ASAP occur in 5% of prostate biopsies. Current recommendation is for a repeat biopsy within 3-6months of initial diagnosis as 30- 40% may develop prostate cancer (CaP) within a 5-year period. The natural history of these patients diagnosed following targeted and saturation biopsies (TPBx), in the MRI-era remains unclear. Our aim is to follow-up these patients and determine their risk of CaP.

From 2015 to 2024, we collected prospective single-centre data of consecutive patients who had TPBx. 1,155 cases of TPBx were performed for PI-RADS≥3 lesions. 47 patients (of total 49 cases of TPBx) yielded histology of ASAP. 5 patients were excluded as their review was <6months. 34 patients were followed up prospectively with regular PSA every 6-12months and a repeat MRI scan was performed if PSA was up-trending. Repeat TBx was recommended if there was a similar or new lesion on repeat imaging.

Cancer detection rate was 60.0% and CS rate (group grade≥2) was 42.6%. In the ASAP cohort, 6.1% (3/49) patients had no target lesions, 44.8%(22/49) PI-RADS 3, 46.9% (23/49) PI-RADS 4 and 2.0% (1/49) PI-RADS 5 lesions. 16.3% (8/49) ASAP was found in initial targeted cores only and 81.6% (40/49) in saturation cores only. 2% (1/49) ASAP was found in both targeted and saturation cores. 34 patients were followed up for a median 24.5 months (IQR 13–38.5) and 8 were lost to follow up. Median age 67yrs (IQR 62–69.5), PSA 7.33mg/mL(IQR 5.06–11.24) and PSA density 0.15ng/ml2(IQR 0.11–0.20), median prostate volume 57.10ml(IQR 47.60–72.10), median target size 8.91mm(IQR 5.95–11.56) and median target cores taken 7(IQR 5–11). Diagram 1 showed patient real-life flow chart. 21/34 were stable during their review. 13/34 had repeated MRI scan for PSA up-trending; 46.1% (6/13) PIRADS scoring remained the same, 53.8% (8/13) downgraded and 0% (0/13) had their index lesion upgraded. In the repeated MRI group, 9/13 continued with PSA surveillance and 4/13 had a repeated TBx. Out of all 5 patients with repeat TBx, cancer detection was 20% (1/5) and was found to have CS cancer. This was on the original lesion and there was no new de novo cancer. 2 patients had ASAP again on saturation core only.

CS cancer detection was 2.9%(1/34) during ASAP follow-up. They will not need a repeat TBx within 1 year. We recommend a follow up every 12 months with PSA surveillance and a repeat MRI scan if PSA is up trending and a repeat biopsy for PI-RADS 4 and 5 lesions.