New findings challenge European Association of Urology (EAU) guidelines that recommend refraining from confirmatory prostate biopsies during active surveillance in patients diagnosed with prostate cancer with upfront MRI, according to a presentation at the American Urological Association’s 2022 annual meeting in New Orleans, Louisiana.

The findings are from the multicenter prospective PRIAS study, which provides clinical data on patients on active surveillance. 

A total of 732 patients underwent MRI-informed confirmatory biopsies at a median PSA of 6.4 ng/mL. Of these, 524 were diagnosed without upfront MRI and 208 with upfront MRI. The men underwent a second MRI prior to confirmatory biopsies. All subsequently underwent targeted biopsies.

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At confirmatory biopsy, 39 patients with upfront MRI (19%) and 108 patients without upfront MRI (21%) were reclassified, Ivo de Vos, MD, of Erasmus Medical Center in Rotterdam, The Netherlands, reported on behalf of his research team. He and his colleagues observed reclassification to Gleason grade group 3 in 7% and 6% of patients with and without upfront MRI, respectively. They also found no significant difference in risk for reclassification at confirmatory biopsies between the groups, whereas MRI outcome, digital rectal examination (DRE) findings, and PSA density were significant predictors of reclassification.

Compared with no lesions found on MRI, PIRADS 3, 4, and 5 lesions were significantly associated with approximately 5.2-, 7.7-, and 12.1-fold increased odds of reclassification into a higher grade group, according to the investigators. Compared with benign findings on DRE, suspicious findings were significantly associated with a 2.1-fold increased risk for grade group reclassification. Each 0.1 ng/mL/mL increase in PSA density at the time of MRI scans was significantly associated with a 17% increased risk for grade group reclassification.

“Our results show that upfront MRI does not reduce reclassification rates at confirmatory biopsy and as such does not support the EAU guidelines recommendation to simply omit confirmatory biopsies if upfront MRI is used,” the authors concluded. “In preventing unnecessary biopsies during AS, our results highlight the importance of MRI outcome.”


Luiting H, de Vos II, Remmers S, et al. Upfront MRI is the new standard, have confirmatory biopsies become obsolete? Presented at AUA 2022, May 13-16, 2022, New Orleans, Louisiana. Poster MP43-05.