Increasing the Number of Biopsy Cores Around Prostate Cancer Targeted Lesions in the Transition Zone to Improve Biopsy Accuracy: A Combined Retrospective and Prospective Study

doi:10.21203/rs.3.rs-5011281/v1

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Increasing the Number of Biopsy Cores Around Prostate Cancer Targeted Lesions in the Transition Zone to Improve Biopsy Accuracy: A Combined Retrospective and Prospective Study

https://doi.org/10.21203/rs.3.rs-5011281/v1

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Background

Prostate biopsy (PBx) plays a pivotal role in diagnosing prostate cancer (PCa). However, the prostate biopsy results for transition zone (TZ) tumors were found to be less accurate than those for peripheral zone tumors. The objective of this study was to identify potential under-detection of TZ PCa and to validate a new biopsy template that increases the number of cores around TZ targeted lesions to improve biopsy accuracy for TZ tumors.

Materials and Methods

This study comprised two components: a retrospective analysis and a randomized clinical trial. The retrospective study included 217 patients who underwent radical prostatectomy following "12 + X" template transperineal transrectal ultrasound-magnetic resonance imaging-fusion PBx between 2018 and 2021 at our institution. The clinical trial investigated biopsy efficacy for clinically significant PCa (csPCa) in 400 patients who underwent either modified "18 + X" template PBx for TZ lesion or "12 + X" template PBx following systematic sampling between 2022 and 2023 at our center.

Results

The retrospective analysis revealed that the "12 + X" template, comprising 4 cores in TZ, failed to adequately detect csPCa in the TZ. “18 + X” template was constructed based on the results of retrospective analysis. Conversely, in the prospective trial, the "18 + X" template, with 10 cores in TZ, outperformed the "12 + X" template in detecting TZ csPCa without a corresponding increase in complications. Building upon the result, "18 + X" template was improved to the "New 12" and "New 12 + X" templates, with 8 cores in TZ and 4 cores in peripheral zone, while maintaining the same csPCa detection rate for TZ patients.

Conclusions

Our study demonstrated that increasing the number of biopsy cores around targeted lesions in the TZ improves biopsy accuracy and reduces the number of biopsies in non-targeted regions without compromising overall accuracy. The new template offers a promising approach to improve biopsy for patients with TZ lesions.

Trial Registration:

This study was approved by Clinical trial registration in China Clinical Trial Registry (ChiCTR2200056386). Registered 04 February 2022, https://www.chictr.org.cn

Prostate cancer

Transition zone

Prostate biopsy

Biopsy template

MRI

Since the onset of the 20th century, prostate biopsy (PBx), as the primary diagnostic method for PCa ¹, has been the subject of extensive research. For instance, transperineal (TP) PBx has emerged as a method capable of reducing the risk of infection and sepsis when compared to transrectal PBx ^{2, 3}. Additionally, TP-PBx offers sufficient core length and enhances sampling of the prostate tip and gland ⁴. Nonetheless, significant differences persist among commonly employed clinicians' perineal template-guided biopsy protocols, including the mapping method (Barzell), the sector method (Ginsburg), the 10-sector method, and the 12-core method ⁵.

In recent discussions surrounding systematic biopsy (SB) and targeted biopsy (TB), the "12 + X" PBx approach, which combines SB with TB, has garnered increasing popularity ^{6, 7} and is recommended by major guidelines ⁸. However, it is common for cancer diagnoses to undergo further upgrading or downgrading during radical prostatectomy (RP) following PBx ^{9, 10}. Furthermore, research indicates that such adjustments are more prevalent in patients with transitional zone (TZ) tumors compared to those with peripheral zone (PZ) tumors ¹¹. The inadequate sampling of cores in the TZ area within the "12 + X" TP-PBx template may be contributing to this issue in patients with TZ tumors. Recently, measures to increase the unmber of the biopsy cores around the targeted lesion have been recommended by the guidelines¹². Hence, we undertook a retrospective study to identify potential defects in the "12 + X" TP-PBx template and endeavored to design and validate a new biopsy template that increases the number of cores around TZ targeted lesions to improve biopsy accuracy for TZ tumors in a prospective trial.

