Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 3270 ORIGINAL PAPER No conflict of interest declared. biopsy has been established within 12 months from ini- tial diagnosis, there are no definitive data regarding the number of systematic needle cores (extended or satura- tion biopsy) and the best procedure to diagnose all the csPCa reducing the number of scheduled biopsies. In our study, the reclassification rate for csPCa at 8-year scheduled transperineal biopsy has been prospectively evaluated in men enrolled in AS protocol. MATERIALS AND METHODS From May 2013 to September 2017, 160 patients aged between 52 and 73 years (median age 63) with very low risk PCa were enrolled in an AS protocol. After institu- tional review board and ethical committee approval were granted, informed consents were obtained from all par- ticipants included in the study. Presence of the following criteria defined eligibility: life expectancy greater than 10 years, clinical stage T1C, PSA below 10 ng/ml, PSA densi- ty (PSAD) ≤ 0.20, ≤ 2 unilateral positive biopsy cores, Gleason score 6/International Society of Urologic Pathology (ISUP) Grade Groups (GG) 1 (6), maximum core percent- age of cancer (GPC) ≤ 50% (7). All the patients six months after the PCa diagnosis underwent pelvic mpMRI 3.0 Tesla evaluation before confirmatory transperineal saturation prostate biopsy (SPBx; range: 24-32 cores); the procedure was performed with the use of a GE Logiq P6 ecograph (General Electric; Milwaukee, WI) supplied with a bi-planar trans-rectal probe (5-7.5 MHz) using a tru-cut 18 gauge needle (Bard; Covington, GA) under sedation and antibiotic prophylaxis (8, 10). All mpMRI examinations were performed using a 3.0 Tesla scanner, (ACHIEVA 3T; Philips Healthcare Best, the Netherlands) equipped with surface 16 channels phased-array coil placed around the pelvic area with the patient in the supine position; multi- planar turbo spin-echo T2-weighted (T2W), axial diffusion weighted imaging (DWI) and axial dynamic contrast enhanced (DCE) were performed for each patient. The mpMRI lesions characterized by Prostate Imaging Reporting and Data System (PI-RADS) version 2 scores ≥ 3 were considered suspicious for cancer and submitted to four targeted cores; two radiologists blinded to pre-imag- ing clinical parameters evaluated the mpMRI data sepa- Introduction: The reclassification rate for clinically significant prostate cancer (csPCa) in men enrolled in Active Surveillance (AS) as been prospective- ly evaluated. Patients and methods: One hundred patients with very low risk PCa underwent after 8 years a scheduled transperineal prostate biopsy (SPBx = 20 cores) combined with additional mpMRI/TRUS fusion biopsies (4 cores) of lesions PI-RADS scores ≥ 3. All the patients, after initial diagnosis, previously had mpMRI evaluation combined with transperineal saturation prostate biopsy (confirmatory and 3-year scheduled biopsy). Risk reclassification at repeat biopsy triggering the recommen- dation for active treatment was defined as over 3 or more than 10% of positive cores, Gleason score > 6/ISUP Grade Group ≥ 2, greatest percentage of cancer (GPC) > 50%. Results: Multiparametric MRI was suspicious (PI-RADS ≥ 3) in 30 of 100 cases (30.0%); 70 (70.0%) vs. 20 (20.0%) vs. 10 (10.0%) patients had a PI-RADS score ≤ 2 vs. 3 vs. 4, respec- tively. Two (2.0%) patients with PI-RADS score 3 and 4 were upgraded (ISUP Grade Group 2); SPBx and MRI/TRUS fusion biopsy diagnosed 100% and 0% of csPCa, respectively. Conclusions: Transperineal SPBx combined with mpMRI at ini- tial confirmatory biopsy allow to select an high number of men at very low risk of reclassification during the AS follow up (2.0% of the