What does this research mean for the field?

Combining multiparametric magnetic resonance imaging (mpMRI) with prostate-specific antigen density (PSAd) allows for a more effective risk-stratification strategy in selecting patients for prostate biopsy, reducing unnecessary procedures while maintaining high detection rates of clinically significant prostate cancer. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

What question did this study set out to answer?

This study aims to identify the best biopsy strategy by combining mpMRI PI-RADS scores and PSAd levels to improve prostate cancer detection and minimize unnecessary procedures.

March 16, 2026Open Access

Combining Multiparametric Magnetic Resonance Imaging and Prostate-Specific Antigen Density in Selecting Patients for Prostate Biopsy

GDGoran DerimachkovskiNational Institute of Emergency Medicine "Pirogov"GGGeorgi Stoyanov GeorgievUniversity Clinic of Traumatology KDKrastyo DraginovNational Institute of Emergency Medicine "Pirogov"

Key Points

This study aims to identify the best biopsy strategy by combining mpMRI PI-RADS scores and PSAd levels to improve prostate cancer detection and minimize unnecessary procedures.
Retrospective analysis of 511 men with clinical suspicion of prostate cancer.
Assessment of mpMRI PI-RADS scores and prostate-specific antigen density before biopsy.
Evaluation of various mpMRI/PSAd thresholds for accuracy in detecting clinically significant prostate cancer.
Decision curve analysis to determine the net benefit and outcomes.
Optimal biopsy strategy includes lesions with PI-RADS 4 or 5 and PI-RADS 3 with PSAd ≥0.15 ng/mL/mL.
Negative predictive value of the strategy was 91%, while the positive predictive value was 43%.
16% of men (80 out of 511) could have avoided unnecessary biopsies.
Overdiagnosis of insignificant prostate cancer reduced by 9% (15 out of 159).
Only 4% (7 out of 194) of clinically significant prostate cancer cases were missed.

Abstract

Introduction: Multiparametric magnetic resonance imaging (mpMRI) combined with prostate-specific antigen density (PSAd) has emerged as an effective risk-stratification tool for guiding prostate biopsy decisions. This study aimed to determine the optimal, clinically feasible biopsy strategy by combining the mpMRI Prostate Imaging-Reporting and Data System (PI-RADS) score and PSAd to minimize unnecessary biopsies while maximizing the detection of clinically significant prostate cancer (csPCa; Gleason score GS ≥7), using transperineal targeted and systematic biopsy as the reference standard. Methods: We retrospectively analyzed data from 511 men with clinical suspicion of prostate cancer (PCa) (PSA: >4 ng/mL; PI-RADS ≥3), who underwent pre-biopsy mpMRI and a subsequent combination of targeted and systematic transperineal prostate biopsy. Various mpMRI/PSAd thresholds were assessed based on their accuracy for detecting csPCa, their predictive value, the proportion of avoided biopsies, and net benefit and outcomes from decision curve analysis. Results: The overall analysis showed that the optimal strategy was to perform biopsy for lesions assessed as PI-RADS 4 and 5 or PI-RADS 3 lesions with PSAd of ≥0. 15 ng/mL/mL. This combined approach yielded a negative predictive value (NPV) of 91% and a positive predictive value (PPV) of 43%. Implementing this strategy would have avoided biopsy in 16% (80/511) of the men and reduced the overdiagnosis of insignificant PCa by 9% (15/159) while missing only 4% (7/194) of csPCa cases. Conclusion: Combining mpMRI with PSAd provides a robust, risk-stratified approach to PCa diagnosis. Men with equivocal mpMRI findings (PI-RADS 3) and low PSAd (<0. 15 ng/mL/mL) may safely defer immediate prostate biopsy, reducing unnecessary procedures and the burden of overdiagnosis.

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