Perilesional Biopsies Enhance Detection of Clinically Significant Prostate Cancer

Overview

This prospective, surgeon-blinded study evaluated the addition of six perilesional biopsies (PB) to standard systematic (SB) and targeted biopsies (TB) in men with suspicious prostate MRI findings. The addition of PB improved detection rates of clinically significant prostate cancer (csPCa) without increasing detection of clinically insignificant cancer (ciPCa).

Background

Multiparametric MRI followed by combined systematic and MRI-ultrasound fusion targeted biopsies is the current gold standard for prostate cancer diagnosis per EAU guidelines. However, the role of perilesional biopsies, sampling the tissue surrounding MRI-identified lesions, remains under investigation. Prior studies suggest that up to 15% of csPCa may be missed without systematic biopsies, and that approximately 86% of csPCa lie within 10 mm of the MRI lesion. This study aimed to assess whether adding PB could replace systematic biopsies without loss of csPCa detection.

Data Highlights

The study enrolled men with PSA 4-20 ng/ml and prostate volume ≤100 ml, excluding prior prostate interventions or cancer. Each patient underwent a blinded 12-core systematic biopsy, followed by 3-5 targeted biopsies and 6 perilesional biopsies around the MRI lesion. The primary outcome was csPCa detection (ISUP grade ≥2), comparing SB+TB alone versus SB+TB+PB. Secondary outcome was detection of ciPCa (ISUP grade 1).

Key Findings

• Adding six perilesional biopsy cores around the MRI lesion increased detection rates of clinically significant prostate cancer compared to standard systematic plus targeted biopsies alone.
• The addition of PB did not lead to an increased detection of clinically insignificant prostate cancer, maintaining diagnostic specificity.
• The study design minimized operator bias by performing systematic biopsies blinded to MRI findings before targeted and perilesional biopsies.
• Approximately 86% of csPCa were detected within a 10 mm radius of the MRI-identified lesion, supporting the rationale for perilesional sampling.
• The study was conducted in a real-life clinical setting with MRI scans from multiple institutions, enhancing generalizability.

Clinical Implications

Incorporating perilesional biopsies into the prostate biopsy protocol may improve detection of clinically significant prostate cancer without increasing overdiagnosis of insignificant disease. This approach could potentially reduce the need for extensive systematic biopsies, decreasing patient morbidity while maintaining diagnostic accuracy. Clinicians should consider perilesional sampling especially in patients with PI-RADS ≥3 lesions to optimize biopsy yield.

Conclusion

This prospective, surgeon-blinded study demonstrates that adding perilesional biopsies to standard systematic and targeted biopsy protocols enhances detection of clinically significant prostate cancer without increasing detection of clinically insignificant disease. These findings support further integration of perilesional sampling into prostate cancer diagnostic pathways.

References

1. EAU Guidelines 2019 -- Multiparametric MRI in Prostate Cancer Diagnosis
2. ISUP Grade Group Definitions -- Clinically Significant Prostate Cancer
3. Previous Multi-center Randomized Studies -- Combined Biopsy Approaches
4. Studies on Perilesional Biopsies -- Detection Rates and Biopsy Strategies