cases at 8 years from diagnosis); these data could be use- ful to reduce the number of scheduled repeated prostate biopsy during the AS follow up. Key wORDS: Saturation biopsy; Active surveillance; Targeted prostate biopsy; Confirmatory prostate biopsy. Submitted 25 June 2022; Accepted 3 July 2022 INTRODUCTION Active surveillance (AS) is an alternative (1-3) to radical treatment of low-risk prostate cancer (PCa) reducing the risk of overtreatment (50% of the cases) (1) and allowing a strict monitoring over time by scheduled clinical evaluations. Multiparametric magnetic resonance imaging (mpMRI) and mpMRI/TRUS (transrectal ultrasound) fusion targeted biopsy have improved systematic biopsies in the diagnosis of clinically significant PCa (csPCa) (4, 5), reducing the reclassification rate during the follow up of men in AS. Although the timing to perform confirmatory Confirmatory transperineal saturation prostate biopsy combined with mpMRI decrease the reclassification rate in men enrolled in Active Surveillance: Our experience in 100 men submitted to eight-years scheduled biopsy Pietro Pepe 1, Ludovica Pepe 1, Michele Pennisi 1, Filippo Fraggetta 2 1 Urology Unit, Cannizzaro Hospital, Catania, Italy; 2 Pathology Unit, Cannizzaro Hospital, Catania, Italy. DOI: 10.4081/aiua.2022.3.270 Summary 271Archivio Italiano di Urologia e Andrologia 2022; 94, 3 Prostate biopsy and active surveillance rately and independently;i moreover, one urologist with more than 25 years of experience performed the biopsy procedure. The data were collected following the Screening Tool to Alert to Right Treatment (START) criteria (9). At con- firmatory biopsy 43/160 (26.8%) were upgraded; con- versely, the 117 patients who met clinical criteria to con- tinue AS protocol were submitted every six months to PSA, PSAD and clinical evaluation. At three years from diagno- sis of cancer (range: 24-30 months), also in the presence of stable clinical parameters, the remaining 110/117 men enrolled in AS (7 men abandoned the protocol) underwent scheduled repeated SPBx combined with mpMRI/TRUS fusion guided-biopsies of suspicious lesions with PI-RADS ≥ 3 (4 targeted fusion cores) (11) and 5.4% of them were upgraded. The Clavien-Dindo grading system for the clas- sification of biopsy complications was used (12). During the entire follow up 11/160 (6.8%) men autonomously decided to leave the AS protocol (other 4 men abandoned the protocol after 3-years follow up); on the contrary, after 8 years from the initial diagnosis the remaining 100 patients who were not upgraded at previ- ous follow up visits, again underwent scheduled SPBx (20 cores) combined with mpMRI/TRUS fusion biopsies (4 cores) in the presence of lesions with PI-RADS score ≥ 3. Risk reclassification at repeat biopsy, triggering the rec- ommendation for active treatment, was defined as over 3 or more than 10% of positive cores, Gleason score > 6/ISUP Grade Group ≥ 2, greatest percentage of cancer (GPC) > 50%. Patients being reclassified underwent definitive treatment (radical prostatectomy or external radiotherapy). RESULTS Clinical parameters of the 100 patients included in the AS protocol who underwent repeated prostate biopsy are list- ed in the Table 1; median PSA value increased 1.3 ng/ml (range: 0-2.2 ng/ml) from time of diagnosis to 8-year scheduled repeat biopsy. Two (2.0%) patients had unfavourable biopsy histology and were reclassified based on upgrading (2 cases = Gleason score 3 + 4/Grade Group 2), number of positive cores (5 and 6 needle positive cores) and GPC (50% and 80%). In detail, all csPCa were located only in the anterior zone of the gland. Of the remaining 98 (98%) patients, 70 (70.0%) were found to have