“Fewer Cores Without Losing Accuracy” — A New Strategy of MRI-Targeted Biopsy Plus Ipsilateral Systematic Biopsy of the Index Lesion in Prostate Cancer
Editor’s Note: Prostate cancer is one of the most common genitourinary malignancies among men in China. For patients clinically suspected of prostate cancer, MRI-targeted biopsy combined with systematic biopsy is recommended by current guidelines. One key direction in optimizing prostate biopsy is to reduce the number of biopsy cores while preserving diagnostic performance. At the recent ESMO Asia Congress, Dr. Yongbing Cheng from the team of Professor Hongqian Guo(Nanjing Drum Tower Hospital, Affiliated Medical College of Nanjing University) presented a de-escalation strategy combining MRI-targeted biopsy with ipsilateral systematic biopsy of the index lesion. The study demonstrated non-inferiority of this approach, offering a better option for patients. Urology Frontier invited Dr. Cheng to share the study results and his outlook on future AI applications.
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Urology Frontier: Could you briefly introduce the key features of MRI-targeted biopsy combined with ipsilateral systematic biopsy of the index lesion? Which major pain points of current combined biopsy strategies does it aim to address, and what progress has your team achieved?
Dr. Yongbing Cheng:
Prostate biopsy mainly includes targeted biopsy and systematic biopsy. Standard systematic biopsy usually involves 12 cores, while targeted biopsy typically samples 2–4 cores per lesion, often for 1–2 target lesions, resulting in a total of about 2–8 targeted cores. In terms of total core numbers, systematic biopsy still accounts for a substantial proportion in clinical practice. Consequently, most optimization studies have focused on modifying the systematic component, with many alternative schemes proposed.
Based on a synthesis of prior research, we asked a new question: could systematic biopsy limited to the side harboring the index lesion achieve diagnostic performance comparable to standard bilateral systematic biopsy? This approach would be simpler and more feasible for widespread clinical adoption.
At Nanjing Drum Tower Hospital, under the leadership of Professor Guo Hongqian, we were among the first in China to advance subspecialty development. Within our prostate biopsy team, colleagues such as Professors Qiu Xuefeng and Huang Haifeng have accumulated extensive experience. In parallel, we promoted PSA-based prostate cancer screening across Nanjing, identifying many patients requiring biopsy and providing a strong real-world foundation for technical refinement. Previously, we also conducted multiple studies on biopsy strategies, such as determining how many suspicious lesions require targeted sampling.
In the current study, we designed a multicenter, self-paired clinical trial to compare the detection rates of clinically significant prostate cancer between two approaches: MRI-targeted biopsy combined with ipsilateral systematic biopsy of the index lesion versus standard bilateral systematic biopsy. The difference in detection rates was only 1.6%, and the lower bound of the 95% confidence interval was 2.69%, below the prespecified non-inferiority margin of 3%. These results support the conclusion that ipsilateral systematic biopsy alone is sufficient for diagnosis when combined with targeted biopsy.
Clinically, this strategy offers clear benefits. Halving the number of systematic cores shortens procedure time and reduces the workload for pathologists. For patients, fewer cores translate into lower risks of biopsy-related complications and improved comfort during the procedure.
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Urology Frontier: In recent years, AI-assisted MRI-fusion targeted biopsy has shown potential to improve detection of clinically significant prostate cancer. How do you view the role of AI in future precision prostate biopsy?
Dr. Yongbing Cheng:
The integration of artificial intelligence into medicine is progressing rapidly. In prostate precision biopsy, AI can play a role in at least two major areas.
First, in diagnosis, AI can help integrate multimodal imaging data obtained before biopsy. By combining MRI, transrectal ultrasound, PSMA PET/CT, and other imaging modalities, AI can facilitate more accurate lesion localization.
Second, during the biopsy procedure itself. Current MRI–ultrasound fusion biopsy relies on either cognitive fusion, which depends heavily on physician experience, or software fusion. Software fusion includes rigid and elastic registration, but both have limitations in accuracy. With AI’s advanced image-analysis capabilities, more precise fusion registration and optimal biopsy trajectory planning may be achievable. This would allow operators to target lesions with greater accuracy—potentially achieving a true “one-shot hit.”
Yongbing Cheng, MD, PhD
Nanjing Drum Tower Hospital, Affiliated Medical College of Nanjing University
