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Updated: Jul 2, 2026
A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound
Published on: March 21, 2025
Predictors of false-positive results in men with Prostate Imaging-Reporting and Data System 4 lesions
Hee Youn Kim1, Seung-Ju Lee1, Jung Hoon Kim2
1Department of Urology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
Background:
To identify predictive factors of false-positive results in men with Prostate Imaging-Reporting and Data System (PI-RADS) 4 lesions on multiparametric MRI and to evaluate potential factors for improving risk stratification in this high-risk category.
Methods:
We retrospectively analyzed 811 men with PI-RADS 4 lesions who underwent prostate biopsy (November 2020-February 2025). Clinical data [age, PSA, PSA density (PSAD), prostate volume] and radiographic features {anatomical location [peripheral zone (PZ) vs. transitional zone (TZ)], multiplicity} were assessed. Multivariate logistic regression analysis identified independent predictors of false-positive results. Interaction between location and multiplicity was evaluated for zone-specific risk profiles.
Results:
Of the 811 patients, 523 (64.5%) had benign pathology (false-positive). Independent predictors of false-positive results included younger age, lower PSAD, prior negative biopsy, and TZ location. TZ lesions had significantly higher odds of a false-positive result compared to PZ lesions (OR: 6.919, 95% CI: 4.440-10.781, P < 0.001). A divergent pattern was observed between location and multiplicity: in the PZ, multiplicity did not affect cancer risk, whereas in the TZ, multiple lesions showed a trend toward benign pathology (P = 0.087), with the lowest predicted cancer probability (10.0%) in patients with multiple TZ lesions.
Conclusion:
False-positive PI-RADS 4 assessments were associated with features characteristic of BPH, particularly TZ localization and lower PSAD. Current biopsy recommendations may be suboptimal for patients with these benign-favoring features. Incorporating lesion localization and volume-adjusted metrics into risk stratification could potentially reduce unnecessary biopsies.
Insights
False-positive Prostate Imaging-Reporting and Data System (PI-RADS) 4 results are linked to benign prostatic hyperplasia features, especially in the transitional zone. Identifying these factors can help reduce unnecessary prostate biopsies.
Area of Science:
- Radiology
- Urology
- Oncology
Background:
- Multiparametric MRI is crucial for prostate cancer detection.
- Prostate Imaging-Reporting and Data System (PI-RADS) 4 lesions represent an intermediate-risk category.
- Distinguishing benign from malignant PI-RADS 4 lesions is challenging, leading to potential overtreatment.
Purpose of the Study:
- To identify predictive factors for false-positive PI-RADS 4 assessments.
- To evaluate strategies for improving risk stratification in men with PI-RADS 4 lesions.
- To reduce unnecessary prostate biopsies in this patient group.
Main Methods:
- Retrospective analysis of 811 men with PI-RADS 4 lesions undergoing prostate biopsy.
- Assessment of clinical factors (age, PSA, PSA density [PSAD], prostate volume) and radiographic features (lesion location, multiplicity).
- Multivariate logistic regression and interaction analysis to identify predictors of false-positive results.
Main Results:
- Over 64% of PI-RADS 4 lesions were false-positives (benign pathology).
- Independent predictors of false-positives included younger age, lower PSAD, prior negative biopsy, and transitional zone (TZ) location.
- TZ lesions had a significantly higher odds of being false-positive (OR: 6.919).
- Multiple TZ lesions showed a trend toward benign pathology, with the lowest cancer probability (10.0%) in this subgroup.
Conclusions:
- False-positive PI-RADS 4 findings are associated with benign prostatic hyperplasia (BPH) features, particularly TZ localization and lower PSAD.
- Current biopsy guidelines may be suboptimal for patients with benign-favoring PI-RADS 4 features.
- Incorporating lesion localization and volume-adjusted metrics can enhance risk stratification and potentially decrease unnecessary biopsies.
