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Updated: Dec 19, 2025
A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound
Published on: March 21, 2025
The Use of Multiparametric Magnetic Resonance Imaging for Follow-up of Patients Included in Active Surveillance
Marco Roscigno1, Armando Stabile2, Giovanni Lughezzani3
1Department of Urology, ASST Papa Giovanni XXIII, Bergamo, Italy.
Introduction:
The objective of this study was to test Prostate Imaging Reporting and Data System (PI-RADS) classification on multiparametric magnetic resonance imaging (mpMRI) and MRI-derived prostate-specific antigen density (PSAD) in predicting the risk of reclassification in men in active surveillance (AS), who underwent confirmatory or per-protocol follow-up biopsy.
Materials And Methods:
Three hundred eighty-nine patients in AS underwent mpMRI before confirmatory or follow-up biopsy. Patients with negative (-) mpMRI underwent systematic random biopsy. Patients with positive (+) mpMRI underwent targeted fusion prostate biopsies + systematic random biopsies. Different PSAD cutoff values were tested (< 0.10, 0.10-0.20, ≥ 0.20). Multivariable analyses assessed the risk of reclassification, defined as clinically significant prostate cancer of grade group 2 or more, during follow-up according to PSAD, after adjusting for covariates.
Results:
One hundred twenty-seven (32.6%) patients had mpMRI(-); 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. The rate of reclassification to grade group 2 PCa was 16%, 22%, 31%, and 39% for mpMRI(-) and PI-RADS 3, 4, and 5, respectively, in case of PSAD < 0.10 ng/mL2; 16%, 25%, 36%, and 44%, in case of PSAD 0.10 to 0.19 ng/mL2; and 25%, 42%, 55%, and 67% in case of PSAD ≥ 0.20 ng/mL2. PSAD ≥ 0.20 ng/mL2 (odds ratio [OR], 2.45; P = .007), PI-RADS 3 (OR, 2.47; P = .013), PI-RADS 4 (OR, 2.94; P < .001), and PI-RADS 5 (OR, 3.41; P = .004) were associated with a higher risk of reclassification.
Conclusion:
PSAD ≥ 0.20 ng/mL2 may improve predictive accuracy of mpMRI results for reclassification of patients in AS, whereas PSAD < 0.10 ng/mL2 may help selection of patients at lower risk of harboring clinically significant prostate cancer. However, the risk of reclassification is not negligible at any PSAD cutoff value, also in the case of mpMRI(-).
Insights
Prostate Imaging Reporting and Data System (PI-RADS) classification and prostate-specific antigen density (PSAD) predict reclassification risk in active surveillance (AS). Higher PSAD and PI-RADS scores increase risk, but even negative MRI scans warrant caution.
Area of Science:
- Urology
- Radiology
- Oncology
Background:
- Active surveillance (AS) is a strategy for managing low-risk prostate cancer.
- Multiparametric magnetic resonance imaging (mpMRI) and prostate-specific antigen density (PSAD) are used to monitor patients in AS.
- Predicting reclassification risk is crucial for guiding treatment decisions in AS.
Purpose of the Study:
- To evaluate the predictive accuracy of PI-RADS classification and MRI-derived PSAD for reclassification risk in men undergoing AS.
- To determine the utility of PSAD cutoffs in conjunction with mpMRI findings for risk stratification.
Main Methods:
- A cohort of 389 patients in AS underwent mpMRI followed by biopsy.
- Patients with negative mpMRI had systematic random biopsy; positive mpMRI led to targeted fusion biopsies plus systematic biopsies.
- Multivariable analyses assessed reclassification risk (grade group ≥2) based on PSAD values (<0.10, 0.10-0.20, ≥0.20) and PI-RADS scores.
Main Results:
- Reclassification rates increased with higher PI-RADS scores (3, 4, 5) and PSAD values (≥0.20 ng/mL²).
- PSAD ≥0.20 ng/mL² (OR 2.45) and PI-RADS 3 (OR 2.47), 4 (OR 2.94), 5 (OR 3.41) were significantly associated with higher reclassification risk.
- Even with mpMRI-negative scans, a non-negligible reclassification risk was observed across PSAD cutoffs.
Conclusions:
- PSAD ≥0.20 ng/mL² can enhance mpMRI's predictive accuracy for reclassification in AS.
- PSAD <0.10 ng/mL² may aid in selecting lower-risk patients, but vigilance is needed regardless of PSAD or MRI findings.
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