V. Scattoni Biopsia ecoguidata

Bioptic strategies: targerted biopsy

LIMITATIONS OF RANDOM PROSTATE BIOPSIES A. Oversampling B. Undersampling C: Undersampling- missing

Bioptic strategies: randomized

Controversies: different aims Do we want to detect all the prostate cancers? Do we want to detect and, at the same time, characterize all the prostate cancers? Do we want to detect and characterize only the significant prostate cancers?

Potential tools of T-PBx Initial biopsy (poorly defined) Reduce false negatives Improve risk classification Reduce repeat biopsies Reduce overdetection Repeated biopsy Increase cancer detection Reduce further repeat biopsy In AS Improve risk stratification Reduce need for repeat biopsy

Agreement TBx and SBx: 69% TBX missed 22% all cancers 83% low risk 12% intermediate risk 5% high risk

TBX missed 13% GS>=7 26% all cancers SBx missed 26% GS>=7 14% all cancers

MRI-TBx compared to TRUS-Bx did not differ in overall cancer detection a higher rate of detection of significant Pca. A lower rate of detection of insignificant Pca Improvement in significant prostate cancer detection by MRI-TBx in men with previous negative biopsy rather than in men with initial biopsy

Fusing MRI for targeted biopsies MRI-MRI fusion (in-bore biopsy) MRI – TRUS fusion via a software platform Cognitive fusion

MRI-TRUS image fusion targeted biopsy Complex procedure Image acquisition, Image interpretation, Software accuracy of the device Biopsy operator ability, skill and expertice Cost

Guichard G et al: Eur Urol 2007 6 12 18 21 Increased cancer detection (%) 34% 9,8% 2,4% -

24PBX

DRE neg Age < 65 yrs PV < 60 gr DRE neg Age > 65 yrs PV < 60 gr DRE neg Age < 65 yrs PV > 60 gr DRE pos

CONCLUSIONS Randomized extended and saturation prostate PBx have dominated the scene in the past, are still the gold standard, but probably do not represent the future. mpMRI is changing the indications and approaches in prostate cancer diagnosis and surveillance TPBx has the potential to reduce overdiagnosis Unless you do not change philosophy in prostate cancer diagnosis, randomized prostate biopsy cannot be omitted in favor to target biopsy only. To maximize prostate cancer detection it is necessary to combine both random e saturation biopsy