Editing AUA: Early Detection of Prostate Cancer (2023) (section)

=== If MRI performed prior to biopsy ===
*'''<span style="color:#ff0000">If no abnormal lesions on prostate MRI but concern for elevated risk for GG2+ prostate cancer, proceed with a systematic biopsy.</span>'''
** ≈1 in 10 patients who have a negative prostate MRI may have GG2+ cancer on biopsy,
***Negative predictive value (NPV) of a “negative” MRI (defined as PIRADS 1 to 2) to detect GG2+ prostate cancer among biopsy-naïve patients was 91%.
** A systematic biopsy should include a minimum of 12 cores
** Various templates employing these principles exist for transrectal and transperineal approaches.
*'''<span style="color:#ff0000">For biopsy-naïve patients with abnormal lesions on prostate MRI, perform targeted biopsies and may also perform a systematic template biopsy.</span>'''
** Adding a systematic biopsy to the target only approach
***Advantage: 
****Optimizes cancer yield, potentially finding more GG2+ cancer
*****Incremental yield of off-target biopsy samples may be influenced by the sampling error associated with software image registration at targeted biopsy
***Disadvantages: 
****Potentially finding more GG1 cancer
****May increase patient discomfort and other biopsy-associated complications due to larger number of cores
*'''Software registration of MRI and ultrasound images during fusion biopsy may be used, when available.'''
** Targeted prostate biopsy of a visible lesion on mpMRI can be performed using software-based registration of mpMRI images and real-time ultrasound or cognitive registration.
***Conflicting evidence on cancer detection rates comparing software-based vs. cognitive registration
*** Disadvantages of software based fusion biopsy program:
****Technical issues (e.g., software bugs, system crashes)
****Operator error
****Unusual anatomy (e.g., large prostates, previous transurethral resections of the prostate). 
*****The ability to perform cognitive fusion techniques using anatomic fiducial markers such as intraprostatic cysts may augment software-based fusion approaches in some cases such as to minimize the risk of misregistration. 
***Clinicians who adopt the cognitive fusion technique exclusively should undergo advanced training in MRI interpretation to optimize cancer detection.
* '''<span style="color:#ff0000">≥2 needle biopsy cores per target should be obtained in patients with suspicious prostate lesion(s) on MRI.</span>'''
** ≥2 cores per target provides the most reproducible and accurate cancer detection rate.
***The optimal number of biopsy cores per MRI target may differ based on multiple factors including 
****Patient characteristics (e.g., age, PSA, biopsy naïve versus prior biopsy)
****Target characteristics (e.g., size, location, PIRADS classification)
****Biopsy approach/technique (e.g., software fusion versus cognitive fusion, transrectal vs. transperineal).
***The incremental value in cancer detection is diminished after obtaining >3 cores per target.
** For prostate cancer risk group stratification, all cores from the same MRI target should be considered as a single core.