Clinical Scorecard: The Enhanced Role of Systematic Biopsy in Men Suspected of Prostate Cancer Undergoing Biparametric MRI-Guided Biopsy: A Multi-Center Validation Study

At a Glance

Key Highlights

• Biparametric MRI (bpMRI) offers a simplified, contrast-free imaging protocol to detect and localize prostate cancer lesions.
• MRI-targeted biopsy (TBx) shows superiority over systematic biopsy (SBx) but omitting SBx risks missing 10-16% of clinically significant prostate cancers.
• A nomogram based on MRI volumetric parameters and clinical data was developed and validated to guide when SBx should be added to TBx.

Guideline-Based Recommendations

Diagnosis

• Perform biparametric MRI using IMPROD protocol for men with suspected prostate cancer.
• Use MRI-targeted biopsy of suspicious lesions identified on bpMRI.
• Consider systematic biopsy in addition to targeted biopsy to reduce risk of missing csPCa, especially in cases with smaller lesions or large prostate volume.

Management

• Use cognitive targeting or MRI-TRUS fusion platforms for biopsy targeting.
• Perform 12-core systematic biopsy following targeted biopsy to maximize detection of csPCa.
• Apply multivariable models incorporating MRI volumetric parameters to decide on the necessity of systematic biopsy.

Monitoring & Follow-up

• Evaluate biopsy results using Gleason grading system by experienced uropathologists blinded to MRI findings.
• Monitor rates of clinically significant and insignificant prostate cancer detection in both TBx and SBx cores.

Risks

• Systematic biopsy increases risks of infection, bleeding, and pain due to additional core sampling.
• Higher detection of clinically insignificant prostate cancer with SBx may lead to overtreatment.
• Omitting SBx risks missing 10-16% of clinically significant prostate cancers.

Patient & Prescribing Data

Men with suspicious biparametric MRI findings (Likert/PIRADS score > 2) undergoing prostate biopsy.

Combining TBx with SBx improves detection of clinically significant prostate cancer; decision to omit SBx should be guided by MRI volumetric parameters and clinical risk models.

Clinical Best Practices

• Use biparametric MRI protocols without contrast to reduce costs and increase accessibility.
• Ensure MRI images are reported by experienced radiologists and centrally reviewed for consistency.
• Perform both targeted and systematic biopsies to optimize detection of clinically significant prostate cancer until predictive models are validated.
• Use volumetric analysis of prostate and lesion size to inform biopsy strategy.
• Maintain blinded pathology review to avoid bias in Gleason grading.

References

• IMPROD and MULTI-IMPROD trial protocols and data
• MULTI-IMPROD trial data
• Twitter series on imaging findings