The following is a summary of “Molecular and diffusion features for identification of clinically significant prostate cancer in PI-RADS 3 lesions,” published in the July 2024 issue of Urology by Ajami et al.

The approach to managing PI-RADS 3 lesions on multiparametric MRI (mpMRI) remains less definitive compared to higher-scored lesions, posing a challenge for clinicians in risk assessment and biopsy decision-making. In this study, researchers investigated clinical and radiological characteristics associated with clinically significant prostate cancer (csPCa) in men with PI-RADS 3 index lesions undergoing mpMRI-targeted biopsy.

The study group conducted a retrospective analysis of a prospective database comprising patients who underwent targeted and systematic biopsies between 2015 and 2023 for PI-RADS 3 lesions identified on mpMRI. Baseline variables of the lesions’ PSA density (PSAd), 4Kscore, prostate size, and apparent diffusion coefficient (ADC) values were collected. Logistic regression, receiver operating characteristic (ROC), and decision curve analyses (DCA) were employed to assess the predictive value of these clinicoradiologic factors for csPCa.

A total of 230 patients were included, with a median age of 65 years. Median prostate size and PSA levels were 50 g and 6.26 ng/mL, respectively. Clinically significant prostate cancer was detected in 17.4% of patients, while 27.5% had Gleason group 1 cancer. Univariable logistic regression identified age, BMI, prostate size, PSAd, ADC, and 4Kscore as significant predictors of csPCa (P < 0.05). PSAd demonstrated the highest predictive performance with an area under the curve (AUC) of 0.679. In multivariable analysis, PSAd and 4Kscore were independently associated with csPCa. The combination of PSAd with clinical parameters provided superior net benefit compared to other predictors. Notably, among patients with PSAd < 0.15, 4Kscore emerged as a significant predictor of csPCa (OR = 3.25, P = 0.032).

PSAd and 4Kscore exhibit superior predictive accuracy for identifying csPCa in patients with PI-RADS 3 lesions, surpassing the predictive value of ADC. Particularly, 4Kscore demonstrates heightened predictive utility in patients with low PSAd levels. These findings offer valuable insights for clinicians grappling with ambiguous lesions, aiding in informed decision-making regarding the necessity of biopsy. Integrating PSAd and 4Kscore into clinical practice could enhance risk stratification strategies for patients with equivocal findings on mpMRI.

Source: sciencedirect.com/science/article/abs/pii/S1078143924004988