Patients

Retrospective study

The retrospective study comprised 217 patients who underwent laparoscopic RP following "12 + X" TP transrectal ultrasound (TRUS)-magnetic resonance imaging (MRI)-fusion PBx between 2018 and 2021 at our center. Inclusion criteria: (1) All preoperative examinations, including blood tests and multiparameter-MRI (MP-MRI), as well as biopsy and RP, were conducted at our center between December 2018 and January 2021; (2) PCa was confirmed by primary biopsy. Exclusion criteria: (1) Prostate Imaging Reporting and Data System (PI-RADS) score < 4 (MRI lesions less likely to be real tumors lesions; in the lesion level analysis, the positive rate of PI-RADS 1 was 2% versus 4% for PI-RADS 2 and 20% for PI-RADS 3¹³); (2) Diffuse MRI lesions or unclear MRI data; (3) Prostate-specific antigen (PSA) > 100 ng/ml (inaccurate measurements); (4) Neoadjuvant therapy (changes in clinical features).

Prospective trial

Power estimates were predicated on the probability of detecting clinically significant prostate cancer (csPCa) in men with PI-RADS score 4 or more lesions on MP-MRI ¹³. A total of 400 patients who underwent modified "18 + X" for TZ tumors or "12 + X" TP TRUS-MRI-fusion PBx after systematic sampling from 2022 to 2023 were included. Inclusion criteria: (1) All preoperative investigations, including blood tests and MP-MRI, were completed at our center; (2) Biopsy was performed in accordance with guideline-recommended criteria¹²; (3) Primary biopsy was performed. Exclusion criteria for prospective studies were consistent with the retrospective study. Systematic sampling: Independent, blinded administrators numbered enrolled patients in groups according to time of visit. Systematic sampling was employed to divide every ten individuals into experimental and control groups in a 7:3 ratio. This approach aimed to enhance the likelihood of patients joining the experimental group, potentially benefiting them and facilitating the acquisition of informed consent. The flowchart is depicted in Fig. 1.

Biopsy method

“12 + X” TP TRUS-MRI-fusion PBx

The "12 + X" TP TRUS-MRI-fusion PBx was performed as previously described ¹⁴. In brief, TRUS and MRI imaging software fusion positioning were utilized for perineal 12-core system (Fig. 2a) and X-core targeted biopsy (Fig. 2b).

18 + X” TP TRUS-MRI-fusion PBx

The biopsy procedure remained identical to that described previously. However, the placement of the biopsy core was modified, and its distribution is illustrated in Fig. 2c. According to the distribution of positive cores in TZ tumor biopsy by “18 + X” biopsy template, we gradually improved “New 12 + X”, “New 12” templates for TZ tumors (Fig. 2d).

MP-MRI and Pathological features

All patients underwent examination using the 3T MRI scanner (MAGNETOM Skyra, Siemens Healthineers, Erlangen, Germany). Relevant sequences were obtained as previously described ¹⁵. All MRI parameters were measured according to PI-RADS Guideline V2.1 ¹⁶. Pathological criteria were based on the Society of Urogenital Pathology and the International Society of Urological Pathology (ISUP) guidelines for prostate cancer pathology ¹⁷. All cases were analyzed by two experienced radiologists or pathologists, and in case of disagreement, other experts were consulted. The criterion for csPCa was ISUP grade > 1, with biopsy ISUP grade upgraded from 1 to RP ISUP grade > 1 considered significant ¹⁸.

Statistical analyses

Concurrent control: Following systematic sampling, 280 patients who underwent "18 + X" PBx and 120 patients who underwent "12 + X" PBx were included as a concurrent control group. Self-control: As the "18 + X" PBx contains "12 + X" PBx, 280 patients who underwent "18 + X" PBx were used as a self-control group for both "18 + X" and "12 + X". Primary endpoint: the positive rate of biopsy and the detection rate of csPCa. Secondary endpoint: incidence of biopsy-related complications. Following a normal distribution analysis, continuous variables were t-tested and nonparametrically tested. The Chi-square or Fisher test was employed for categorical variables. GraphPad Prism (8.0.2) and R (4.1.2) were utilized for data analysis. A significance level of P < 0.05 was adopted.

