Diagnostic Performance of Biparametric versus Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis: An Updated Systematic Review and Meta-analysis

Multiparametric magnetic resonance imaging (mpMRI) is widely established as the reference modality for detecting clinically significant prostate cancer (csPC). However, the standard mpMRI protocol requires dynamic contrast-enhanced (DCE) sequences, which add to the scan time, increase costs, and require the administration of gadolinium-based contrast agents. Biparametric MRI (bpMRI) has recently emerged as a highly appealing, streamlined alternative that drops the contrast while retaining the core T2-weighted and diffusion-weighted imaging.

To assess whether omitting contrast compromises diagnostic accuracy, we performed an updated head-to-head systematic review and meta-analysis evaluating 40 studies and over 9,400 patients. Crucially, to the best of our knowledge, this is the first meta-analysis of diagnostic accuracy to apply a formal non-inferiority framework. This approach provides a more conservative and clinically meaningful interpretation. Furthermore, it is the first to incorporate level-one evidence from the multicenter PRIME trial within a pooled framework. By utilizing this rigorous non-inferiority boundary, our analysis demonstrated that bpMRI is indeed non-inferior to mpMRI for detecting csPC at the per-patient level, confirming comparable performance across both sensitivity and specificity.

Methodologically, our non-inferiority assessment was based on the paired absolute differences in sensitivity and specificity between bpMRI and mpMRI. To ensure the robustness of our findings and address observed heterogeneity, we conducted several sensitivity analyses. These included restricting our evaluation to subsets of studies with a lower risk of bias and isolating high-quality prospective cohorts. We also performed meta-regression analyses to investigate if covariates modified the difference between the two modalities. Across these sensitivity analyses, the results remained remarkably consistent, yielding narrower confidence intervals and resolving heterogeneity, further cementing the stability of our primary non-inferiority findings.

Ultimately, our data strongly support the broader implementation of bpMRI as a faster and more accessible diagnostic pathway for the majority of patients. The crucial caveat is that because bpMRI lacks the "safety net" of a contrast sequence, it is fundamentally more vulnerable to suboptimal image acquisition. Therefore, the safe adoption of contrast-free imaging in routine practice will depend entirely on maintaining robust quality assurance, high-quality image acquisition, and standardized reporting protocols.

Written by: Guilherme Strieder de Oliveira, Department of Radiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil

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