Are prostate biopsies necessary in patients with negative or equivocal MRIs and low PSA density? | Top Vip News


A new meta-analysis found that PI-RADS 4 and 5 lesion assessments on magnetic resonance imaging (MRI), as well as prostate-specific antigen density (PSAD), were the only prognostic factors associated with clinically significant prostate cancer ( csPCa).

In the meta-analysis, recently published in Open JAMA Network, researchers reviewed data from 72 studies involving a total of 36,366 patients (median age 65.6 years) with suspected csPCa. All patients in the reviewed studies underwent transrectal and/or transperineal prostate biopsies, and prostate MRI before biopsy, according to the meta-analysis.

The researchers found that 30 percent of unnecessary prostate biopsies could be avoided if doctors forgo biopsy in patients with a PSAD level less than 0.10 ng/mL2 and PI-RADS 3 MRI lesion evaluations. or less. By increasing the PSAD level threshold below 0.15 ng/ml2, the study authors suggested that 48 percent of unnecessary biopsies could be eliminated.

“Our results suggest that combining PI-RADS with PSAD would reduce the number of unnecessary biopsies and improve diagnostic yield. Although the stepwise approach based on PI-RADS and PSAD has been used at some institutions to drive decision-making toward prostate biopsy, current guidelines do not advise against biopsies in patients with low PSAD and equivocal MRI findings due to to the lack of level 1 evidence,” said the study’s lead author, Arya Haj-Mirzaian, MD, MPH, affiliated with the Center for Evidence-Based Imaging and the Department of Radiology at Brigham and Women’s Hospital in Boston, and her colleagues. . “This meta-analysis provides evidence that could potentially influence the evolution of these guidelines.”

Three key takeaways

  1. PI-RADS and PSAD for risk stratification. Assessments of PI-RADS 4 and 5 lesions on MRI, along with prostate-specific antigen density (PSAD), serve as valuable prognostic factors for clinically significant prostate cancer (csPCa). Integration of PI-RADS and PSAD may assist in risk stratification and decision making regarding prostate biopsy.
  2. Reduction of unnecessary biopsies. The meta-analysis suggests that incorporating PSAD levels and MRI lesion assessments may lead to a significant reduction in unnecessary prostate biopsies. Thresholds for PSAD, particularly below 0.10 ng/ml2can help identify patients who may not require an immediate biopsy, potentially avoiding unnecessary procedures.
  3. Greater diagnostic performance. Combining PI-RADS with PSAD improves diagnostic performance for detecting csPCa. Sensitivity rates and negative predictive values ​​are notably high when PSAD-specific thresholds are used in conjunction with MRI lesion assessments, which may help optimize biopsy decisions while maintaining diagnostic accuracy.

The combination of no focal lesions, PI-RADS 2 or lower lesion assessments on MRI, and a PSAD level less than 0.10 ng/ml2 had a sensitivity rate of 83 percent versus 66 percent for lower PSAD at 0.15 ng/ml2 and 35 percent for PSAD. less than 0.20 ng/mL2, according to the authors of the meta-analysis.

Based on findings from eight to 10 studies, the researchers also noted that avoiding prostate biopsy in patients with PI-RADS 3 lesion assessments and a PSAD less than 0.10 ng/mL2 maintained a sensitivity rate of 85 percent. percent and a negative predictive value of 93. percent.

For patients without focal lesions, a PI-RADS score less than or equal to PI-RADS 3, and a PSAD level less than 0.10 ng/ml2, the meta-analysis authors reported a sensitivity rate of 97 percent and a NPV of 94 percent.

“Despite the high sensitivity, 3% to 5% of csPCa cases can still be missed with this approach. “This concern may be addressed by future prospective studies that use a lower threshold for PSAD and incorporate additional variables for further risk stratification,” Haj-Mirzaian and colleagues added.

Regarding limitations of the studies, the authors acknowledged that only a few of the studies reviewed examined clinical variables. They also admitted that the evaluation of the combination of PI-RADS and PSAD assessment was based on a pooled analysis of six to 11 studies with cohorts ranging from 1,454 to 5,288 patients.

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