Descriptive analysis of patients

The clinical characteristics of all patients are shown in Table 1.

"12 + X" failed to deliver sufficient detection efficiency for TZ patients.

The incidence of csPCa detected by biopsy in patients with lesions in the PZ was notably higher than that in patients with lesions in the TZ (92%, n = 121 vs. 78%, n = 83, p = 0.006) (Fig. 3a). However, there was no disparity in the incidence of csPCa determined by RP between PZ and TZ patients (97%, n = 121 VS. 95%, n = 83, p = 0.718) (Fig. 3b). Additionally, a higher incidence of RP-diagnosed csPCa compared to biopsy-detected csPCa was observed in TZ patients (95%, n = 83 vs. 78%, n = 83, p = 0.006) (Fig. 3c), while no such difference was found in PZ patients (97%, n = 121 vs. 92%, n = 121, p = 0.167) (Fig. 3d).

The detection rate of TZ csPCa using the "12 + X" approach surpassed that using "12" alone (82%, n = 79 vs. 67%, n = 79, p = 0.028) (Fig. 3e). Patients with upgraded TZ lesions exhibited a smaller tumor volume ratio compared to those without upgrading (1.26% vs. 3.35%, p = 0.027) (Fig. 3f). Moreover, the incidence of lesions was higher in the transitional zone anterior (TZa) than in the transitional zone posterior (TZp) (right 47% vs. 17%, left 52% vs. 17%, n = 83, p < 0.001) (Fig. 3g).

The construction of the "18 + X" and "18 + X" templates aimed to enhance accuracy compared with "12 + X" in detecting csPCa in the TZ.

The smaller the proportion of tumor volume, the lower the possibility of biopsy to penetrate the main pathological structure, and the more cores were required ¹⁹. The detection rate of TZ csPCa using the “12 + X” approach was higher than that using “12” alone, suggesting that the missed detection of TZ csPCa may be due to the lower distribution of “12” cores in the TZ (Fig. 3e). According to the finding that upgraded TZ patients had a smaller tumor volume ratio than the non-upgraded patients (1.26% vs. 3.35%, p = 0.027), we calculated that if upgraded patients wanted to achieve the biopsy accuracy of the non-upgraded patients, the TZ area might require 10 biopsy cores (3.35/1.26×4 ≈ 10) (Fig. 3f). Combined with the higher incidence of TZa lesions compared to TZp (Fig. 3g), we designed the “18 + X” template (Fig. 2).

Among the enrolled patients, 145 had MP-MRI lesions localized in the TZ. In TZ patients, the positive biopsy rate of “18 + X” was higher than that of “12 + X” (concurrent control: 88%, n = 145 vs. 65%, n = 51, p < 0.001, Fig. 4a; self-control: 87% vs 76%, n = 145, p = 0.016, Fig. 4b). After “12 + X” or “18 + X” PBx, 33 and 127 patients, respectively, were diagnosed with PCa by biopsy. Among them, 23 and 81 patients, respectively, were finally diagnosed with csPCa in the radical specimens. For the detection rate of csPCa in TZ patients: in the concurrent control, “18 + X” was higher than “12 + X” (83%, n = 81 vs 61%, n = 23, p = 0.026, Fig. 4c); in self-control, there was a trend of difference (83% vs. 72%, n = 81, p = 0.092, Fig. 4d). Additionally, there was no significant difference in the incidence of clinically insignificant PCa (concurrent control: 28%, n = 127 vs. 33%, n = 33, p = 0.514, Fig. 4e; self-control: 28% VS 25%, n = 127, p = 0.715, Fig. 4f) and biopsy complications (concurrent control: hematuria, 9%, n = 280 vs. 8%, n = 120, p = 0.700; fever, 1%, n = 280 vs. 2%, n = 120, p = 0.689; uroschesis, 3%, n = 280 vs. 2%, n = 120, p > 0.999, Fig. 4g) between “18 + X” and “12 + X”. The analysis results of total patients, PZ patients, and detailed self-control were shown in Supplements 1–2.

