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Multiparametric MRI/Ultrasound fusion biopsy improves but does not replace standard templatebiopsy for the detection of prostate cancer
Nawar Hanna, MD1, Matthew F. Wszolek, MD1, Francisco J. Gelpi-Hammerschmidt, MD1, Keyan Salari, MD, PhD1, Mukesh Harisinghani, MD2, Douglas M. Dahl, MD1, Michael L. Blute, MD1, Adam S. Feldman, MD, MPH1.
1Massachusetts General Hospital, Department of Urology, Boston, MA, USA, 2Massachusetts General Hospital, Department of Radiology, Boston, MA, USA.

Introduction: Multiparametric MRI (mp-MRI) with fusion transrectal ultrasound (US) guided prostate biopsy is a recent technology, which may improve the accuracy of TRUS prostate biopsy in select patients. There exists a growing debate as to whether mp-MRI targeted biopsy alone without standard template is sufficient for evaluation of patients. We investigate and describe our experience with fusion biopsy.
Materials & Methods: We retrospectively reviewed medical charts of patients undergoing fusion transrectal US-guided biopsy from July 2014 through February 2016. Patients eligible for fusion biopsy had identifiable lesions on mp-MRI compatible to the fusion biopsy system. Each lesion was graded according to the Prostate Imaging Reporting and Data System version 2 (PIRADSv2) by a radiologist. The fusion biopsy procedure included a minimum of 2 core biopsies for each target lesion. After targeted lesions are obtained, the targeting software is turned off and standard 12 core template biopsies are then taken. Patients on active surveillance for low-risk prostate cancer periodically also have 2-4 anteriorly directed cores and these were included in our analysis. Data including biopsy indications, baseline patient characteristics, and pathologic biopsy results were extracted from the medical record. Clinically significant disease was defined as Gleason Score 7 or higher adenocarcinoma of the prostate.
Results: A total of 255 patients with a mp-MRI-identified lesion underwent fusion and standard template biopsy. Indications included elevated PSA (29), rising PSA with prior negative biopsy (134), active surveillance for prostate cancer (85) and isolated abnormal digital rectal exam (7). Within our cohort, mean age was 65.4 (range 46-84), mean was PSA 9.0 ng/ml (range 0.7-86.2 ng/ml), and mean prostate volume 55 cc (range 15-232 cc). Of patients with available PIRADS score (n=227), 7.0%, 29.1%, 41.0%, and 22.9% had PIRADSv2 2, 3, 4 and 5 lesions, respectively. Pathologic results of the fusion-targeted biopsy were compared to those of the concomitantly performed standard template biopsies, and are summarized in Table 1. Of patients with PIRADSv2 4 or 5 lesions (n=145), 40.0% had no cancer, 25.5% had Gleason 6, 25.5% had Gleason 7, and 9.0%, had Gleason 8-10 on final histopathology. Fusion Biopsy of PIRADSv2 3 lesions (n=66) revealed no cancer in 65.2%, Gleason 6 in 15.2%, Gleason 7 in 19.7% and Gleason 8-10,in 0% of patients. Of 83 patients with clinically significant cancer, 26 (31.3%) would have been missed on standard biopsy and 12 (14.5%) would have been missed using fusion biopsy alone. Concordance between both biopsy modalities was 63.1%.
Conclusion: The technology of mp-MRI/US transrectal fusion biopsy improves the detection of clinically significant prostate cancer in select patients. However, our results demonstrate that a significant proportion of Gleason Score 7 or higher lesions will not be detected by targeted biopsy alone. Therefore, standard template biopsies should remain an integral component of any fusion biopsy program.
Fusion Biopsy Results listed in First Row, Random Biopsy Results listed in First Column
Fusion Standard BiopsyNo CancerGleason 6Gleason 3+4Gleason 4+3Gleason ≥ 8Total
No Cancer9917632127
Gleason 62531104171
Gleason 3+424152023
Gleason 4+33047317
Gleason ≥ 82114917
Total13153362015255


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