AUA 2022: Upfront MRI Is the New Standard, Have Confirmatory Biopsies Become Obsolete?

( In a podium presentation at the 2022 American Urologic Association Annual Meeting held in New Orleans and virtually, Dr. De Vos discussed the question of whether confirmatory biopsies are still required for patients on active surveillance, given the widespread utilization of upfront magnetic resonance imaging (MRI) prior to diagnostic biopsy. Notably, this is a question where there is discordance between guidelines: while the AUA guidelines recommend confirmatory biopsies in all patients within two years after diagnosis (a practice based on historical approaches), the EAU guidelines recommend refraining from confirmatory biopsies during active surveillance in patients diagnosed with upfront MRI.

The authors sought to examine the risk difference for grade group (GG) reclassification on confirmatory biopsies between patients included with and without upfront MRI. To do so, they relied on data from the PRIAS study, a multicenter prospective study providing clinical data of patients on active surveillance. In this analysis, the authors selected patients diagnosed with or without upfront MRI, who underwent (a second) MRI before confirmatory biopsies.

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Following MRI, all patients underwent targeted biopsies (±systematic biopsies) of lesions PIRADS ≥3. Where there was no identifiable lesion on MRI, patients underwent systematic biopsy. The authors used multivariable logistic regression analysis to determine the risk difference for GG reclassification at confirmatory biopsies between patients included with and without upfront MRI.

They identified 732 patients underwent MRI informed confirmatory biopsies at a median PSA of 6.4 (interquartile range 4.6-8.4) ng/ml of whom 553 did not have an initial upfront MRI and 262 who did. As is shown below, baseline characteristics of these groups were relatively comparable.

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At confirmatory biopsy, 108 (21%) patients without upfront MRI were reclassified whereas 39 (19%) patients with upfront MRI were reclassified. Reclassification to high-grade histology (GG ≥3) was seen in 6% and 7% of patients without and with upfront MRI, respectively. No significant difference in risk for reclassification at confirmatory biopsies was seen between the two groups (OR 1.11 (95%CI 0.72-1.73), p=0.6) in multivariable regression models, whereas MRI outcome, DRE outcome and PSA density were significant predictors for reclassification.

Thus, the authors conclude that upfront MRI does not reduce reclassification rates at confirmatory biopsy and, as such, does not support the notion that confirmatory biopsies can be omitted if MRI is used upfront.

Presented by: Ivo De Vos, MD, MSc, Erasmus Medical Centre

Written by: Christopher J.D. Wallis, University of Toronto Twitter: @WallisCJD during the 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.

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