Location matters: Reduced detection of csPCa in transition zone versus peripheral zone PI-RADS lesions

Fusion prostate biopsy of prostate imaging report and data system lesions has become an integral part of diagnosis of prostate cancer. Though the scoring system is slightly different between peripheral zone and transition zone located lesions, a score of 4 or 5, regardless of lesion location is associated with a high or very high chance of clinically significant prostate cancer. Our goal is to examine whether lesion location impacts detection of clinically significant prostate cancer, defined as International Society of Urological Pathology grade group ≥2.

Multi-institutional retrospective review of patients who underwent MRI fusion biopsy at 3 tertiary care medical centers between 2017 and 2022. Lesion level review was performed to compare targeted biopsy results for PI-RADS 4 and 5 lesions located in the transition zone and peripheral zone. Primary outcome of interest was detection of clinically significant prostate cancer. Multivariable logistic regression analyses were performed to assess for predictors of clinically significant prostate cancer detection.

Two thousand one hundred twenty eight lesions from 1,635 patients were included. On multivariate analysis, lesions located in the transition zone were independently associated with decreased detection of clinically significant prostate cancer (OR 0.55, P < 0.001). Similarly, detection of grade group 3 or higher prostate cancer was also lower for lesions in the transition zone (adjusted OR: 0.37; 95% CI: 0.26-0.54; P < 0.001). These differences have implications for further workup in patients with negative or low-grade pathology on MRI-TBx of PI-RADS 5 lesions and suggest a needs for reworking of the PI-RADS system.