JU INSIGHT: Precision-guidance vs Systematic Sampling: Optimizing Biopsy Assessment of Secondary Prostate Cancer Suspicious Multiparametric Magnetic Resonance Imaging Lesions

By: Pawel Rachubinski, MD; Jorn H. Witt, MD; Lars Budäus, MD; Joerg Zinke, MD; Bernhard Fangmeyer, MD; Tilmann Spieker, MD; Malte Vetterlein, MD; Kambiz Rahbar, MD; Mykyta Kachanov, MD; Sami-Ramzi Leyh-Bannurah, MD | Posted on: 01 Dec 2022

Rachubinski P, Witt JH, Budäus L, et al. Precision-guidance vs systematic sampling: optimizing biopsy assessment of secondary prostate cancer suspicious multiparametric magnetic resonance imaging lesions. J Urol. 2022;208(6):1203-1213.

Study Need and Importance

Multifocal prostate cancer (PCa) is a common finding in patients undergoing surgical treatment for PCa. Such patients present with multiple lesions on multiparametric magnetic resonance imaging (see Figure), which can be divided into index and secondary lesions.

Compared to the index, the secondary lesion is usually of lesser Prostate Imaging–Reporting and Data System (PI-RADS) score, size, or, on the pathology level, lower-grade PCa. It remains unclear whether secondary lesions should be assessed by targeted biopsy or if the combined approach of targeted index lesion sampling with an additive systematic biopsy might be sufficient.

This is of importance as a reduced/optimized number of biopsy cores taken may decrease biopsy-related morbidity and lower patient discomfort at biopsy.

What We Found

The overall detection rate of clinically significant PCa (csPCa; Gleason score ≥3+4) when targeting index vs index+secondary lesions was 32% vs 38% (P = .035). CsPCa yield of index+secondary lesions targeted sampling vs same strategy but with additive systematic biopsy was 38% vs 42% (P = .2) at the expense of the higher median number of biopsy cores (9 vs 25; P < .001). In the subgroup with ipsilateral index+secondary lesions localization (n = 236), contralateral systematic biopsy detected csPCa in 17%.


Limitations of our study are retrospective design and missing measures of biopsy complications. Moreover, for example, lower resolution imaging, different multiparametric magnetic resonance imaging/transrectal ultrasound fusion modality, or fewer cores sampled from each lesion may influence generalizability of our findings.

Interpretation for Patient Care

Targeted sampling of secondary lesions should be included in targeted biopsy protocols due to added diagnostic information. However, for targeted sampling of index+secondary lesions, an additional systematic biopsy is of limited informative value in terms of overall csPCa detection. However, when index+secondary lesions are located ipsilateral, contralateral systematic biopsy should be recommended for the purpose of prostate lobe information. Our results indicate potential to reduce systematic biopsy cores and associated morbidity.