very low- risk PCa and in 28 (28.0%) cancer was absent (normal parenchyma); PCa was located in the periphery in 48 (48.0%) cases and in the anterior zone in 22 (22.0%) cases and all the 98 patients continued AS. Multiparametric MRI was suspicious (PI-RADS ≥ 3) in 30 of 100 cases (30.0%); 70 (70.0%) vs. 20 (20.0%) vs. 10 (10.0%) patients had a PI-RADS score ≤ 2 vs. 3 vs. 4, respectively. In detail, the PIRADS score in the 2 men reclassified was equal to 3 in one case (50%) and 4 in the other case (50%). High level of concordance in the diagnosis of PI-RADS score between the two radiologists was found (Cohen’s Kappa 0.85). None of the patients had significant complications (only Clavien- Dindo grade I) resulting from the prostate biopsy, requir- ing hospital admission; SPBx and MRI/TRUS fusion biop- sy diagnosed 100% and 0% of csPCa, respectively. Finally, all the men reclassified underwent external hypofraction- ated radiotherapy (13). DISCUSSION The estimated treatment-free probability at 5, 10 and 15 years from diagnosis of patients enrolled in AS protocol with GG1 PCa has been reported equal to 76, 64 and 58%, respectively (14); on the other hand, more than one-third of patients, during follow up, are reclassified (i.e., PCa upgrading and/or increase in disease extent or patient preference) and submitted to curative treatment (15). In detail, the confirmatory biopsy within one year from diagnosis upgrade the highest number of patients; in particular, the transperineal template biopsy upgrade about 38.0% of patients (16). A lot of studies reported on criteria of patient selection and follow up policies of men enrolled in AS protocol: type and timing of imaging, fre- quency of repeat prostate biopsies, use of PSA density and kinetics, genetics biomarkers, use risk calculators, and frequency of clinical follow-up (17-23). Although mpMRI is strongly recommended in patients enrolled in AS pro- tocols (24), at present, systematic prostate biopsies should be always combined with targeted fusion biopsy due to the false negative rate of mpMRI (25-27); more- over, the number of targeted-fusion biopsy (in the pres- ence of PI-RADS ≥ 3) that should be obtained in addition to systematic prostate biopsy in men enrolled in AS pro- tocols (8) has not been established (28). In fact, an accu- rate biopsy histology could reduce the risk of reclassifica- tion allowing to postpone scheduled prostate biopsies in favour of clinical parameters evaluation reducing, at the same time, the complications rate following repeated biopsies (i.e., risk of sepsis and hospitalization) (29). At the same time, an adequate number of needle cores allows to select patients with high volume GG1 PCa at risk of reclassification during follow up (33.4% of the cases) (30). In this respect, the number of systematic and/or targeted biopsy cores is an independent predictor for selection of patients with unfavourable characteristics for AS (31-35). On the other hand, a relevant critical point remain the adherence of patients to scheduled AS follow up; in fact, the estimated drop out to the execution of repeated prostate biopsy at 1 vs. 4 vs. 7 years from ini- tial diagnosis is equal to 11 vs. 30 vs. 29%, respectively (3); therefore, the European Association of Urology (EAU) guidelines strongly recommend to perform repeat biopsy in the presence of clinical suspicion of PCa progression (i,e., PSAD evaluation, progression on mpMRI) instead to Table 1. Clinical parameters of the 100 men enrolled in the Active Surveillance protocol who underwent scheduled eight-years prostate biopsy. Median PSA (range) 6.8 ng/ml (2.1-11.3 ng/ml) Median PSA D (range) 0.12 (0.07-0.18) DRE negative mpMRI PI-RADS score ≤ 2 = 70 cases; 3 = 20 cases; 4 = 10 cases Gleason score 6 (3 + 3) ISUP Grade Group GG1 GPC (range) 20% (5-50%) Prostate weight (range) 58 grams (30-110 grams) PSA: prostate specific antigen; PSAD: PSA density; DRE: digital rectal examination; mpMRI: multiparametric magnetic image resonance; PI-RADS: Prostate Imaging Reporting and Data System; GPC: greatest percentage of cancer; ISUP: International Society of Urologic Pathology. Archivio Italiano di Urologia e Andrologia 2022; 94, 3 P. Pepe, L. Pepe, M. Pennisi, F. Fraggetta 272 repeat biopsies at scheduled times that, anyway, are sug- gested every three years (36, 37). Finally, pathologic parameters play a critical role in identifying appropriate candidates for AS; these findings need to be reproducible and consistently reported by pathologists (38-40). In our series, 2/100 (2.0%) men were reclassified based on upgrading (Gleason score 7/ ISUP Grade Group 2), num- ber of positive cores (5 and 6 positive cores) and GPC (50% and 80%); SPBx and mpMRI/TRUS fusion biopsy detected 100 vs. 0% of csPCa. In definitive, the execution of SPBx plus mpMRI at initial confirmatory biopsy allowed to select an high number of men at a very low risk of reclassification (from GG1 to GG2) during the AS follow up (5.4% and 2.0% of the cases at respectively 3 and. 8 years from diagnosis) (11); these data could be useful to reduce the number of scheduled repeated prostate biopsy during the AS follow up. Regarding our results, some considerations should be made. First, in our series there was not a control arm of men submitted to systematic 12 cores prostate biopsy; therefore, the data obtained have been compared with the literature results. Second, the results were evaluated on biopsy specimens and not on the entire prostate gland. Third, the negative histology of the 9 patients with PI- RADS score 4 should be evaluated during the follow up. Finally, a large number of men including a longer follow up are needed to confirm our results. CONCLUSIONS Transperineal SPBx combined with mpMRI at initial con- firmatory biopsy allow to select an high number of men at very low risk of reclassification during the AS follow up (2.0% of the cases at 8 years from diagnosis); these data could be useful to suggest reducing the number of sched- uled repeated prostate biopsy during the AS follow up. REFERENCES 1. Hugosson J, Roobol MJ, Månsson M, et al. A 16-yr follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol. 2019; 76:43-51. 2. Klotz L. Active surveillance for low-risk prostate cancer. Curr Urol Rep 2015; 16:24. 3. Kalapara AA, Verbeek JFM, Nieboer D, Movember Foundation’s Global Action Plan Prostate Cancer Active Surveillance (GAP3) Consortium: adherence to active surveillance protocols for low-risk prostate cancer: results of the Movember Foundation's Global Action Plan Prostate Cancer Active Surveillance Initiative. Eur Urol Oncol. 2020; 3:80-91. 4. Pepe P, Garufi A, Priolo G, Pennisi M. Can 3 Tesla pelvic phase- array MRI avoid unnecessary repeat prostate biopsy in patients with PSA below 10 ng/ml? Clinical Genitourinary Cancer. 2015: 13:e27-30. 5. Tosoian JI, Mamawala M, Epstein JI, et al. Active surveillance of grade group 1 prostate cancer: long-term outcomes from a large prospective cohort Eur Urol. 2020; 77:675-682. 6. Epstein JI, Egevad L, Amin MB, and Grading Committee.The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol. 2016; 40:244-252, 7. Pepe P, Cimino S, Garufi A, et al. Confirmatory biopsy of men under active surveillance: extended versus saturation versus multi- parametric magnetic resonance imaging/transrectal ultrasound fusion prostate biopsy. Scand J Urol. 2017; 51:260-263. 