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Updated: May 28, 2026
A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound
Published on: March 21, 2025
Limited Incremental Diagnostic Value of Perilesional and Systematic Biopsies in PI-RADS 4-5 Lesions: A Retrospective
Emiliano Scarrone1, Vittorio Canale1, Luca Antonelli2,3
1Department of Urology, ASL AT Cardinal Massaia Hospital, 14100 Asti, Italy.
Objective:
This study aims to evaluate the additional diagnostic value of systematic (SBx) and perilesional biopsies (PBx) compared with targeted biopsy (TBx) in patients with mpMRI-detected PI-RADS 3-4-5 lesions.
Methods:
We performed a retrospective analysis of 208 men with PI-RADS ≥ 3 lesions who underwent mpMRI-ultrasound fusion biopsy at a single institution. Clinically significant prostate cancer (csPCa; ISUP ≥ 2) was identified in 155 patients (74.5%), who constituted the study cohort. All patients underwent a standardized biopsy protocol consisting of 3-5 TBx cores, 3 PBx cores sampled within a 10 mm radius of the index lesion, and 10 SBx cores using the KOELIS Trinity® system. Detection rates of csPCa and ISUP grade upgrading were analyzed and stratified by PI-RADS category.
Results:
TBx csPCa detection rates increased progressively with PI-RADS score: 39% for PI-RADS 3, 50% for PI-RADS 4, and 60% for PI-RADS 5 lesions. PBx showed a 42.5% detection rate of csPCa in PI-RADS 3 and 58% and 85.3% of csPCa in PI-RADS 4 and 5 respectively, whereas SBx detected 34.5% of csPCa in PI-RADS 3, 46% of csPCa in PI-RADS 4, and 60.5% of csPCa in PI-RADS 5. Despite these detection rates, PBx and SBx rarely provided clinically meaningful upgrading over TBx findings. ISUP grade upgrading occurred in only 7.3% of PBx cases and 1.8% of SBx cases in PI-RADS 5 lesions, with similarly low upgrading rates observed in PI-RADS 3-4 lesions.
Conclusions:
In patients with high-grade lesions like PI-RADS 4-5, TBx alone identifies the vast majority of csPCa, while SBx and PBx contribute minimal additional diagnostic or grading benefit. These findings support biopsy de-escalation strategies in high-risk mpMRI settings to reduce unnecessary sampling and procedure-related morbidity. On the other hand, in the PI-RADS 3 subgroup, omitting non-targeted sampling (SBx and/or PBx) may lead to underdiagnosis of higher-grade tumors not captured by TBx alone, potentially resulting in substantial changes in therapeutic strategy and, consequently, patient prognosis.
Insights
Targeted biopsy (TBx) alone is sufficient for most high-grade PI-RADS 4-5 prostate lesions. However, systematic (SBx) and perilesional biopsies (PBx) may help avoid underdiagnosis in PI-RADS 3 cases.
Area of Science:
- Urology
- Oncology
- Radiology
Background:
- Multiparametric MRI (mpMRI) is crucial for detecting prostate cancer.
- PI-RADS scoring stratifies lesion risk, guiding biopsy decisions.
- The diagnostic yield of different biopsy techniques requires further evaluation.
Purpose of the Study:
- To assess the added diagnostic value of systematic biopsies (SBx) and perilesional biopsies (PBx) compared to targeted biopsy (TBx).
- To evaluate these techniques in patients with PI-RADS 3-5 lesions detected by mpMRI.
Main Methods:
- Retrospective analysis of 208 men with PI-RADS ≥ 3 lesions undergoing mpMRI-ultrasound fusion biopsy.
- Standardized protocol included TBx, PBx (within 10 mm of index lesion), and SBx.
- Detection rates of clinically significant prostate cancer (csPCa; ISUP ≥ 2) and ISUP grade upgrading were analyzed.
Main Results:
- TBx detection rates for csPCa increased with PI-RADS score (39% for 3, 50% for 4, 60% for 5).
- PBx and SBx showed higher detection rates but rarely led to clinically meaningful ISUP grade upgrading over TBx.
- ISUP grade upgrading occurred in only 7.3% of PBx and 1.8% of SBx cases in PI-RADS 5 lesions.
Conclusions:
- For PI-RADS 4-5 lesions, TBx alone detects most csPCa, suggesting biopsy de-escalation is feasible.
- Omitting SBx and/or PBx in PI-RADS 3 cases may risk underdiagnosis of higher-grade tumors.
- These findings impact biopsy strategies to optimize cancer detection and minimize morbidity.