PSA-density, DRE, and PI-RADS 5: potential surrogates for omitting biopsy?

Area of Science:

• Urology
• Oncology
• Radiology

Background:

• Histologic confirmation is common before treatment for suspected clinically significant prostate cancer (csPCA).
• Prostate Imaging Reporting and Data System (PI-RADS) 5 lesions indicate a high probability of csPCA.
• Predictors like extracapsular extension (ECE), cT-stage, and PSA-density (PSA-D) require analysis in PI-RADS 5 patients.

Purpose of the Study:

• To evaluate the impact of ECE, cT-stage, and PSA-D on detecting csPCA in patients with PI-RADS 5 lesions.
• To identify predictors of csPCA detection in this specific patient cohort.

Main Methods:

• Retrospective analysis of 493 patients with PI-RADS 5 lesions undergoing MRI/Ultrasound fusion biopsy (2016-2020).
• Logistic regression models (uni- and multivariable) were used to identify csPCA predictors (Gleason-Grade Group [GGG] ≥ 2).
• Risk models were adjusted for ECE, PSA-D, and cT-stage; Receiver Operating Characteristic (ROC) curves and AUCs were calculated.

Main Results:

• csPCA (GGG ≥ 2) was detected in 82% of 493 PI-RADS 5 patients; 7% had no cancer.
• csPCA detection rates were 90% for PI-RADS 5 + PSA-D > 0.2 ng/ml/cc and 100% for PI-RADS 5 + PSA-D > 0.5 ng/ml/cc.
• A model combining PSA-D and cT-stage achieved an Area Under the Curve (AUC) of 0.79.

Conclusions:

• PSA-D and cT-stage are significant predictors of csPCA in PI-RADS 5 patients.
• A PSA-D threshold > 0.5 ng/ml/cc identified csPCA in all PI-RADS 5 patients.
• Consideration of direct treatment for prostate cancer (PCA) is warranted, especially with biopsy complication risks.