8. Pepe P, Garufi A, Priolo GD, et al. Is it time to perform only MRI targeted biopsy? Our experience in 1032 men submitted to prostate biopsy. J Urol. 2018: 200:774-778. 9. Moore CM, Kasivisvanathan V, Scott ES, START Consortium: Standards of Reporting for MRI-targeted Biopsy Studies (START) of the Prostate: Recommendations from an International Working Group. Eur Urol. 2013; 64:544-552, 10. Pepe P, Garufi A, Priolo G, Pennisi M. Transperineal vs transrec- tal MRI/TRUS fusion biopsy: detection rate of clinically significant prostate cancer. Clin Genitourin Cancer. 2017;15:e33-e36. 11. Pepe P, Pepe L, Pennisi M, Fraggetta F. Which prostate biopsy in men enrolled in active surveillance? Experience in 110 men submit- ted to scheduled three-years transperineal saturation biopsy com- bined with fusion targeted cores. Clin Genitourin Cancer. 2021; 19:305-308. 12. Dindo D, Clavien PA. Classification of surgical complications. A new proposal with evaluation in a Cohort of 6336 patients and results of survey. Ann Surg. 2004; 240:205-213. 13. Pepe P, Tamburo M, Pennisi M, et al. Clinical outcomes of hydro- gel spacer injection space OAR in men submitted to hypofractionated radiotherapy for prostate cancer. In Vivo. 2021; 35:3385-3389. 14. Carlsson S, Benfante N, Alvim R, et al. Long-term outcomes of active surveillance for prostate cancer: the Memorial Sloan Kettering Cancer Center experience. J Urol. 2020; 203:1122-1127. 15. Bruinsma SM, Roobol MJ, Carroll PR, Movember Foundation's Global Action Plan Prostate Cancer Active Surveillance (GAP3) con- sortium: Expert consensus document: Semantics in active surveil- lance for men with localized prostate cancer - results of a modified Delphi consensus procedure. Nat Rev Urol. 2017; 14:312-322. 16. Voss J, Pal R, Ahmed S, et al. Utility of early transperineal tem- plate-guided prostate biopsy for risk stratification in men undergoing active surveillance for prostate cancer. BJU Int. 2018; 121:863-870. 17. Giganti F, Pecoraro M, Stavrinides V,, et al. Interobserver repro- ducibility of the PRECISE scoring system for prostate MRI on active surveillance: results from a two-centre pilot study. Eur Radiol. 2020; 30:2082-2090. 18. Pepe P, Vatrano S, Cannarella R, et al. A study of gene expression by RNA-seq in patients with prostate cancer and in patients with Parkinson disease: an example of inverse comorbidity. Mol Biol Rep. 2021; 48:7627-7631. 19. Roscigno M, Stabile A, Lughezzani G, et al. The use of multi- parametric magnetic resonance imaging for follow-up of patients included in active surveillance protocol. Can PSA density discrimi- nate patients at different risk of reclassification? Clin Genitourin Cancer. 2020; 18:e698-e704. 20. Pepe P, Dibenedetto G, Pepe L, Pennisi M. Multiparametric MRI versus SelectMDx accuracy in the diagnosis of clinically significant PCa in men enrolled in active surveillance. In Vivo. 2020; 34:393-396. 21. Lam TBL, MacLennan S, Willemse PM, et al. EAU-EANM- ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel Consensus statements for deferred treatment with curative intent for localised prostate cancer from an international collaborative study (DETEC- TIVE Study). Eur Urol. 2019; 76:790-813. 22. Cooley LF, Emeka AA, Meyers TJ, et al. Factors associated with time to conversion from active surveillance to treatment for prostate 273Archivio Italiano di Urologia e Andrologia 2022; 94, 3 Prostate biopsy and active surveillance cancer in a multi-institutional cohort. multicenter study J Urol. 2021; 206:1147-1156. 23. Pepe P, Roscigno M, Pepe L, et al. Could 68Ga-PSMA PET/CT eval- uation reduce the number of scheduled prostate biopsy in men enrolled in Active Sirveillance protocols? J Clin Med. 2022; 16; 11:3473. 