title: Targeted prostate biopsy in select men for active surveillance: do the Epstein criteria still apply?
abstract: OBJECTIVE
  Established in 1994, the Epstein histological criteria (Gleason score 6 or less, 2 or fewer cores positive and 50% or less of any core) have been widely used to select men for active surveillance. However, with the advent of targeted biopsy, which may be more accurate than conventional biopsy, we reevaluated the likelihood of reclassification upon confirmatory rebiopsy using multiparametric magnetic resonance imaging-ultrasound fusion.
  
  
  METHODS
  We identified 113 men enrolled in active surveillance at our institution who met Epstein criteria and subsequently underwent confirmatory targeted biopsy via multiparametric magnetic resonance imaging-ultrasound fusion. Median patient age was 64 years, median prostate specific antigen was 4.2 ng/ml and median prostate volume was 46.8 cc. Targets or regions of interest on multiparametric magnetic resonance imaging-ultrasound fusion were graded by suspicion level and biopsied at 3 mm intervals along the longest axis (median 10.5 mm). Also, 12 systematic cores were obtained during confirmatory rebiopsy. Our reporting is consistent with START (Standards of Reporting for MRI-targeted Biopsy Studies) criteria.
  
  
  RESULTS
  Confirmatory fusion biopsy resulted in reclassification in 41 men (36%), including 26 (23%) due to Gleason grade 6 or greater and 15 (13%) due to high volume Gleason 6 disease. When stratified by suspicion on multiparametric magnetic resonance imaging-ultrasound fusion, the likelihood of reclassification was 24% to 29% for target grade 0 to 3, 45% for grade 4 and 100% for grade 5 (p=0.001). Men with grade 4 and 5 vs lower grade targets were greater than 3 times more likely to be reclassified (OR 3.2, 95% CI 1.4-7.1, p=0.006).
  
  
  CONCLUSIONS
  Upon confirmatory rebiopsy using multiparametric magnetic resonance imaging-ultrasound fusion men with high suspicion targets on imaging were reclassified 45% to 100% of the time. Criteria for active surveillance should be reevaluated when multiparametric magnetic resonance imaging-ultrasound fusion guided prostate biopsy is used.
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Jim C
authors: JC
authors: Hu
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Edward
authors: E
authors: Chang
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Shyam
authors: S
authors: Natarajan
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Daniel J
authors: DJ
authors: Margolis
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Malu
authors: M
authors: Macairan
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Patricia
authors: P
authors: Lieu
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Jiaoti
authors: J
authors: Huang
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Geoffrey
authors: G
authors: Sonn
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California.
authors: Frederick J
authors: FJ
authors: Dorey
authors: Departments of Urology, Radiology, Pathology and Biomedical Engineering, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California. Electronic address: lmarks@mednet.ucla.edu.
authors: Leonard S
authors: LS
authors: Marks
mesh_terms: D000368:Aged; D006801:Humans; D061705:Image-Guided Biopsy; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D011446:Prospective Studies; D011467:Prostate / Q000473:pathology*; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000628:therapy*; D014463:Ultrasonography; D057832:Watchful Waiting
keywords: magnetic resonance imaging; patient selection; prostate; prostatic neoplasms; ultrasonography