The Value of Systematic Versus Targeted Sampling in Prostate Cancer Detection and the Identification of Adverse Pathologic Features

The value of systematic biopsy (SBx) versus targeted biopsy (TBx) in the detection of prostate cancer and its adverse pathologic (AP) features was compared using a multi-institutional cohort of combined prostate biopsies with treatment-naive prostatic adenocarcinoma (N=1402, time period 2022 to 2025). Analyzed features included the highest International Society of Urological Pathology grade group (GG), clinically insignificant prostate cancer (CIPC, defined as GG1), clinically significant prostate cancer (CSPC, defined as GG ≥2), and AP (overall GG ≥3, cribriform/intraductal carcinoma, ductal features, extraprostatic extension, and/or seminal vesicle invasion). Compared with SBx, TBx more frequently had the highest GG cancer (81.2% vs. 58.8%, P<0.001), CSPC (61.9% vs. 46.9%, P<0.001), and AP (29.2% vs. 21.0%, P<0.001), and less CIPC (31.7% vs. 47.9%, P<0.001). The differences in the frequency of the aforementioned features remained significant when analyzing PI-RADS 4 (n=750) and 5 (n=420) lesions separately. PI-RADS 3 lesions (n=149) showed significant differences between sampling methods for CIPC (P=0.036) and highest GG (P=0.020) only, and transrectal ultrasound-guided biopsies (n=51) for CIPC (P=0.003) only. For PI-RADS 2 lesions (n=7), standard magnetic resonance imaging (n=1), microultrasound (n=6) and positron emission tomography-guided biopsies (n=13), the sample was too small to draw definitive conclusions. If SBx were omitted, the rates of missed CSPC and AP would be 6.8% and 3.4%, respectively. Omission of TBx would result in missed rates of 22.0% for CSPC and 11.6% for AP. While the detection of CSPC and AP was best achieved using combined biopsy, the TBx only approach merits consideration in PI-RADS 4-5 lesions to decrease CIPC diagnoses.