24. Shapiro DD, Gregg JR, Lim AH, et al. Comparing confirmatory biopsy outcomes between MRI-targeted biopsy and standard system- atic biopsy among men being enrolled in prostate cancer active sur- veillance. BJU Int. 2021; 127:340-348. 25. Ploussard G, Beauval JB, Lesourd M, et al. Impact of MRI and targeted biopsies on eligibility and disease reclassification in MRI- positive candidates for active surveillance on systematic biopsies. Urology. 2020; 137:126-132. 26. Pepe P, Garufi A, Priolo G, Pennisi M. Can MRI/TRUS fusion tar- geted biopsy replace saturation prostate biopsy in the re-evaluation of men in active surveillance? World J Urol. 2016; 34:1249-1453. 27. Pepe P, Pepe L, Cosentino S, et al. Detection Rate of 68Ga-PSMA PET/CT vs. mpMRI targeted biopsy for clinically significant prostate cancer. Anticancer Res. 2022; 42:3011-3015. 15785. 28. Pepe P, Pennisi M, Fraggetta F. How many cores should be obtained during saturation biopsy in the era of multiparametric mag- netic resonance? Experience in 875 patients submitted to repeat prostate biopsy. Urology. 2020; 137:133-137. 29. Pepe P, Aragona F. Morbidity following transperineal prostate biopsy in 3,000 patients submitted to 12 vs. 18 vs. more than 24 nee- dle cores. Urology. 2013; 81:1142-1146. 30. Müller G, Bonkat G, Rieken M, et al. Potential consequences of low biopsy core number in selection of patients with prostate cancer for current active surveillance protocols. Urology. 2013; 81:837-842. 31. Lu AJ, Syed JS, Ghabili K, et al. Role of core number and location in targeted magnetic resonance imaging-ultrasound fusion prostate biopsy. Eur Urol. 2019; 76:14-17. 32. Villa L, Salonia A, Capitanio U, et al. The number of cores at first biopsy may suggest the need for a confirmatory biopsy in patients eli- gible for active surveillance-implication for clinical decision making in the real-life setting. Urology. 2014; 84:634-41. 33. Kaye DR, Qi J, Morgan TM, and Michigan Urological Surgery Improvement Collaborative. Pathological upgrading at radical prostatectomy for patients with Grade Group 1 prostate cancer: implications of confirmatory testing for patients considering active surveillance. BJU Int. 2019; 123:846-853. 34. Amin A, Scheltema MJ, Shnier R, et al. The Magnetic Resonance Imaging in Active Surveillance "MRIAS" Trial: use of baseline multi- parametric magnetic resonance imaging and saturation biopsy to reduce the frequency of surveillance prostate biopsies. J Urol. 2020; 203:910-917. 35. Lacetera V, Antezza A, Papaveri A, et al. MRI/US fusion prostate biopsy in men on active surveillance: Our experience. Arch Ital Urol Androl. 2021; 93:88-91. 36. Mottet N, Cornford P, van der bergh RCN, et al. EAU Oncology guideline: Prostate Cancer, Amsterdam 2022. 37. Ediz C, Akan S, Temel MC, Yilmaz O. The importance of PSA- Density in active surveillance for prostate cancer. Arch Ital Urol Androl. 2020; 92:136. 38. Rajwa P, Sprenkle PC, Leapman MS. When and how should Active Surveillance for prostate cancer be de-escalated? Eur Urol Focus. 2021; 7:297-300. 39. Montironi R, Santoni M, Mazzucchelli R, et al. The role of the uro-pathologist in this series should be emphasized as shown by Montironi R, Prostate cancer: from Gleason scoring to prognostic grade grouping. Expert Rev Anticancer Ther. 2016; 16:433-440. 40. Fandella A, Scattoni V, Galosi A, et al. Italian Prostate Biopsies Group: 2016 updated guidelines insights. Anticancer Res. 2017; 37:413-424. Correspondence Pietro Pepe, MD (Corresponding Author) piepepe@hotmail.com Ludovica Pepe, MD Michele Pennisi, MD Urology Unit, Cannizzaro Hospital, Catania (Italy) Filippo Fraggetta, MD Pathology Unit, Cannizzaro Hospital, Catania (Italy)