abnormalities on mp-MRI) in 13% of patients. This result may influence treatment choices, particularly for those patients considering focal therapy for PCa."
(I'm still looking for at least one other paper that concluded the standard cores should be added to the targets.) For me this seems like a no-brainer. You are there on the table, numbed up, not going anywhere for the moment. You doc has his biopsy wand you know where. I've seen a number of forum Brothers whose PIRADS 5 lesion turned out not to be cancer, but whose random core(s) hit clinically significant PCa. We know both biopsies and MRIs miss existing cancer. I do not see any good reason for not taking the standard cores in all prostate zones.
Post Edited (DjinTonic) : 3/2/2020 2:53:49 PM (GMT-7)