PIRADS ≥ 4 MRI lesion: Is performing systematic biopsies still essential for detecting clinically significant prostate cancer?

Introduction: In the era of targeted prostate biopsies, the necessity of performing randomized biopsies systematically is under question. Our objective is to evaluate the rate of clinically significant prostate cancer (csPCa), defined by presence of ISUP >= 2 prostate cancer, diagnosed only on randomized cores in case of a PIRADS >= 4 target lesion on MRI. The secondary objective is to evaluate whether specific variables can predict the presence of undetected csPCa in targeted biopsies. Methods: Retrospective data on targeted biopsies performed from 2015 to 2021 in our hospital were collected. Procedures were performed with MRI/Transrectal US fusion Trinity platform from Koelis (R) . All the MRI images were reviewed and the targets were classified using the PIRADS V2.1 classification. Inclusion criteria comprised procedures featuring at least one PIRADS >= 4 targeted lesion were included. All procedures consisted 1-4 targeted cores and 12 -core systematic biopsy. Results: We included 358 patients. In 44 patients (12.3%) csPCa was exclusively detected in randomized cores. Among these cases, only 12 patients (27.2%) showed no cancer on the targeted biopsies. Merely 4 patients (9.09%) lacked csPCa-positive cores on the same side as the index lesion. Factors such as PSA, PSA density, prostate volume, and digital rectal examination showed no significant association with the presence of csPCa exclusively on randomized cores. Likewise, the size, location, and PIRADS classification of the target demonstrated no significant impact. Conclusion: Our findings indicate that in 12.3% of cases, targeted biopsies alone are insufficient for detecting the presence of csPCa. As such, systematic biopsies remain necessary to date. Level of evidence: 4. (c) 2024 Elsevier Masson SAS. All rights reserved.