Multiparametric MRI-targeted biopsy has significantly enhanced the detection of prostate cancer, leading some guidelines to suggest that systematic biopsy may no longer be necessary. However, there is still uncertainty regarding the effectiveness of MRI-targeted biopsy alone, particularly in detecting clinically significant cancers (Gleason score ≥ 7) at varying PSA levels. This study also assesses the adequate PSA levels required for each biopsy technique.

A retrospective review included 381 patients undergoing simultaneous MRI fusion-targeted (≥2 cores per lesion) and systematic TRUS (12-core) biopsies. PSA levels categorized patients: <4, 4–10, 10–20, 20–50, and >50 ng/mL. Detection rates of clinically significant cancers were compared between methods.

The median PSA was 8.7 ng/mL (IQR 6.1–13.3). Most lesions were located posteriorly (right posterior 30%, left posterior 27%), with fewer detected anteriorly (right anterior 9.7%, left anterior 16%), at the apex (right 4.5%, left 6.5%), and base (right 4%, left 2.3%). MRI lesions predominantly PIRADS 4 (47.4%) or 5 (41.3%). (table 1) MRI-targeted biopsy positive findings in 84.5% of patients compared to 83.7% positivity with systematic TRUS biopsy. MRI-targeted biopsies failed to detect malignancies in 15.5% of cases, while systematic TRUS biopsies would miss 16.3% of detected cancers. Overall, the rate of clinically significant cancer detection was slightly higher in MRI-targeted biopsy (58.7%) compared to systematic TRUS biopsy (56.2%). Stratified by PSA levels, clinically significant detection rates increased with rising PSA for both biopsy methods (table 2)

MRI-targeted biopsy enhances clinically significant prostate cancer detection at intermediate PSA levels (4–50 ng/mL), yet systematic TRUS biopsy identifies additional cancers, notably at higher PSA levels (>50 ng/mL). Combining both biopsy techniques maximizes diagnostic accuracy