Improved "New 12” and “New 12 + X” templates showed equivalent detection rates of csPCa in TZ patients.

Based on the distribution of positive cores in TZ patient biopsies using the “18” and “18 + X” templates, we gradually refined the “New 12” and “New 12 + X” templates for TZ patients (Fig. 2). The process of refinement is illustrated in Fig. 4h and Supplement 3.

A self-control study was conducted on 145 patients with TZ lesions (81 patients with radical prostatectomy). There was no significant difference in the positive biopsy rate among the four biopsy templates of “18”, “New 12”, “18 + X”, and “New 12 + X” (83% vs. 79% vs. 87% vs. 83%, n = 145, p > 0.050), as shown in Fig. 4i. Similarly, there was no significant difference in the detection rate of csPCa among the four biopsy templates (80% vs. 80% vs. 83% VS 83%, n = 81, p > 0.050), as depicted in Fig. 4j.

PBx plays a pivotal role in diagnosing PCa ⁸. Currently, TP-PBx is widely employed for PCa patients ²⁰. However, the choice of biopsy template for TP-PBx remains a topic of debate ⁰. Our study identified a potential limitation in the widely used “12 + X” PBx template. Despite patients with TZ tumors exhibiting a similar incidence of csPCa as those with PZ tumors, the “12 + X” biopsy failed to provide sufficient detection efficiency. Consequently, we augmented the number of biopsy cores in the TZ region, resulting in the “18 + X” PBx template. In our prospective trial, we observed that “18 + X” outperformed “12 + X” in detecting csPCa in TZ (83% vs. 61% p = 0.026), without increasing the incidence of biopsy complications and ciPCa. Subsequently, based on the “18 + X”, we refined the “New 12” and “New 12 + X” templates for TZ tumors by reducing the core distribution of the PZ region. Further analysis revealed that “New 12”, “New 12 + X”, and “18 + X” achieved similar csPCa detection rates for TZ tumors (80% vs. 83% vs. 83%, p > 0.050). The result demonstrated that increasing the number of biopsy cores around targeted lesions in the TZ improves biopsy accuracy and reduces the number of biopsies in non-targeted regions without compromising overall accuracy.

Advances in MRI technology and the continuous updating of the PI-RADS guidelines have empowered MRI results to influence biopsy and treatment options for PCa, as well as facilitate lesion localization ^{7, 21–23}. A meta-analysis by Oerther, B., et al., which included 1946 lesions, revealed cancer detection rates by lesion level: 2% (95% CI: 0–8%) for PI-RADS 1, 4% (1–9%) for PI-RADS 2, 20% (13–27%) for PI-RADS 3, 52% (43–61%) for PI-RADS 4, and 89% (76–97%) for PI-RADS 5.¹³ To ensure the accuracy of lesion localization and consistency between MRI findings and actual lesions, we included only patients with a PI-RADS score > 3.

Based on MRI lesion localization, we found that the “12 + X” biopsy failed to provide sufficient detection efficiency for PCa patients with MRI lesions in TZ. Similar findings were reported by Augustin, who observed inconsistent Gleason scores between TZ cancer biopsies and RP specimens ¹¹. Furthermore, we calculated that TZ area requires 10 cores. Then, we distributed 10 cores according to the incidence of lesions in TZa was higher than that in TZp. A previous study also showed that the incidence of pre-PCa was higher than that of post-PCa²⁴. Finally, we designed the “18 + X” TP-PBx template.

In prospective trials, the “18 + X” had a higher detection rate for TZ csPCa in both concurrent controls and self-control. In an earlier clinical trial, Guichard et al.²⁵ found that adding TZ biopsy to the original 12-core biopsy template (sextant plus lateral biopsy) increased the overall detection rate by 7.2% (p = 0.023). Although the original 12-cores biopsy template was different from the present, it still reflected the importance of TZ biopsy. Queiroz et al.²⁶ and Presti et al.²⁷ also found that additional extended cores in TZ increase cancer detection rates without increasing the incidence of complications. In our study, increasing the number of cores in the TZ also did not increase the incidence of complications, which was still similar to the study from Xiang et al. ³. In addition, there was no difference in the incidence of ciPCa between “18 + X” and “12 + X”. “18 + X” is not like saturated biopsy. Although saturated biopsy improves the detection rate, it also increases the detection rate of ciPCa, complications, and pain ²⁸.

