title: Missing the Mark: Prostate Cancer Upgrading by Systematic Biopsy over Magnetic Resonance Imaging/Transrectal Ultrasound Fusion Biopsy.
abstract: Multiparametric magnetic resonance imaging and fusion biopsy detect more high risk prostate cancer and less low risk prostate cancer than systematic biopsy. However, there remains a small subset of patients in whom systematic biopsy captures higher grade disease than fusion biopsy. We sought to identify potential mechanisms of the failure of fusion biopsy in the detection of clinically significant prostate cancer.
  
  
  
  We reviewed a prospectively maintained database of patients who underwent multiparametric magnetic resonance imaging followed by fusion biopsy and systematic biopsy from 2007 to 2014. In patients in whom disease was upgraded to clinically significant disease (Gleason 7 or greater) by systematic biopsy over fusion biopsy, independent re-review of magnetic resonance imaging, archived biopsy imaging and whole mount pathology as well as needle coordinate mapping were performed. Multivariate logistic regression analysis was done to determine predictors of upgrading by systematic biopsy.
  
  
  
  Disease was upgraded based on systematic biopsy over fusion biopsy in 135 of 1,003 patients (13.5%), of whom only 62 (6.2%) were upgraded to intermediate (Gleason 7) and high risk (Gleason 8 or greater) prostate cancer (51 or 5.1% and 11 or 1.1%, respectively). On multivariate analysis lower prostate specific antigen (p <0.001), higher magnetic resonance imaging prostate volume (p <0.001) and a lower number of target cores (p = 0.001) were predictors of upgrading by systematic biopsy. Main mechanisms of under grading by fusion biopsy included multiparametric magnetic resonance imaging reader oversight, presence of magnetic resonance imaging invisible cancer, fusion biopsy technique error and intralesion Gleason heterogeneity.
  
  
  
  Magnetic resonance imaging and fusion biopsy rarely missed clinically significant prostate cancer as only 62 of 1,003 cases (6.2%) were upgraded to clinically significant disease by systematic biopsy. Imaging and biopsy techniques are continually refined. Further studies will help clarify mechanisms of fusion biopsy failure and the patient populations that benefit from systematic biopsy in addition to fusion biopsy.
authors: Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Akhil
authors: A
authors: Muthigi
authors: Department of Urology, University of Michigan, Ann Arbor, Michigan.
authors: Arvin K
authors: AK
authors: George
authors: Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Abhinav
authors: A
authors: Sidana
authors: Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Michael
authors: M
authors: Kongnyuy
authors: Biometric Research Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD.
authors: Richard
authors: R
authors: Simon
authors: Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Vanessa
authors: V
authors: Moreno
authors: Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Maria J
authors: MJ
authors: Merino
authors: Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Peter L
authors: PL
authors: Choyke
authors: Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Baris
authors: B
authors: Turkbey
authors: Center for Interventional Oncology, National Cancer Institute & Clinical Center, National Institutes of Health, Bethesda, Maryland.
authors: Bradford J
authors: BJ
authors: Wood
authors: Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
authors: Peter A
authors: PA
authors: Pinto
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration / Q000379:methods*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D011467:Prostate / Q000473:pathology*; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology*; D012189:Retrospective Studies
keywords: diagnostic imaging; image-guided biopsy; magnetic resonance imaging; prostatic neoplasms; risk