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目的:探讨系统联合靶向前列腺穿刺中次要病灶(SL)靶向穿刺对有临床意义前列腺癌(CsPCa)的诊断价值。方法:回顾性分析2021年1月至2023年2月南京鼓楼医院收治的380例行前列腺穿刺活检患者的病例资料。中位年龄70(65，76)岁。中位前列腺特异性抗原(PSA)9.1(5.96，13.62)ng/ml。中位前列腺体积39.1(29.27，53.25)ml。中位前列腺特异性抗原密度(PSAD)0.2(0.15，0.38)ng/ml 2。患者穿刺前均行MRI检查，有≥2个前列腺影像报告和数据系统(PI-RADS)评分≥3分的病灶。将PI-RADS评分最高的病灶定义为主要病灶(IL)，第二高的病灶定义为SL；对于PI-RADS评分相同的，将病灶最大径更大者定义为IL，第二大者定义为SL。中位IL最大径为1.3(1.06，1.66)cm，中位SL最大径为0.9(0.69，1.20)cm。IL与SL中位最大径比值为1.4(1.10，1.91)，中位最大径差值为0.9(0.20，1.89)cm。238例(62.63%)IL位于外周带，255例(67.10%)SL位于外周带。204例(53.68%)IL和SL分布在前列腺同侧。根据IL与SL病灶PI-RADS评分组合分为IL3与SL3组96例(25.26%)，IL4与SL3组79例(20.78%)、IL4与SL4组98例(25.78%)、IL5与SL3组21例(5.52%)、IL5与SL4组76例(20.00%)、IL5与SL5组10例(2.63%)。所有患者均行系统联合靶向前列腺穿刺。比较系统穿刺(SB)＋IL和SL靶向穿刺(SB＋IL＋SL)与系统穿刺＋IL靶向穿刺(SB＋IL)的CsPCa检出率。采用多变量logistic回归分析影响CsPCa检出率的因素。 结果:本研究SB＋IL＋SL和SB＋IL对CsPCa的检出率分别为78.95%(300/380)和78.16%(297/300)，差异无统计学意义( P>0.05)。多变量logistic回归分析结果显示，PSA( OR＝1.11，95% CI 1.05～1.20， P<0.01)、前列腺体积( OR＝0.98，95% CI 0.96～0.99， P<0.01)、SL最大径( OR＝0.19，95% CI 0.08～0.50， P<0.01)、IL与SL最大径比值( OR＝0.34，95% CI 0.16～0.68， P<0.01)、IL与SL最大径差值( OR＝1.50，95% CI 1.10～2.29， P<0.05)、IL与SL PI-RADS评分组别[IL4与SL3组( OR＝4.79，95% CI 2.21～10.91， P<0.01)，IL4与SL4组( OR＝23.11，95% CI 8.09～85.28， P<0.01), IL5与SL3/4/5组( OR＝15.28，95% CI 5.21～48.55， P<0.01)]是CsPCa检出率的影响因素。 结论:对于前列腺MRI检查具有至少2个PI-RADS评分≥3分病灶的患者，行系统联合靶向穿刺时，省略SL靶向穿刺可获得相近的诊断效果。

Objective:To evaluate the diagnostic value of targeted biopsy of secondary lesion (SL) in systematic biopsy (SB) combined targeted biopsy for clinically significant prostate cancer (CsPCa).Methods:A retrospective analysis was conducted on the data of patients who underwent systematic biopsy combined target biopsy at Nanjing Drum Tower Hospital from January 2021 to February 2023, and they had at least two Prostate Imaging-Reporting and Data System (PI-RADS) score ≥3 lesions on prostate magnetic resonance imaging. The study included patients with a median age of 70 (65, 76) years old, median prostate specific antigen (PSA) was 9.1 (5.96, 13.62) ng/ml, median prostate volume was 39.1 (29.27, 53.25) ml, and median PSAD was 0.2 (0.15, 0.38) ng/ml 2.The index lesion (IL) was defined as the one with the highest PI-RADS score and SL was defined as the one with the second-highest PI-RADS score. If the two lesions had the same PI-RADS score, the one with larger maximum diameter was IL and the other one was SL. The median maximum diameter of IL and SL were 1.3 (1.06, 1.66) cm and 0.9 (0.69, 1.20) cm, respectively. The median maximum diameter ratio of IL and SL was 1.48 (1.10, 1.91), and the median maximum diameter difference of IL and SL was 0.9 (0.20, 1.89) cm. The IL in peripheral zone was found in 238 patients (62.63%) and SL in peripheral zone was found in 255 patients (67.10%). There were 204 patients (53.68%) having both IL and SL on the same side of prostate. According to the combination of PI-RADS scores of IL and SL, patients were categorized into various groups: 96 patients (25.26%) with IL3 and SL3, 79 (20.78%) with IL4 and SL3, 98 (25.78%) with IL4 and SL4, 21 (5.52%) with IL5 and SL3, 76 (20.0%) with IL5 and SL4, and 10 (2.63%) with IL5 and SL5. Targeted biopsy was performed on at least two of the most significant lesions. Comparison was performed in the detection rate of CsPCa between SB+ IL+ SL and SB+ IL (SL was omitted). To explore the factors influencing the detection rate of CsPCa, a multivariate logistic regression analysis was used. Results:The detection rate of CsPCa in this study was 78.95% (300/380) based on SB+ IL+ SL. After omitting SL target biopsy, the detection rate of CsPCa was 78.16% (297/380, P>0.05) under the condition of SB+ IL. No significant differences were noted between the two groups. The multivariate logistic regression analysis showed that PSA ( OR=1.11, 95% CI 1.05-1.20, P<0.01), prostate volume ( OR=0.98, 95% CI 0.96-0.99, P<0.01), SL maximum diameter ( OR=0.19, 95% CI 0.08-0.50, P<0.01), ratio of IL and SL maximum diameter ( OR=0.34, 95% CI 0.16-0.68, P<0.01), difference of IL and SL maximum diameter ( OR=1.50, 95% CI 1.10-2.29, P<0.05), and PI-RADS score group of IL and SL (IL3 vs. SL3 as the reference, IL4 vs. SL3 OR=4.79, 95% CI 2.21-10.91, P<0.01, IL4 vs. SL4 OR=23.11 95% CI 8.09-85.28, P<0.01, IL5 vs. SL3/4/5 OR=15.28 95% CI 5.21-48.55, P<0.01) were the influencing factors for detection rate of CsPCa. Conclusions:For patients with at least two PI-RADS score≥3 lesions on prostate magnetic resonance imaging, omitting SL can almost maintain the same detection efficacy.