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Updated: Oct 18, 2025
A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound
Published on: March 21, 2025
Should men undergo MRI before prostate biopsy - CON
Eric H Kim1, Gerald L Andriole1
1Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO.
Abstract:
Prostate magnetic resonance imaging (MRI) is increasingly used prior to biopsy in response to the overdiagnosis and overtreatment of prostate cancer (CaP) associated with prostate-specific antigen (PSA) based screening. However, technical limitations in the conventional diffusion-weighted imaging (DWI) sequences as well as the high degree of radiologist-to-radiologist variability in interpreting prostate MRI result in inadequate accuracy. Specifically, the insufficient negative predictive value (NPV) of prostate MRI (76%-87%) does not allow biopsy to be omitted in the negative MRI setting. Additionally, the variable, and relatively low positive predictive value (PPV) of MRI (27%-44%) provides only an incremental improvement in risk prediction compared to readily available clinical tools such as the Prostate Cancer Prevention Trial risk calculator. This small benefit is likely confined to the minority of patients with positive MRI findings in a typically under-sampled region of the prostate (e.g., anterior lesions), which may be obviated by newer biopsy approaches and tools such as transperineal prostate biopsy and micro-ultrasound technology. With these considerations in mind, pre-biopsy prostate MRI in its current form is unlikely to provide a clinically significant benefit, and should not be considered as routine practice until its accuracy is sufficiently improved.
Insights
Current prostate MRI before biopsy has limited accuracy. Insufficient negative and positive predictive values mean it does not significantly improve prostate cancer diagnosis or risk prediction over existing methods.
Area of Science:
- Urology
- Radiology
- Oncology
Background:
- Prostate cancer (CaP) overdiagnosis and overtreatment necessitate improved diagnostic strategies.
- Prostate-specific antigen (PSA) screening has led to concerns regarding overdiagnosis.
- Pre-biopsy prostate magnetic resonance imaging (MRI) is being adopted to refine diagnosis.
Purpose of the Study:
- To evaluate the clinical utility and accuracy of pre-biopsy prostate MRI.
- To assess the impact of prostate MRI on prostate cancer diagnosis and risk stratification.
- To determine if current prostate MRI protocols offer a significant benefit over existing clinical tools.
Main Methods:
- Analysis of conventional diffusion-weighted imaging (DWI) sequences in prostate MRI.
- Assessment of radiologist interpretation variability.
- Evaluation of negative predictive value (NPV) and positive predictive value (PPV) of prostate MRI.
- Comparison of MRI performance against the Prostate Cancer Prevention Trial risk calculator.
Main Results:
- Technical limitations in DWI sequences and inter-reader variability reduce prostate MRI accuracy.
- Prostate MRI exhibits insufficient NPV (76%-87%), precluding omission of biopsy in negative cases.
- Variable and low PPV (27%-44%) offers minimal incremental benefit over risk calculators.
- Potential benefits are limited to specific patient subgroups and may be superseded by new biopsy technologies.
Conclusions:
- Pre-biopsy prostate MRI, in its current form, does not provide clinically significant benefits for routine practice.
- Improvements in accuracy are needed before widespread adoption of prostate MRI is recommended.
- Emerging biopsy techniques may offer superior diagnostic capabilities.
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