“The Human Pincushion”. Back in 2016, I posted a blog in which I referred to the conventional TRUS prostate biopsy as a pincushion. Why? Because it involved at least 12 needles placed in a gland roughly the size of a walnut. Not only did this often entail pain, it came with risk of infection, blood in urine or sperm, and even erectile dysfunction. This sounds bad, but blind, systematic biopsies have additional risks with even worse implications:

• It often picked up insignificant prostate cancer (PCa), leading to overly aggressive treatment. Implication: potential urinary and sexual side affects when it might never have posed a threat to begin with.
• It often missed significant PCa, leading to Active Surveillance for the insignificant PCa it did find. Implication: missing a treatment window while a potentially deadly tumor continued to grow.
• Sometimes it missed PCa altogether. Implication: as least one repeat biopsy as PSA continued to rise.

Well, that was years ago, and much has changed since then. The American Urological Association (AUA) now recognizes the importance of ensuring that a biopsy is justified before sticking needles in an innocent prostate gland. In fact, as of June 2023 the official AUA peer-reviewed journal carries updated guidelines that “provide a framework to facilitate clinical decision-making” regarding initial and repeat biopsies.^[i]

The consensus-based recommendations not only emphasize “shared decision-making (SDM) and tailored risk evaluations to guide the decision for a prostate biopsy,” they also address “the significance of non-cancerous, yet potentially significant, pathologic findings identified in biopsies.” In other words, a doctor and patient should discuss together the possible advantages and risks of having a biopsy, and the patient should know in advance what his options are if the biopsy only finds precancerous cells (e.g., ASAP, high grade PIN, etc.) or Grade Group 1 (GG1 which is considered insignificant).

mpMRI and the biopsy revolution

The important factor that has revolutionized prostate biopsy is multiparametric MRI (mpMRI) prior to biopsy. The authors of the updated guidelines acknowledge the role that mpMRI has played in determining whether or not a biopsy is warranted. Furthermore, clinicians should utilize the PI-RADS score system to predict the presence of clinically significant disease. According to the authors, “Multiple studies have confirmed that the PI-RADS score, either on a per lesion or per patient basis, correlates with likelihood of detecting any cancer and GG2+ cancer.”

MRI targeted biopsy is superior to systematic TRUS biopsy

If mpMRI reveals evidence of clinically significant PCa, it is necessary to sample that area so tumor cells can be examined under a microscope. This means a needle biopsy. Sorry, guys, but in today’s world it’s still the only way to obtain a definitive diagnosis and plan treatment accordingly.

However, there’s an increasing trend toward targeting the needles into the area identified by MRI along with PI-RADS as harboring clinically significant disease. According to the updated recommendations, “Clinically significant prostate cancer was detected more often in patients undergoing mpMRI, and patients undergoing MRI targeted biopsy had fewer insignificant cancers detected (9% versus 22%).” In short, mpMRI is the best method for a) identifying suspiciously dangerous lesions, and b) directing one or more biopsy needles precisely into such areas. Thus, MRI greatly lowers the risk of a treatment mismatch and all the implications that come with it.

That said, the authors discuss when the use of systematic biopsy is advisable. In particular, they point to multiple risk factors that may characterize an individual patient (race, age, total PSA, PSA density, percent free PSA, family history. If such a patient’s combined risk factors suggest GG2+ PCa but his MRI is negative, the authors recommend a systematic biopsy as a way to interrogate the entire gland, even though it increases the risk of overdetecting clinically insignificant disease.

The Sperling Prostate Cancer has long been in the forefront of mpMRI, PI-RADS, and in-bore MRI guided targeted biopsy. In addition, we have integrated Artificial Intelligence in our imaging services to increase efficiency and accuracy especially when it comes to detection and diagnosis. Contact us for more information.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Wei JT, Barocas D, Carlsson S, Coakley F et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part II: Considerations for a Prostate Biopsy. J Urol. 2023 Jul;210(1):54-63.