Schoots, IG; Nieboer, D; Giganti, F; Moore, CM; Bangma, CH; Roobol, MJ; (2018) Is magnetic resonance imaging‐targeted biopsy a useful addition to systematic confirmatory biopsy in men on active surveillance for low‐risk prostate cancer? A systematic review and meta‐analysis. BJU International , 122 (6) pp. 946-958. 10.1111/bju.14358.

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Abstract

BACKGROUND: Active surveillance of prostate cancer is recommended for men with Gleason 3+3 on standard TRUS-guided biopsy. Confirmatory assessment can include repeat standard TRUS-guided biopsy, and/or MRI with targeted biopsy when indicated. OBJECTIVE: To systematically review and meta-analyse evidence regarding the additional value of MRI and MRI-targeted biopsies to confirmatory systematic biopsies in identifying high-grade prostate cancer in men with low-risk disease on TRUS biopsy. METHODS: A systematic review of the Embase, Medline, Web-of-science, Google scholar, and Cochrane library was performed according to the PRISMA guidelines. Identified reports were critically appraised according to the QUADAS-2 criteria. Studies reporting men with Gleason 3+3 prostate cancer who had chosen active surveillance based on transrectal systematic biopsy findings and had undergone MRI with systematic +/- targeted biopsy at confirmatory assessment were included. The primary outcome was detection of any Gleason pattern 4 or higher. RESULTS: Included reports (6) of men on active surveillance (n=1159) showed cancer upgrading (Gleason ≥3+4) in 27% [95%CI: 22-34%] using a combined approach of MRI targeted biopsies and confirmatory systematic biopsies. MRI-targeted biopsies alone would have missed cancer upgrading in 10% [95%CI: 8-14%] and standard biopsies alone would have missed cancer upgrading in 7% [95%CI: 5-10%]. No pathway was favorable to the other (RR 0.92 [95%CI: 0.79, 1.06]). 35% [95%CI: 27-43%] of men with a positive MRI were upgraded, compared to 12% [95%CI: 8-18%] of men with a negative MRI being upgraded (RR 2.77 [95%CI: 1.76-4.38]). CONCLUSIONS: A pre-biopsy MRI should be performed before confirmatory systematic TRUS-guided biopsies in men on Active Surveillance, together with MRI-targeted biopsies when indicated. A combined approach maximises cancer detection, although other factors within multivariate risk prediction can be used to aid the decision to biopsy in these men.

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