Role of multiparametric magnetic resonance imaging and targeted biopsy in the detection of clinically significant prostate cancer in patients with abnormal digital rectal examination

Abstract Background Few studies examined the role of prostate MRI in patients with abnormal digital rectal examination (DRE) and/or PSA > 10 ng/ml. In a cohort of non-screened patients with abnormal DRE, we investigated the rate of avoidable prostate biopsies and potentially missed clinically significant prostate cancer (csPCa) with negative MRI, and the concordance between targeted biopsy (TBx) and systematic biopsy (SBx) in detecting csPCa with positive MRI. Methods We retrospectively examined 199 biopsy-naïve patients with abnormal DRE who underwent prostate MRI before transperineal biopsy. Prostate Imaging - Reporting And Data System (PI-RADS) v2.1 ≥ 3 category of the index lesion defined a positive MRI. Combined TBx/SBx and SBX alone was performed for positive and negative MRI, respectively. An International Society of Urogenital Pathology Grade Group ≥2 defined csPCa. We calculated csPCa detection rate of TBx, SBx and combined TBx/SBx. The Cohen kappa statistic was used to measure the concordance between TBx and SBx. Results Ninety-one (45.7%) csPCa cases were detected. MRI was positive in 153 (76.9%) patients. In the 46 patients with negative MRI, SBx detected 5 (10.9%) csPCa cases. Prostate biopsy could, thus, be avoided in 41/199 (20.6%) patients at the cost of missing 5/91 (5.5%) csPCa cases. The concordance between TBx and SBx in detecting csPCa with positive mpMRI was substantial (k 0.70). Specifically, 6/86 (6.9%) csPCa cases were detected with TBx, and 17/86 (19.7%) with SBx alone. Concordance was almost perfect (k 0.82) in patients with PSA > 10 ng/ml. Only 4/38 (10.5%) csPCa cases were missed by TBx, and only 1 (2.6%) csPCa case was identified by TBx alone. Conclusion MRI in patients with abnormal DRE could avoid roughly 21% of unnecessary biopsies at the cost of missing approximately 6% of csPCa cases. Moreover, MRI and TBx complemented SBx in detecting csPCa in the subgroup with PSA > 10 ng/ml.