Combined Use of Prostate-specific Antigen Density and Magnetic Resonance Imaging for Prostate Biopsy Decision Planning: A Retrospective Multi-institutional Study Using the Prostate Magnetic Resonance Imaging Outcome Database (PROMOD).

Previous studies suggested that prostate-specific antigen (PSA) density (PSAd) combined with magnetic resonance imaging (MRI) may help avoid unnecessary prostate biopsy (PB) with a limited risk of missing clinically significant prostate cancer (csPCa; Gleason grade group [GGG] >1).

To define optimal diagnostic strategies based on the combined use of PSAd and MRI in patients at risk of prostate cancer (PCa).

A retrospective analysis of the international multicenter Prostate MRI Outcome Database (PROMOD), including 2512 men having undergone PSAd and prostate MRI before PB between 2013 and 2019, was performed.

Rates of avoided PB, missed GGG 1, and csPCa according to 10 strategies based on PSAd values and MRI reporting scores (Prostate Imaging Reporting and Data System [PI-RADS]/Likert/IMPROD biparametric prostate MRI Likert). Decision curve analysis (DCA) was used to statistically compare the net benefit of each strategy. Combined systematic and targeted biopsies were used for reference.

According to DCA, the best strategy in biopsy-naive patients was #7 (PI-RADS/Likert 4-5 or PI-RADS/Likert 3 if PSAd >0.2), which avoided 41.2% PBs while missed 44% of GGG 1 and 10.9% of csPCa cases. From a clinical standpoint, however, strategies with a lower risk of missing csPCa included #10 (PI-RADS/Likert 4-5 or PI-RADS 3 if PSAd >0.10 or PSAd >0.2), which avoided 27% PBs while missing 24.4% GGG 1 and 4% csPCa cases, or #5 (PI-RADS/Likert 3-5 or PSAd>0.15), which avoided 14.7% PBs while missing 9.3% GGG 1 and 1.7% csPCa cases. Similar results were found in patients with a previous negative biopsy. This study is limited by its retrospective nature, and no central review of MRI and histopathological findings.

Combined PSAd and MRI findings allows individualization of the decision to perform PB on the basis of the risk of missing PCa that both patients and clinicians are ready to accept to avoid this procedure.

We compared several biopsy strategies based on a combination of prostate magnetic resonance imaging findings and prostate-specific antigen density, providing a readily available tool for each center and practicing urologist to counsel patients about their individual risk of significant prostate cancer.

European urology oncology. 2020 Sep 21 [Epub ahead of print]

Ugo Giovanni Falagario, Ivan Jambor, Anna Lantz, Otto Ettala, Armando Stabile, Pekka Taimen, Hannu J Aronen, Juha Knaapila, Ileana Montoya Perez, Giorgio Gandaglia, Nicola Fossati, Alberto Martini, Vito Cucchiara, Wolfgang Picker, Erik Haug, Parita Ratnani, Kenneth Haines, Sara Lewis, Nair Sujit, Oscar Selvaggio, Francesca Sanguedolce, Luca Macarini, Luigi Cormio, Tobias Nordström, Ash Tewari, Alberto Briganti, Peter J Boström, Giuseppe Carrieri

Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy; Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Electronic address: ., Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Radiology, University of Turku, Turku, Finland; Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland., Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Urology, Karolinska University Hospital, Solna, Sweden., Department of Urology, University of Turku and Turku University Hospital, Turku, Finland., Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy., Institute of Biomedicine, University of Turku, Turku, Finland; Department of Pathology, Turku University Hospital, Turku, Finland., Department of Radiology, University of Turku, Turku, Finland; Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland., Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy., Department of Radiology, Aleris Cancer Center, Oslo, Norway., Section of Urology, Vestfold Hospital Trust, Tønsberg, Norway., Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA., Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA., Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA., Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy., Department of Pathology, University of Foggia, Foggia, Italy., Department of Radiology, University of Foggia, Foggia, Italy., Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy; Department of Urology, Bonomo Teaching Hospital, Andria, Italy., Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Urology, Karolinska University Hospital, Solna, Sweden.