Department of Urology, Ankara Etlik City Hospital, Ankara, Turkey.
Department of Radiology, School of Medicine, Ankara University, Ankara, Turkey.
Clin Genitourin Cancer. 2024 Jun;22(3):102071. doi: 10.1016/j.clgc.2024.102071. Epub 2024 Mar 8.
Recent guidelines suggest that biopsy may be omitted in some groups of patients with PI-RADS 3 lesions on mpMRI. In this study, we aimed to evaluate biopsy strategies involving prostate-specific antigen density (PSAd) to avoid unnecessary biopsy versus the risk of missing clinically significant prostate cancer (csPCa) in patients with PI-RADS 3 lesions.
Data of 616 consecutive patients who underwent PSAd and mpMRI before prostate biopsy between January 2017 and January 2022 at a single center were retrospectively assessed. All of these patients underwent combined cognitive or fusion targeted biopsy of suspicious lesions and transrectal ultrasonography guided systematic biopsy. PI-RADS 3 based strategies with PSAd and mpMRI combination were created. For each strategy, avoided unnecessary biopsy, reduced ISUP Grade 1, and missed ISUP Grade ≥ 2 ratios were determined. Decision curve analysis (DCA) was used to statistically compare the net benefit of each strategy.
DCA revealed that patients who had PI-RADS 3 lesions with PSAd ≥ 0.2, and/or patients who had PI-RADS 4 and 5 lesions had the most benefit, under the threshold probability level between 10% and 50%, which avoided 48.2% unnecessary prostate biopsies and reduced 51% of ISUP grade 1 cases, while missed 17.5% of ISUP grade ≥ 2 cases. (22.1% for ISUP grade 2 and 8.8% for ISUP grade ≥ 3). Strategy 1 (PI-RADS 4-5 and/or PSAd ≥ 0.2), 3 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15), and 7 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15 and/or PI-RADS 2 if PSAd ≥ 0.2) were the next three best strategies.
mpMRI combined with PSAd strategies reduced biopsy attempts in PI-RADS 3 lesions. Using these strategies, the advantage of avoiding biopsy and the risk of missing the diagnosis of csPCa can be discussed with the patient, and the biopsy decision can be made afterwards.
最近的指南建议，对于磁共振成像前列腺影像报告和数据系统（PI-RADS）评分 3 分的某些患者群体，可能可以省略活检。在这项研究中，我们旨在评估涉及前列腺特异性抗原密度（PSAd）的活检策略，以避免对 PI-RADS 3 分病变患者进行不必要的活检，同时降低漏诊临床显著前列腺癌（csPCa）的风险。
回顾性分析了 2017 年 1 月至 2022 年 1 月期间在一家单中心接受 PSAd 和 mpMRI 检查后行前列腺活检的 616 例连续患者的数据。所有患者均接受可疑病灶的融合靶向或认知活检以及经直肠超声引导的系统活检。制定了基于 PI-RADS 3 分的 PSAd 和 mpMRI 联合策略。对于每种策略，确定了避免不必要的活检、降低 ISUP 分级 1 以及漏诊 ISUP 分级≥2 的比例。采用决策曲线分析（DCA）对每种策略的净获益进行统计学比较。
DCA 显示，在阈值概率水平在 10%至 50%之间，对于 PI-RADS 3 分病变且 PSAd≥0.2 的患者，以及对于 PI-RADS 4 和 5 分病变的患者，具有最大获益，避免了 48.2%的不必要前列腺活检，降低了 51%的 ISUP 分级 1 病例，同时漏诊了 17.5%的 ISUP 分级≥2 病例（ISUP 分级 2 为 22.1%，ISUP 分级≥3 为 8.8%）。策略 1（PI-RADS 4-5 分和/或 PSAd≥0.2）、3（PI-RADS 4-5 分和/或 PSAd≥0.15 分且 PI-RADS 3 分）和 7（PI-RADS 4-5 分和/或 PSAd≥0.15 分且 PI-RADS 3 分且 PSAd≥0.2 分）是接下来的三个最佳策略。
mpMRI 联合 PSAd 策略可减少 PI-RADS 3 分病变的活检次数。使用这些策略，可以与患者讨论避免活检的优势和漏诊 csPCa 的风险，并随后做出活检决策。