Recent guidelines recommend increasing the number of biopsy cores around targeted lesions and reducing the number of cores in non-targeted regions to achieve more accurate biopsy results with fewer cores¹². However, specific implementation strategies remain unclear. In further analysis, we refined the “New 12 + X” templates for TZ tumors based on the “18 + X” template by reducing the core distribution in the PZ region. This achieved the same effect as the “18 + X” template. Compared with the “12 + X”, the “New 12 + X” increased the number of biopsy cores in the TZ region and decreased the number of biopsy cores in the PZ region. This demonstrated that increasing the number of biopsy cores around targeted lesions in the TZ improves biopsy accuracy and reduces the number of biopsies in non-targeted regions without compromising overall accuracy. Similar results have been reported in a study for PZ tumors. Biopsy in patients with PZ tumors that omits the TZ region showed similar rates of detection of csPCa to biopsy in patients without the TZ region²⁹. Certainly, “New 12 + X” provides an idea for the unique biopsy template of TZ and PZ.

Additionally, we unexpectedly found that the "New 12" approach achieved the same results as the "New 12 + X" approach. In a study of 291 patients by Mortezavi et al. ²⁸,129 (44.3%) were found by TB, 176 (60.5%) were found by saturated PBx, and 187 (64.3%) were found by combined PBx. Kaufmann et al. ³⁰ showed similar results, indicating that by increasing the number of cores, the results of TB could be achieved or even exceeded. This also proves that our template can achieve the effect of combined PBx in the TZ region by appropriately increasing the number of cores in the TZ region. This may provide an alternative for medical facilities and patients unable to perform targeted biopsies.

The present study has a few limitations. First, to ensure the correspondence between MRI lesions and real lesions, we discarded some patients with PI-RADS < 4, which may allow our study to exclude some Pca patients. Secondly, as a high-volume referral medical center, the disease patterns observed at our institution may not accurately reflect those in the community. Thirdly, this was a single-center prospective study, and our results require prospective validation of multicenter studies.

We have designed the more effective “18 + X” and “New 12 + X” biopsy templates specifically for patients with TZ tumors, achieving a higher detection rate of csPCa without increasing complications. Our study demonstrated that increasing the number of biopsy cores around targeted lesions in the TZ improves biopsy accuracy and reduces the number of biopsies in non-targeted regions without compromising overall accuracy. The new template offers a promising approach to improve biopsies for patients with TZ lesions and provides practical insights for applying guideline recommendations to increase the number of cores around targeted lesions.

csPCa, clinically significant prostate cancer; ciPCa, clinically insignificant prostate cancer; IQR, interquartile; MRI, magnetic resonance imaging; PCa, prostate cancer; TZ, transitional zone; PZ, peripheral zone; PBx, prostate biopsy; PI-RADS, Prostate Imaging Reporting and Data System; PSA, prostate-specific antigen; RP, radical prostatectomy; SB, systematic biopsy; TRUS, transrectal ultrasound; TP, transperineal; TB, targeted biopsy;

Conflict of Interest

The authors report no conflicts of interest in this work.

Ethics Statement

This study was approved by the Institutional Review Board of First Affiliated Hospital of Soochow University (approval number: NO.2021 (033)) and Clinical trial registration in China Clinical Trial Registry (ChiCTR2200056386, https://www.chictr.org.cn), and informed consent was obtained from each patient.

Data Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Funding

This work was supported by the Jiangsu Provincial Key Research and Development Program (No.BE2020655 and No. BE2020654), the National Natural Science Foundation of China (Grant No. 32200533), the General Program of Jiangsu Health Commission (No. H2019040), and the Gusu Health Personnel Training Project of Suzhou City (No. GSWS2019033).

