Determinants of decision-making in biopsy of PI-RADS 3 transition zone lesions

Cancer rates for Prostate Imaging-Reporting and Data System (PI-RADS) 3 lesions are low. We aimed to determine the clinical and magnetic resonance imaging (MRI) parameters that can provide risk stratification for PI-RADS 3 transition zone (TZ) lesions to guide decision for biopsy, which can improve the cost-effectiveness of resource utilisation.

The MRI scans of all patients who underwent MRI-ultrasound fusion targeted biopsy from 1 May 2016 to 31 December 2022 were retrospectively assessed by two board-certified abdominal radiologists. The following data were collected and analysed serum prostate-specific antigen, Prostatic Health Index (PHI), prostate volume, histological results, lesion size, location, diffusion-weighted imaging (DWI) parameter scores and overall PI-RADS score.

Two hundred and fourteen TZ lesions were included. Among 131 PI-RADS 3 lesions, those with marked restricted diffusion (DWI score ≥4), diameter ≥1 cm, prostrate-specific antigen density (PSAD) ≥0.11 and PHI ≥34 were more likely to contain clinically significant prostate cancer (csPCa; P = 0.04, 0.02, 0.049 and 0.05, respectively), with areas under the receiver operating characteristics curve of 0.9, 0.76, 0.84 and 0.80, respectively. Apical lesions were more likely to contain csPCa compared to midgland or basal lesions (P = 0.01).

Clinical parameters (PSAD and PHI) and MRI features (lesion size, DWI score, lesion location) can be used to risk stratify PI-RADS 3 TZ lesions and guide decision for targeted biopsy.