Optimal biopsy approach for detection of clinically significant prostate cancer

Abstract

Prostate cancer (PCa) diagnostic and therapeutic work-up has evolved significantly in the last decade, with pre-biopsy multiparametric MRI now widely endorsed within international guidelines. There is potential to move away from the widespread use of systematic biopsy cores and towards an individualised risk-stratified approach. However, the evidence on the optimal biopsy approach remains heterogeneous, and the aim of this review is to highlight the most relevant features following a critical assessment of the literature. The commonest biopsy approaches are via the transperineal (TP) or transrectal (TR) routes. The former is considered more advantageous due to its negligible risk of post-procedural sepsis and reduced need for antimicrobial prophylaxis; the more recent development of local anaesthetic (LA) methods now makes this approach feasible in the clinic. Beyond this, several techniques are available, including cognitive registration, MRI–Ultrasound fusion imaging and direct MRI in-bore guided biopsy. Evidence shows that performing targeted biopsies reduces the number of cores required and can achieve acceptable rates of detection whilst helping to minimise complications and reducing pathologist workloads and costs to health-care facilities. Pre-biopsy MRI has revolutionised the diagnostic pathway for PCa, and optimising the biopsy process is now a focus. Combining MR imaging, TP biopsy and a more widespread use of LA in an outpatient setting seems a reasonable solution to balance health-care costs and benefits, however, local choices are likely to depend on the expertise and experience of clinicians and on the technology available.

Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway

“…When MRI is positive (PI-RADS ≥3), systematic sampling of the background gland is recommended in addition to 2-4 target biopsies, with 12 cores typically taken through transrectal biopsy and up to 24 cores taken through transperineal approaches 2,52,53 . When target cores are negative, tumours have been shown to be localised in areas adjacent to the target, supporting the benefit of taking additional "perilesional" or "focal saturation" biopsies around the tumour-suspicious region 8,51,54,55 ; thus, MRI-directed sampling could potentially limit the overall number of cores required. Pathologists will typically report the biopsy samples according to the ISUP guidelines 56 .…”

“…When a lesion is identified, a biopsy will typically be performed through transrectal or transperineal route; options include lesion targeting either in the MRI suite, using a freehand "cognitive" approach, or using MRI-ultrasound systems, which combine the existing MR images with a peri-procedural real time ultrasound. The latter approach requires the prostate gland to be segmented on each modality for image fusion, and the target to be outlined on the diagnostic MR images 51 . When MRI is positive (PI-RADS ≥3), systematic sampling of the background gland is recommended in addition to 2-4 target biopsies, with 12 cores typically taken through transrectal biopsy and up to 24 cores taken through transperineal approaches 2,52,53 .…”

“…Fusion software should undergo regular manufacturer-specific QC assessment, which might include phantom studies 123 . The commercially available MRTB-fus systems can be divided into two main groups: rigid and elastic image fusion 51 . The rigid systems use anatomical landmarks to fuse the prostate contour from MRI with real-time ultrasound images 51 .…”

“…The commercially available MRTB-fus systems can be divided into two main groups: rigid and elastic image fusion 51 . The rigid systems use anatomical landmarks to fuse the prostate contour from MRI with real-time ultrasound images 51 . Elastic fusion systems use contours from both MRI and ultrasound images, and the software subsequently uses both contours to correct for deformation and movement of the prostate during the biopsy procedure 124 .…”

Comparison of MRI-guided Ultrasound Fusion Biopsy and Cognitive Targeted Biopsy in the Diagnosis of Clinically Significant Prostate Cancer: Lesion Size Matters

“…As the 2nd most prevalent male malignancy, prostate cancer (PCa) caused over 30,000 deaths in the United States in 2022 1 . Moreover, PCa was also estimated to have 12% increased from 2001 to 2035 2 and about 15% male would be diagnosed to have PCa throughout their lifetimes 3 .…”