AUA 2024: Characteristics of PI-RADS 5 Lesions with a Negative or Gleason Grade Group 1 Biopsy

( The 2024 American Urological Association (AUA) Annual Meeting held in San Antonio, TX was host to a prostate cancer detection and screening moderated poster session. Lindsey Webb presented the results of a study evaluating the characteristics of PIRADS 5 lesions in men with a negative or Grade Group 1 biopsy.

Despite a high positive predictive value for identifying clinically significant prostate cancer, up to 18% of PI-RADS (Prostate Imaging Reporting and Data System) 5 lesions are found to be benign on biopsy. However, limited information is available to help determine if a subset of PI-RADS 5 lesions will have benign or clinically insignificant pathology prior to biopsy. This study aimed to assess the pre-biopsy clinical factors that could be utilized to predict a discrepancy between imaging and histopathology and thus, avoid low-yield biopsies.


Using a prospectively collected database, the investigators retrospectively reviewed 838 PI-RADS 5 lesions from 646 patients at their institution between May 2014 and October 2022. Demographic, MRI, and biopsy information, as well as other clinical characteristics, were recorded. The Gleason grade groups were classified into benign, GG1, and ≥GG2. Potential associations between these variables and prostate cancer outcomes were evaluated using multivariable logistic regression analyses.

Of the 838 PI-RADS 5 lesions identified, 13% were negative for any malignancy and 18% demonstrated GG1 disease. 574 (68%) demonstrated evidence of ≥GG2 disease.


Patients with inflammation on the biopsy specimen had significantly lower odds of harboring GG1 (OR: 0.14) or ≥GG2 disease (OR: 0.037). Of 23 patients with inflammation, 9 of whom had known pre-biopsy prostatitis, only 1 had GG1 or ≥GG2 disease diagnosed at biopsy. Other variables associated with decreased odds of ≥GG2 disease in these PI-RADS 5 lesions included:

  • Transitional zone lesion (versus peripheral zone; OR: 0.43; p<0.001)
  • Prior negative biopsy (OR: 0.25; p<0.001)
  • Being on active surveillance (OR: 0.25, p<0.001)
  • Higher number of lesions present (ORs for 3, 4, and 5 lesions: 0.38, 0.11, and 0.05, respectively)

Conversely, the odds of ≥GG2 disease were increased in:

  • Older patients (OR: 1.07; p<0.001)
  • Those with higher PSA levels (OR: 1.10; p=0.024)


The study investigators concluded that in men with PI-RADS 5 lesions, there are pre-biopsy characteristics that are associated with decreased odds of ≥GG2 prostate cancer, and thus may be used to guide biopsy decision making. The presence of inflammation is associated with very low odds for ≥GG2 disease. Development of pre-biopsy characteristics that identify/predict inflammation may allow improved risk stratification and allow some men to avoid unnecessary prostate biopsies.

Presented by: Lindsey Webb, BSME, Medical Student, University of Central Florida, Research Fellow at Yale School of Medicine, New Haven, CT

Written by: Rashid Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2024 American Urological Association (AUA) Annual Meeting, San Antonio, TX, Fri, May 3 – Mon, May 6, 2024.