CRediT authorship contribution statement

Xin Chen and Chen Huang contributed equally to this work. Xin Chen: Conceptualization, Methodology, Software, Formal analysis, Investigation, Writing – Original Draft, Visualization. Chen Huang: Methodology, Software, Investigation, Validation, Resources, Writing – Original Draft. Chenchao Zhou: Methodology, Investigation, Resources. Yu Li: Software, Investigation, Validation. Renpeng Huang: Methodology, Software, Validation, Writing – Original Draft. Jie Bao: Methodology, Software, Validation, Writing – Original Draft. Yuxin Lin: Data Curation, Writing – Review & Editing, Supervision, Funding acquisition. Michael C. Truß: Conceptualization, Methodology, Investigation, Writing – Review & Editing, Supervision. Jianquan Hou: Writing – Review & Editing, Supervision, Funding acquisition, Resources, Project administration. Yuhua Huang: Data Curation, Writing – Review & Editing, Supervision, Funding acquisition, Resources, Project administration. Xuedong Wei: Conceptualization, Methodology, Writing – Review & Editing, Supervision, Funding acquisition, Resources, Project administration. All authors have read and agreed to the published version of the manuscript.

Acknowledgments

The authors are indebted to all patients and their relatives.

Bhanji Y, Allaway MJ, Gorin MA. Recent Advances and Current Role of Transperineal Prostate Biopsy. Urol Clin North Am. 2021;48(1):25–33.
Berry B, Parry MG, Sujenthiran A, et al. Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study. BJU Int. 2020;126(1):97–103.
Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis. World J Surg Oncol. 2019;17(1):31.
Ficarra V, Martignoni G, Novella G, et al. Needle core length is a quality indicator of systematic transperineal prostate biopsy. Eur Urol. 2006;50(2):266–71.
Sidana A, Blank F, Wang H, Patil N, George AK, Abbas H. Schema and cancer detection rates for transperineal prostate biopsy templates: a review. Ther Adv Urol. 2022;14:671515781.
Ahdoot M, Wilbur AR, Reese SE, et al. MRI-Targeted, Systematic, and Combined Biopsy for Prostate Cancer Diagnosis. N Engl J Med. 2020;382(10):917–28.
Klotz L, Chin J, Black PC et al. Comparison of Multiparametric Magnetic Resonance Imaging-Targeted Biopsy With Systematic Transrectal Ultrasonography Biopsy for Biopsy-Naive Men at Risk for Prostate Cancer: A Phase 3 Randomized Clinical Trial. 7; 2021:534–42.
Edward M. Schaeffer MPC©. NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer (Version 4.2022 — May 10, 2022). https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1459
Bittner N, Merrick G, Taira A, et al. Location and Grade of Prostate Cancer Diagnosed by Transperineal Template-guided Mapping Biopsy After Negative Transrectal Ultrasound-guided Biopsy. Am J Clin Oncol. 2018;41(8):723–9.
Epstein JI, Feng Z, Trock BJ, Pierorazio PM. Upgrading and downgrading of prostate cancer from biopsy to radical prostatectomy: incidence and predictive factors using the modified Gleason grading system and factoring in tertiary grades. Eur Urol. 2012;61(5):1019–24.
Augustin H, Erbersdobler A, Graefen M, et al. Differences in biopsy features between prostate cancers located in the transition and peripheral zone. BJU Int. 2003;91(6):477–81.
Cornford P, van den Bergh RCN, Briers E et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2024.
Oerther B, Engel H, Bamberg F, Sigle A, Gratzke C, Benndorf M. Cancer detection rates of the PI-RADSv2.1 assessment categories: systematic review and meta-analysis on lesion level and patient level. Prostate Cancer Prostatic Dis. 2021.
Huang C, Huang Y, Pu J, et al. Comparison of MRI/US Fusion Targeted Biopsy and Systematic Biopsy in Biopsy-Naïve Prostate Patients with Elevated Prostate-Specific Antigen: A Diagnostic Study. Cancer Manag Res. 2022;14:1395–407.
