Is magnetic resonance imaging‐targeted biopsy a useful addition to systematic confirmatory biopsy in men on active surveillance for low‐risk prostate cancer? A systematic review and meta‐analysis.

Objective: To systematically review and meta‐analyse evidence regarding the additional value of magnetic resonance imaging (MRI) and MRI‐targeted biopsies to confirmatory systematic biopsies in identifying high‐grade prostate cancer in men with low‐risk disease on transrectal ultrasonography (TRUS) biopsy, as active surveillance (AS) of prostate cancer is recommended for men with Gleason 3 + 3 on standard TRUS‐guided biopsy. Confirmatory assessment can include repeat standard TRUS‐guided biopsy, and/or MRI with targeted biopsy when indicated. Methods: A systematic review of the Embase, Medline, Web‐of‐science, Google scholar, and Cochrane library was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Identified reports were critically appraised according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)‐2 criteria. Studies reporting men with Gleason 3 + 3 prostate cancer who had chosen AS based on transrectal systematic biopsy findings and had undergone MRI with systematic ± targeted biopsy at confirmatory assessment were included. The primary outcome was detection of any Gleason pattern ≥4. Results: Included reports (six) of men on AS (n = 1 159) showed cancer upgrading (Gleason ≥3 + 4) in 27% (95% confidence interval [CI] 22–34%) using a combined approach of MRI‐targeted biopsies and confirmatory systematic biopsies. MRI‐targeted biopsies alone would have missed cancer upgrading in 10% (95% CI 8–14%) and standard biopsies alone would have missed cancer upgrading in 7% (95% CI 5–10%). No pathway was more favourable than the other (relative risk [RR] 0.92, 95% CI 0.79–1.06). In all, 35% (95% CI 27–43%) of men with a positive MRI were upgraded, compared to 12% (95% CI 8–18%) of men with a negative MRI being upgraded (RR 2.77, 95% CI 1.76–4.38). Conclusions: A pre‐biopsy MRI should be performed before confirmatory systematic TRUS‐guided biopsies in men on AS, together with MRI‐targeted biopsies when indicated. A combined approach maximises cancer detection, although other factors within multivariate risk prediction can be used to aid the decision to biopsy in these men. [ABSTRACT FROM AUTHOR]