Outcomes of a Diagnostic Pathway for Prostate Cancer Based on Biparametric MRI and MRI-Targeted Biopsy Only in a Large Teaching Hospital

Simple Summary Prostate cancer (PCa) is diagnosed with tissue biopsy. The biopsy strategy may include needle cores covering the whole gland randomly and/or targeting abnormalities on imaging. This process aims to detect dangerous PCa; small cancers need not to be diagnosed. When deciding on biopsy and the biopsy strategy, an MRI scan has become an increasingly important tool. MRI can be used to decide to biopsy and to potentially use targeted biopsy cores only. A database of men suspected of PCa was used. It found that when solely relying on MRI to biopsy, 34% fewer men would undergo biopsy, but 7% of the potentially dangerous tumors would not have been detected. With targeted biopsy cores only, 75% fewer needle cores would be needed, but another 9% of potentially dangerous PCa would remain undetected. These missed lesions were usually the smaller ones. This information is helpful to balance the pros/cons of an MRI-based pathway.Abstract Background: Diagnostic pathways for prostate cancer (PCa) balance detection rates and burden. MRI impacts biopsy indication and strategy. Methods: A prospectively collected cohort database (N = 496) of men referred for elevated PSA and/or abnormal DRE was analyzed. All underwent biparametric MRI (3 Tesla scanner) and ERSPC prostate risk-calculator. Indication for biopsy was PIRADS >= 3 or risk-calculator >= 20%. Both targeted (cognitive-fusion) and systematic cores were combined. A hypothetical full-MRI-based pathway was retrospectively studied, omitting systematic biopsies in: (1) PIRADS 1-2 but risk-calculator >= 20%, (2) PIRADS >= 3, receiving targeted biopsy-cores only. Results: Significant PCa (GG >= 2) was detected in 120 (24%) men. Omission of systematic cores in cases with PIRADS 1-2 but risk-calculator >= 20%, would result in 34% less biopsy indication, not-detecting 7% significant tumors. Omission of systematic cores in PIRADS >= 3, only performing targeted biopsies, would result in a decrease of 75% cores per procedure, not detecting 9% significant tumors. Diagnosis of insignificant PCa dropped by 52%. PCa undetected by targeted cores only, were ipsilateral to MRI-index lesions in 67%. Conclusions: A biparametric MRI-guided PCa diagnostic pathway would have missed one out of six cases with significant PCa, but would have considerably reduced the number of biopsy procedures, cores, and insignificant PCa. Further refinement or follow-up may identify initially undetected cases. Center-specific data on the performance of the diagnostic pathway is required.