Urologists may be able to skip systematic biopsy (SB) and perform targeted prostate biopsy (TB) alone in men with PI-RADS 5 lesions and a PSA density greater than 15%, a new study concludes.

In patients with PI-RADS 5 on multiparametric magnetic resonance imaging (mpMRI) and PSA density greater than 0.15 ng/mL2, SB marginally increases detection of clinically significant prostate cancer, but not overall prostate cancer detection in comparison with TB alone, Andre Luis Abreu, MD, of the University of Southern California, Los Angeles, and colleagues reported in The Journal of Urology.

In their study, 112 men had a PI-RADS 5 lesion on mpMRI and underwent both SB and MRI-fusion TB at a tertiary center. Clinically significant prostate cancer of Grade group 2 (3+4) or higher was detected in 72%, 81%, and 85% of men by SB, TB, and SB+TB, respectively. SB detected clinically significant prostate cancer in only 4% more cases compared with TB.

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In a subgroup of 78 patients with a PSA density exceeding 0.15 ng/mL2, the detection rate of clinically significant prostate cancers was even higher. Clinically significant prostate cancer was detected in 79%, 91%, and 95% of this group by SB, TB, and SB+TB, respectively. Forgoing SB in this subgroup of patients would have missed only 4% of clinically significant prostate cancer cases. SB did not affect patients’ management and can be skipped in this population, according to the investigators.

“Omitting SB, and therefore decreasing the number of cores taken, may reduce adverse events and complications, time to biopsy and specimens processing, and workload for urologists and pathologists,” Dr Abreu’s team wrote. “Additionally, it may improve cost-effectiveness and patients’ satisfaction, increase the number of procedures performed daily and shorter time for diagnosis.”

The authors noted that their study was performed in a tertiary center where all images were reviewed by a radiologist with more than 10 years’ experience in reading prostate MRI scans and all biopsies were performed by 2 urologists with extensive experience performing MRI fusion biopsy. “Although these make the study uniform, they may raise concern that the results may not be extrapolated to non-tertiary centers,” they wrote. “Therefore, urologists should be aware about radiologist expertise and discrepancy interpreting MRI prostate and their own confidence performing MRI-informed TB.”


Alessandro Tafuri, Atsuko Iwata, Aliasger Shakir et al. Systematic biopsy of the prostate can be omitted in men with PI-RADS 5 and prostate specific antigen density greater than 15%. J Urol. Aug;206(2):289-297. doi:10.1097/JU.0000000000001766