Multiparametric MRI (mpMRI) is increasingly employed to reduce unnecessary prostate biopsies while maintaining detection of clinically significant prostate cancer (csPCa). False-negative (FN) mpMRI lead to delayed diagnosis. This study aimed to identify clinical and reader-associated factors associated with FN mpMRI.
We retrospectively identified patients who underwent prostate mpMRI followed by prostate biopsy within one year. FN cases were compared to true negative (TN) cases in Analysis #1 and to true positive (TP) cases in Analysis #2 using logistic regression and propensity score matching. A sensitivity analysis assessed patients who initially deferred biopsy after negative mpMRI. csPCa was defined as Gleason Grade Group (GG)≥2 and positive mpMRI as PI-RADS ≥3.
6,679 biopsied patients were identified with 663 TN, 133 FN, and 2993 TP cases included. Multivariable models predicting csPCa in the negative mpMRI setting found FN cases more frequently had a positive family history, Black race, high PSA density, and more PI-RADS 2 compared to TN cases. FN mpMRIs were more often read by radiologists without fellowship training (p=0.001) and with fewer cumulative annual mpMRI reads (68/yr vs. 84/yr, p<0.001). Compared to TP cases, FN cases had lower csPCa volume and grade (GG2: FN 76% vs TP 46). FN cases had more frequent MRI signs of BPH and prostatitis and lower mpMRI radiologist read volume compared to TP cases. >50 radiologist reads/year was protective against FN mpMRI in both analyses. Of 4,069 patients initially deferring biopsy after negative mpMRI, 17% had repeat mpMRI, 12% had biopsy, and 3.4% had csPCa at a median of 2 years.
Clinical predictors of csPCa remain similar among patients with negative mpMRI. MRI BPH and prostatitis along with lower radiologist read volume differentiated FN from TP cases. Enhanced clinical stratification tools and mpMRI refinements could improve confidence in forgoing biopsy for patients with a negative mpMRI.
The Journal of urology. 2026 Mar 23 [Epub ahead of print]
Marina Schnauss, Nicole Handa, Ramin Nateghi, Ridwan Alam, Jae W Jang, Mitchell M Huang, Aaron Abrams, Clayton Neill, Sai Kaushik Shankar Ramesh Kumar, Nikki Hubbard, Emma McGarrity, Yutai Li, Adam B Murphy, Ulas Bagci, Anugayathri Jawahar, Lee A D Cooper, Ashley E Ross, Hiten D Patel
Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA., Northwestern Medicine Enterprise Data Warehouse, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States of America., Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA., Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.