Identifying Candidates for Biopsy Omission in Prostate Cancer Using mpMRI and PSMA PET/CT

The superior diagnostic capabilities of novel imaging modalities such as multiparametric prostate magnetic resonance imaging MRI (mpMRI) and prostate-specific membrane-antigen positron emission tomography/computed tomography (PSMA PET/CT) might provide data for consideration of a prostate biopsy-omitting approach in a selected subgroup of patients with prostate cancer.

Patients who underwent radical prostatectomy (RP) for prostate cancer between December 2015 and December 2024 were retrospectively evaluated, and only patients who underwent mpMRI and PSMA PET/CT were included in the study. After recording patient characteristics (age, prostate-specific antigen [PSA], PSA density [PSAD]), mpMRI characteristics (Prostate Imaging Reporting And Data System [PI-RADS] score, number of lesions, size of the index lesion), and PSMA PET characteristics (prostatic SUVmax ≥12 = PRIMARY 5), adverse pathology (≥pT3a or pN1 or GG≥3) rates at RP were investigated. Multivariable logistic regression analysis was performed to determine the independent predictors of adverse pathology.

The median age and serum PSA of 413 patients included in the study were 64.9 years (interquartile range [IQR]: 58.3-69.9) and 7.0 ng/dl (IQR: 4.9-9.4). The RP pathology revealed that 248 out of 413 patients (60%) had adverse features (58 out of 413 had GG4 or 5 disease). The multivariable analysis revealed that age, serum PSAD, PI-RADS-5 score on mpMRI, and prostatic SUVmax ≥12 (PRIMARY-5) on PSMA PET were independent predictors of adverse pathology. Based on these results, the combination of PSAD, MRI, and PSMA PET has consistently resulted in adverse pathology: PSAD >0.15 ng/ml/cc AND PI-RADS-5 AND PRIMARY 5.

A combination of serum PSAD, PI-RADS score on mpMRI, and PRIMARY score on PSMA PET/CT has consistently resulted in adverse pathology, indicating consideration of a biopsy-omitting approach if further studies endorse these findings.