Targeted, Perilesional and Systematic Biopsies: A Prospective Registry Study

Perilesional biopsy is increasingly proposed as a substitute for systematic biopsy, but the evidence is mostly retrospective, based on relabeled systematic cores. We aimed to assess the added value of perilesional and distant systematic sampling using a prospectively defined template.

Consecutive patients with a suspicious magnetic resonance imaging lesion were included in a prospective institutional registry and underwent transperineal fusion biopsy with a predefined template. Targeted and perilesional cores of the suspicious lesion were taken for each patient, and distant systematic cores were left to the discretion of the operator. Each core was analyzed separately, using the 2019 ISUP recommendations. The primary endpoint was the incremental detection of clinically significant cancer (csPCa, i.e., ISUP grade group ≥2) and the grade change attributable to perilesional cores.

Of 513 patients, 422 were analyzed. Targeted cores alone detected csPCa in 224 patients (53%), while targeted plus perilesional cores detected csPCa in 235 (56%) (+2.6, 95% CI 1.1-4.0; p=0.001). The aggregate grade (i.e., targeted plus perilesional cores) increased in 70 (17%) with no downgrade. Among 325 patients with systematic sampling, detection rose from 54% to 57% (+2, 95% CI 0.6-3.7; p=0.02). Systematic cores added nothing in 308 (95%) patients, cost 194 cores per additional csPCa, and yielded as many ISUP grade group 1 as significant cancers.

Perilesional cores mainly reclassify the index lesion, supporting systematic use. Distant systematic biopsy informs in a limited number of patients and may be discussed individually.