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Efficient sampling methods in systematic biopsy that could be performed in combination with MRI-guided biopsy

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Title: Efficient sampling methods in systematic biopsy which could be performed in addition to MRI-guided biopsy

Noboru Numao; Masaya Ito; SoichiroYoshida; Minato Yokoyama; Junichiro Ishioka; YohMatsuoka; KazutakaSaito; Yasuhisa Fujii; Kazunori Kihara

Department of Urology, Tokyo Medical and Dental University, Graduate School, Tokyo, Japan.


Background & Objective

Although usefulness of magnetic resonance imaging (MRI)-guided biopsy (MRBX) has been established, significance of additional systematic biopsy has not been fully elucidated. In this study, we analyzed efficient sampling methods in systematic biopsy which could be performed in addition to MRBX.

Patients and Methods

September 2011 and January 2014 at a single academic center. Prebiopsy 1.5T multiparametric MRI (T2-weighted, diffusion-weighted  and/or dynamic  contrast-enhanced imaging in principle) and then prostate biopsy.

N = 390

Excluded 108 men because of

PSA >40 ng/ml (n=15), obvious clinical T3-4 disease (n=74), biopsy with fewer cores for severe  comorbidity (n=19)

Study cohort : N = 282

MRBX + Systematic 14-core biopsy (S14PBX)

MRBX was performed under cognitive fusion or MRI/TRUS fusion using a real-time virtual sonography system. On MRBX, four-core samplings for one suspicious lesion on MRI were performed.

The S14PBX protocol was a transperineal 14-core biopsy or a combined 14-core biopsy of transperineal 8-core and transrectal 6-core biopsies, and each biopsy included 6 or 4 anterior samplings, respectively.

Significant cancer (SC) was defined as clinical stage ≥ T2b, biopsy Gleason score ≥ 4+3, or maximum cancer length ≥ 5 mm. SC-core was defined as a biopsy cancer core with Gleason score ≥ 4+3 or cancer length ≥ 5 mm.

We assessed SC detected only by S14PBX (missed by MRBX). We assessed SC identified as indolent cancer only by MRBX but upgraded to SC by additional S14PBX. In these SC underestimated by MRBX we assessed positive sampling sites of SC-core in S14PBX, and explored efficient systematic biopsy protocol that can compensate for MRBX-underestimation.


The detection rate of SC using both MRBX and S14PBX was 59% (162/282).

9 SC was detected only by S14PBX (missed by MRBX).

8SC was identified as indolent cancer only by MRBX but upgraded to SC by additional S14PBX.

Transperineal 6-core (bilateral anterior, mid and posterior samplings from the apex) samplings could efficiently  identify 12 of the 17 SCs as SC and appears to strike a balance between number of sampling cores in additional systematic biopsy and SC identification.

Balanced combination of MRI-guided biopsy and systematic biopsy

MRBX + Systematic transperineal 6-core biopsy


Additional systematic transperineal 6-core biopsy could efficiently reduce underestimation of MRI-guided biopsy.

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