Clinical application of systematic prostate biopsy combined with contrast-enhanced ultrasound guided targeted biopsy in patients with PSA gray zone

Abstract

Abstract Objective To investigate the clinical value of combining systematic prostate biopsy with contrast-enhanced ultrasound (CEUS)-guided targeted biopsy in patients with serum prostate-specific antigen (PSA) levels in the gray zone. Methods A total of 167 patients in the PSA gray zone treated at Zhejiang Provincial Hospital of Traditional Chinese Medicine from January 2022 to October 2024 were retrospectively analyzed and divided into a systematic biopsy group and a combined biopsy group. Both groups underwent transperineal biopsy under transrectal ultrasound guidance. In the combined biopsy group, CEUS was used to identify suspicious lesions for targeted biopsy, followed by reduced-core systematic biopsy in non-targeted regions; both groups received 10-core biopsies. Results The combined targeted biopsy group showed significantly higher detection rates for prostate cancer (PCa) (57.32% vs. 30.59%; OR = 3.05, 95% Confidence interval(CI) 1.61–5.76; Absolute risk difference ( ARD ) = 26.7%) and clinically significant prostate cancer (csPCa) (46.34% vs. 12.94%; OR = 5.81, 95% CI 2.70–12.52; ARD = 33.4%) than the systematic biopsy group (all P < 0.001). The combined targeted group also yielded more positive biopsy cores (2.05 ± 2.32 vs. 0.80 ± 1.68, P < 0.001) and a higher proportion of Gleason score ≥ 7 lesions among detected PCa cases (80.85% vs. 42.31%, P < 0.001). Subgroup analyses suggested greater diagnostic benefits in patients aged > 70 years or with prostate volume ≤ 60 mL. Multivariate regression confirmed biopsy method as an independent predictor for both PCa ((Adjusted odds ratio( aOR ) = 2.619, P = 0.008) and csPCa ( aOR = 5.171, P < 0.001). Complication rates did not differ significantly between the two groups (all P > 0.05). Conclusion CEUS-guided systematic biopsy combined with targeted biopsy significantly improves the detection rates of PCa and csPCa in patients with PSA gray zone levels, with a favorable safety profile. Subgroup analyses suggest that older patients and those with smaller prostate volumes may derive greater benefits; however, these exploratory findings warrant confirmation in future prospective studies.