He D, Wang X, Fu C, et al. MRI-based radiomics models to assess prostate cancer, extracapsular extension and positive surgical margins. Cancer Imaging. 2021;21(1):46.
Turkbey B, Rosenkrantz AB, Haider MA, et al. Eur Urol. 2019;76(3):340–51. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2.
Epstein JI, Kryvenko ON. A Comparison of Genitourinary Society Pathology and International Society of Urological Pathology Prostate Cancer Guidelines. Eur Urol. 2021;79(1):3–5.
Stabile A, Dell'Oglio P, Soligo M, et al. Assessing the Clinical Value of Positive Multiparametric Magnetic Resonance Imaging in Young Men with a Suspicion of Prostate Cancer. Eur Urol Oncol. 2021;4(4):594–600.
Zhu H, Ding X, Lu S, et al. The Application of Biopsy Density in Transperineal Templated-Guided Biopsy Patients With PI-RADS < 3. Front Oncol. 2022;12:918300.
Schmeusser B, Levin B, Lama D, Sidana A. Hundred years of transperineal prostate biopsy. Ther Adv Urol. 2022;14:671520210.
Elwenspoek MMC, Sheppard AL, McInnes MDF, et al. Comparison of Multiparametric Magnetic Resonance Imaging and Targeted Biopsy With Systematic Biopsy Alone for the Diagnosis of Prostate Cancer. JAMA Netw Open. 2019;2(8):e198427.
Padhani AR, Barentsz JO, Villeirs G, et al. PI-RADS Steering Committee: The PI-RADS Multiparametric MRI and MRI-directed Biopsy Pathway. Radiology. 2019;292(2):464–74.
Shabsigh A, Lee CT. Closing the Loop on the Role of Multiparametric Magnetic Resonance Imaging-Targeted Prostate Biopsy. 154; 2019:818.
Kudlackova S, Kurfurstova D, Kral M, Hruska F, Vidlar A, Student V. Do not underestimate anterior prostate cancer. Biomedical Papers. 2021;165(2):198–202.
Guichard G, Larré S, Gallina A, et al. Extended 21-sample needle biopsy protocol for diagnosis of prostate cancer in 1000 consecutive patients. Eur Urol. 2007;52(2):430–5.
Queiroz MR, Falsarella PM, Moreira Valle LG, et al. Is a sampling transition zone important to increase the detection of prostate cancer in systematic prostatic biopsies? Acta Radiol (Stockholm Sweden: 1987). 2021;62(6):815–20.
Presti JJ, Chang JJ, Bhargava V, Shinohara K. The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: results of a prospective clinical trial. J Urol. 2000;163(1):163–6.
Mortezavi A, Märzendorfer O, Donati OF, et al. Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging and Fusion Guided Targeted Biopsy Evaluated by Transperineal Template Saturation Prostate Biopsy for the Detection and Characterization of Prostate Cancer. J Urol. 2018;200(2):309–18.
Kachanov M, Leyh-Bannurah S, Roberts MJ, et al. Optimizing Combined Magnetic Resonance Imaging (MRI)-Targeted and Systematic Biopsy Strategies: Sparing the Multiparametric MRI-Negative Transitional Zone in Presence of Exclusively Peripheral Multiparametric MRI-Suspect Lesions. J Urol. 2022;207(2):333–40.
Kaufmann B, Saba K, Schmidli TS, et al. Prostate cancer detection rate in men undergoing transperineal template-guided saturation and targeted prostate biopsy. Prostate. 2022;82(3):388–96.

Table 1 is available in the Supplementary Files section.

No competing interests reported.

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Increasing the Number of Biopsy Cores Around Prostate Cancer Targeted Lesions in the Transition Zone to Improve Biopsy Accuracy: A Combined Retrospective and Prospective Study

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Version 1

Abstract

Background

Materials and Methods

Results

Conclusions

Trial Registration:

Figures

Introduction

Material and Methods

Patients

Retrospective study

Prospective trial

Biopsy method

18 + X” TP TRUS-MRI-fusion PBx

MP-MRI and Pathological features

Statistical analyses

Results

Descriptive analysis of patients

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

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