Long Depaquit Thibaut, Uleri Alessandro, Peyrottes Arthur, Corral Renaud, Toledano Harry, Chiron Paul, Bastide Cyrille, Baboudjian Michael
Department of Urology, HIA Sainte-Anne, Toulon, France; Department of Urology, North Hospital, AP-HM, Marseille, France.
Department of Urology, North Hospital, AP-HM, Marseille, France.
Fr J Urol. 2025 Apr;35(3):102853. doi: 10.1016/j.fjurol.2024.102853. Epub 2025 Jan 2.
A significant proportion of newly diagnosed prostate cancer (PCa) cases are slow growing with a low risk of metastatic progression. There is a lack of data concerning the optimal biopsy regimen for improving diagnosis yield in PI-RADS3 lesions. This study aimed to assess the diagnostic value of current biopsy regimens in PI-RADS 3 lesions and identify clinical predictors to improve clinically significant PCa (csPCa) detection.
This retrospective study included patients from two academic centers between 2017 and 2024 who benefitted from prostate biopsies for a PI-RADS 3 lesion. Prostate biopsies were performed via either a transrectal or a transperineal route according to local resources. All patients underwent systematic and targeted cores. Targeted biopsies were performed using MRI-ultrasound fusion software or cognitive fusion. Patients were categorized based on biopsy results: benign, clinically insignificant (insignPCa, i.e. ISUP 1), or csPCa (ISUP≥2). The primary endpoint was to assess the detection rate of csPCa in MRI-targeted biopsies alone and in MRI-targeted+ipsilateral systematic cores in comparison to the gold standard MRI-targeted+systematic biopsies. Then, the percentage of csPCa missed and insignPCa diagnoses avoided were calculated referring to the gold standard MRI-targeted+systematic template.
A total of 163 men with at least one PI-RADS 3 index lesion were identified. Ninety-one (55.8%) lesions were benign, 52 (32%) were insignPCa and 20 (12.3%) were csPCa. Of the 20 patients with csPCa, the diagnosis was made with targeted cores in 12 patients and with systematic cores in 8 patients. If no biopsies were performed, 12.3% of csPCa would have gone undiagnosed. Targeted biopsies alone would have missed 4.9% of csPCa but avoided 24.5% of insignPCa. Targeted biopsies with systematic cores solely performed on the same side as the index lesion would have missed 3.8% of csPCa and avoided 12.9% of insignPCa. We reported no significant differences in detection rate of csPCa between MRI-targeted cores alone vs. the gold standard template (7.4% vs. 12.3%; P=0.9) and between MRI-targeted cores+ipsilateral systematic cores vs. the gold standard template (8.5% vs. 12.3%; P=1.2). At multivariable analysis age, clinical T stage, and mpMRI lesion size were predictors of csPCa.
As a small proportion of PI-RADS 3 lesions are associated with csPCa, the value of biopsies is questionable. Targeted biopsies with systematic cores on the same side as the index lesion may improve detection of csPCa and reduce overdiagnosis of indolent CaP. Clinical T stage and lesion size on MRI can potentially predict the presence of clinically significant CaP.
相当一部分新诊断的前列腺癌（PCa）病例生长缓慢，发生转移进展的风险较低。目前缺乏关于提高PI-RADS 3类病变诊断率的最佳活检方案的数据。本研究旨在评估当前活检方案对PI-RADS 3类病变的诊断价值，并确定改善临床显著前列腺癌（csPCa）检测的临床预测因素。
这项回顾性研究纳入了2017年至2024年间来自两个学术中心的患者，这些患者因PI-RADS 3类病变接受了前列腺活检。根据当地资源，经直肠或经会阴途径进行前列腺活检。所有患者均接受了系统和靶向活检。使用MRI-超声融合软件或认知融合进行靶向活检。根据活检结果对患者进行分类：良性、临床意义不显著（insignPCa，即ISUP 1级）或csPCa（ISUP≥2级）。主要终点是评估单独MRI靶向活检以及MRI靶向+同侧系统活检与金标准MRI靶向+系统活检相比时csPCa的检出率。然后，参照金标准MRI靶向+系统模板计算漏诊的csPCa百分比和避免诊断为insignPCa的百分比。
共识别出163例至少有一个PI-RADS 3类指标病变的男性患者。91例（55.8%）病变为良性，52例（32%）为insignPCa，20例（12.3%）为csPCa。在20例csPCa患者中，12例通过靶向活检确诊，8例通过系统活检确诊。如果未进行活检，12.3%的csPCa将无法被诊断。仅进行靶向活检会漏诊4.9%的csPCa，但可避免24.5%的insignPCa。仅对与指标病变同侧进行靶向活检加系统活检会漏诊3.8%的csPCa，并避免12.9%的insignPCa。我们报告单独MRI靶向活检与金标准模板相比，csPCa检出率无显著差异（7.4%对12.3%；P = 0.9），MRI靶向活检+同侧系统活检与金标准模板相比也无显著差异（8.5%对12.3%；P = 1.2）。多变量分析显示，年龄、临床T分期和mpMRI病变大小是csPCa的预测因素。
由于一小部分PI-RADS 3类病变与csPCa相关，活检的价值值得怀疑。对与指标病变同侧进行靶向活检加系统活检可能会提高csPCa的检测率，并减少惰性CaP的过度诊断。临床T分期和MRI上的病变大小可能潜在地预测临床显著CaP的存在。
