Optimizing the Number of Cores Targeted During Prostate Magnetic Resonance Imaging Fusion Target Biopsy

Background: The number of prostate biopsy cores that need to be taken from each magnetic resonance imaging (MRI) region of interest (ROI) to optimize sampling while minimizing overdetection has not yet been clearly elucidated. Objective: To characterize the incremental value of additional MRI-ultrasound (US) fusion targeted biopsy cores in defining the optimal number when planning biopsy and to predict men who might benefit from more than two targeted cores. Design, setting, and participants: This was a retrospective cohort study of MRI-US fusion targeted biopsies between 2015 and 2017. Intervention: MRI-US fusion targeted biopsy in which four biopsy cores were directed to each MRI-targeted ROI. Outcomes measurement and statistical analysis: The MRI-targeted cores represent- ing the first highest Gleason core (FHGC) and first clinically significant cancer core (FCSC; GS >= 3 + 4) were evaluated. We analyzed the frequency of FHGC and FCSC among cores 1-4 and created a logistic regression model to predict FHGC >2. The number of unnecessary cores avoided and the number of malignancies missed for each Gleason grade were calculated via clinical utility analysis. The level of agreement between biopsy and prostatectomy Gleason scores was evaluated using Cohen's kappa. Results and limitations: A total of 479 patients underwent fusion targeted biopsy with four individual cores, with 615 ROIs biopsied. Among those, FHGC was core 1 in 477 (76.8%), core 2 in 69 (11.6%), core 3 in 48 (7.6%), and core 4 in 24 men (4.0%) with any cancer. Among men with clinically significant cancer, FCSC was core 1 in 191 (77.8%), core 2 in 26 (11.1%), core 3 in 17 (6.2%), and core 4 in 11 samples (4.9%). In comparison to men with a Prostate Imaging-Reporting and Data System (PI-RADS) score of 5, patients were significantly less likely to have FHGS >2 if they had PI-RADS 4 (odds ratio [OR] 0.287; p = 0.006), PI-RADS 3 (OR 0.284; p = 0.006), or PI-RADS 2 (OR 0.343; p = 0.015). Study limitations include a single-institution experience and the retrospective nature. Conclusions: Cores 1-2 represented FHGC 88.4% and FCSC 88.9% of the time. A PI-RADS score of 5 independently predicted FHGC >2. Although the majority of cancers in our study were appropriately characterized in the first two biopsy cores, there remains a proportion of men who would benefit from additional cores. Patient summary: In men who undergo magnetic resonance imaging-ultrasound fusion targeted biopsy, the first two biopsy cores diagnose the majority of clinically significant cancers. However, there remains a proportion of men who would benefit from additional cores. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.