title: Further reduction of disqualification rates by additional MRI-targeted biopsy with transperineal saturation biopsy compared with standard 12-core systematic biopsies for the selection of prostate cancer patients for active surveillance.
abstract: Active surveillance (AS) is commonly based on standard 10-12-core prostate biopsies, which misclassify ~50% of cases compared with radical prostatectomy. We assessed the value of multiparametric magnetic resonance imaging (mpMRI)-targeted transperineal fusion-biopsies in men under AS.
  
  
  
  In all, 149 low-risk prostate cancer (PC) patients were included in AS between 2010 and 2015. Forty-five patients were initially diagnosed by combined 24-core systematic transperineal saturation biopsy (SB) and MRI/transurethral ultrasound (TRUS)-fusion targeted lesion biopsy (TB). A total of 104 patients first underwent 12-core TRUS-biopsy. All patients were followed-up by combined SB and TB for restratification after 1 and 2 years. All mpMRI examinations were analyzed using PIRADS. AS was performed according to PRIAS-criteria and a NIH-nomogram for AS-disqualification was investigated. AS-disqualification rates for men initially diagnosed by standard or fusion biopsy were compared using Kaplan-Meier estimates and log-rank tests. Differences in detection rates of the SB and TB components were evaluated with a paired-sample analysis. Regression analyses were performed to predict AS-disqualification.
  
  
  
  A total of, 48.1% of patients diagnosed by 12-core TRUS-biopsy were disqualified from AS based on the MRI/TRUS-fusion biopsy results. In the initial fusion-biopsy cohort, upgrading occurred significantly less frequently during 2-year follow-up (20%, P<0.001). TBs alone were significantly superior compared with SBs alone to detect Gleason-score-upgrading. NPV for Gleason-upgrading was 93.5% for PIRADS⩽2. PSA level, PSA density, NIH-nomogram, initial PIRADS score (P<0.001 each) and PIRADS-progression on consecutive MRI (P=0.007) were significant predictors of AS-disqualification.
  
  
  
  Standard TRUS-biopsies lead to significant underestimation of PC under AS. MRI/TRUS-fusion biopsies, and especially the TB component allow more reliable risk classification, leading to a significantly decreased chance of subsequent AS-disqualification. Cancer detection with mpMRI alone is not yet sensitive enough to omit SB on follow-up after initial 12-core TRUS-biopsy. After MRI/TRUS-fusion biopsy confirmed AS, it may be appropriate to biopsy only those men with suspected progression on MRI.
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.|Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: J P
authors.initials: JP
authors.lastname: Radtke
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: T H
authors.initials: TH
authors.lastname: Kuru
authors.affiliation: Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Bonekamp
authors.affiliation: Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: M T
authors.initials: MT
authors.lastname: Freitag
authors.affiliation: Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: M B
authors.initials: MB
authors.lastname: Wolf
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Düsseldorf, Germany.
authors.forename: C D
authors.initials: CD
authors.lastname: Alt
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: G
authors.initials: G
authors.lastname: Hatiboglu
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Boxler
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Pahernik
authors.affiliation: Institute of Pathology, University of Heidelberg, Heidelberg, Germany.
authors.forename: W
authors.initials: W
authors.lastname: Roth
authors.affiliation: Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: M C
authors.initials: MC
authors.lastname: Roethke
authors.affiliation: Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: H P
authors.initials: HP
authors.lastname: Schlemmer
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Hohenfellner
authors.affiliation: Department of Urology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: B A
authors.initials: BA
authors.lastname: Hadaschik
mesh_terms: D000368:Aged; D001706:Biopsy / Q000379:methods; D018450:Disease Progression; D006801:Humans; D061705:Image-Guided Biopsy / Q000379:methods; D053208:Kaplan-Meier Estimate; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D011379:Prognosis; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D057832:Watchful Waiting