Do patients with a PI-RADS 5 lesion identified on magnetic resonance imaging require systematic biopsy in addition to targeted biopsy?

Magnetic Resonance Imaging (MRI)-targeted prostate biopsy (MRI-TB) improves the detection of prostate cancer. These biopsies typically involve both a 12-core systematic biopsy (SB) and MRI-TB of the lesion. Since the majority of PI-RADS 5 lesions represent clinically significant cancers, the utility of SB in addition to MRI-TB is unclear. We evaluate the utility of SB in the setting of PI-RADS 5 lesions in biopsy naïve and active surveillance patients.

Patients undergoing MRI-TB+SB with a PI-RADS 5 lesion were retrospectively reviewed in a prospectively collected database. Pathology obtained from the MRI-TB was then compared to that of the SB, and each was reported based on the highest Gleason Grade from the sample. In patients with a prior biopsy, we identified instances in which the MRI-TB+SB resulted in upgraded pathology and further subdivided these patients based on whether the pathology upgrade was a result of the TB or the SB.

We identified PI-RADS 5 lesions in 97 patients. All lesions biopsied were found to be prostate cancer, and 86.9% were clinically significant. Gleason Grade from the MRI-TB of the PI-RADS 5 lesions was the same or higher to that of the SB in all but 3 cases (3.1%). Among 59 patients with a prior prostate biopsy, 54 had upgraded pathology from MRI-TB+SB (91.5%). Of these 54 patients, MRI-TB pathology of the PI-RADS 5 lesion was the same or higher to that of the SB in 52 patients (96.3%). In all patients with higher Gleason Grade on SB than MRI-TB, the MRI-TB demonstrated GG3 or higher and SB did not change subsequent clinical management.

In the presence of a PI-RADS 5 lesion, SB offers minimal additional clinical value and could potentially be omitted when performing MRI-TB.

Urologic oncology. 2021 Jan 12 [Epub ahead of print]

Justin N Drobish, Mark D Bevill, Chad R Tracy, Shawn M Sexton, Maheen Rajput, Catherine M Metz, Paul T Gellhaus

Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA., Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA., Carver College of Medicine, University of Iowa, Iowa City, IA., Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA., Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA. Electronic address: .