How to cite: Leapman MS. Leapman MS. MRI Fusion Biopsy: The Role of Both Targeted and Systematic Core Sampling. Grand Rounds in Urology. October 23, 2025. Accessed Apr 2026. https://grandroundsinurology.com/mri-fusion-biopsy-the-role-of-both-targeted-and-systematic-core-sampling/
Summary
Michael S. Leapman, MD, MHS, Associate Professor of Urology, Associate Professor of Chronic Disease Epidemiology, and Vice Chair of Research in the Department of Urology, Yale University, New Haven, Connecticut, presents the case for combining magnetic resonance imaging (MRI)-targeted biopsy with systematic core sampling when evaluating patients with suspected prostate cancer. Dr. Leapman argues that while targeted biopsy improves detection of aggressive disease, MRI-only strategies have important limitations that justify the continued role of systematic biopsy.
He outlines three core reasons for adding systematic sampling. First, MRI-targeted biopsy has a documented false-negative rate, leading to clinically significant cancers being missed due to limitations in MRI visibility. Second, technical factors, such as registration errors during fusion biopsy, introduce sampling inaccuracies that can lead to underdetection. Third, prostate cancer heterogeneity and multifocality mean that clinically significant tumors may exist outside MRI-visible regions.
Dr. Leapman reviews guideline recommendations, emphasizing that current guidance supports targeted biopsy while still allowing or recommending systematic sampling in both initial and repeat biopsy settings. He explains how prostate biopsy is a tool not only for diagnosis, but also for assessing disease extent, estimating aggressiveness, guiding treatment decisions, and supporting emerging focal therapy approaches.
Dr. Leapman uses data from randomized trials and whole-mount pathology studies to illustrate the limitations of MRI visibility, including evidence that MRI detects only a portion of total lesions and misses a meaningful fraction of clinically significant disease.
Dr. Leapman also explores mechanisms of biopsy failure, including fusion misregistration, and reviews perilesional sampling as a potential strategy to mitigate these errors. In particular, he highlights the clinical implications in focal therapy, where undetected out-of-field disease contributes to local failure. He concludes that adding systematic cores modestly increases procedure time, improves diagnostic completeness, and reduces oncologic risk.
About the 28th Annual Southwest Prostate Cancer Symposium:
Presented by Program Chairs Nelson N. Stone, MD, Richard G. Stock, MD, and William K. Oh, MD, this conference educated attendees about advances in the management of localized and advanced prostate cancer, with a focus on imaging, technology, and training in the related devices. It included a scientific session, as well as live demonstrations of surgical techniques.
ABOUT THE AUTHOR
Michael S. Leapman, MD, is an Associate Professor of Urology, an Associate Professor of Chronic Disease Epidemiology, and Vice Chair of Research in the Department of Urology at Yale University in New Haven, Connecticut. Dr. Leapman also serves as the Clinical Lead for the Prostate and Urologic Cancer Program at the Yale Smilow Cancer Center, where he directs multidisciplinary efforts to improve the care of patients with prostate and other genitourinary cancers. His clinical practice is devoted to the management of prostate and other urologic malignancies, with a particular expertise in robotic and minimally invasive approaches to radical prostatectomy.
Dr. Leapman earned his medical degree from the University of Maryland in Baltimore. He completed an internship in General Surgery and a residency in Urology at Mount Sinai Hospital in New York, New York. Dr. Leapman then completed a fellowship in Urologic Oncology at the University of California, San Francisco. He earned his Master’s in Health Science from Yale University.
Dr. Leapman’s research focuses on questions related to how advanced imaging, biomarkers, and large-scale data analysis can be applied to improve detection, risk stratification, and management of prostate cancer, and ultimately to improve clinical outcomes. He has authored and co-authored more than 270 articles and book chapters in his field. He has been recognized for his contributions, including the John N. Forrest Jr. Prize for Mentorship in Student Research, Merit Award: Conquer Cancer Foundation of the American Society of Clinical Oncology, Best Poster: European School of Oncology Conference on Active Surveillance, and the First Place Essay, History Section: American Urological Association Western Section.
