Molecular and diffusion features for identification of clinically significant prostate cancer in PI-RADS 3 lesions

•PIRADS 3 lesion represents a “gray zone” where further tools are needed for decision making for risk stratification and prostate biopsy.•4k score has better performance in predicting clinically significant prostate cancer in patients with PIRADS 3 lesions and PSA density less than 0.15 ng/mL/cm3.•U...

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Bibliographic Details
Published in:	Urologic oncology Vol. 42; no. 11; pp. 370.e9 - 370.e14
Main Authors:	Ajami, Tarek, Han, Sunwoo, Porto, Joao G., Kimbel, Isabella, Szczotka, Zoe, Guerard, Timothy, VanderVeer-Harris, Nathan, Ledesma, Braian R., Acosta, Patricia Castillo, Kryvenko, Oleksandr N., Parekh, Dipen J., Stoyanova, Radka, Reis, Isildinha M., Punnen, Sanoj
Format:	Journal Article
Language:	English
Published:	United States Elsevier Inc 01-11-2024
Subjects:	4Kscore Aged Diffusion Magnetic Resonance Imaging - methods Humans Image-Guided Biopsy - methods Male Middle Aged Multiparametric Magnetic Resonance Imaging - methods Multiparametric MRI PI-RADS 3 Prospective Studies Prostate cancer Prostatic Neoplasms - diagnostic imaging Prostatic Neoplasms - pathology PSA density 4Kscore Prostate cancer Multiparametric MRI PI-RADS 3 PSA density
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Summary:	•PIRADS 3 lesion represents a “gray zone” where further tools are needed for decision making for risk stratification and prostate biopsy.•4k score has better performance in predicting clinically significant prostate cancer in patients with PIRADS 3 lesions and PSA density less than 0.15 ng/mL/cm3.•Using a threshold of PSA density of 0.1 ng/mL/cm3 or 4k score of 10% would help reduce unnecessary biopsy without missing a significant proportion of clinically significant prostate cancer. The recommendation to perform biopsy of PIRADS 3 lesions has not been adopted with strength as compared to higher scored lesions on multiparametric MRI. This represents a challenging scenario and an unmet need for clinicians to apply a risk adapted approach in these cases. In the present study, we examined clinical and radiologic characteristics in men with PI-RADS 3 index lesions that can predict csPCa on mpMRI-target biopsy. Revision of a prospective database with patients who underwent targeted and systematic biopsies from 2015 to 2023 for PI-RADS 3 lesions identified on mpMRI. Baseline variables were collected, such as PSA density (PSAd), 4Kscore, prostate size, and the apparent diffusion coefficient (ADC) value of the lesion on mpMRI. Logistic regression, receiver operating characteristic (ROC) and decision curve analyses (DCA) assessing the association between clinic-radiologic factors and csPCa were performed. Overall, 230 patients were included in the study and the median age was 65 years. The median prostate size and PSA were 50 g and 6.26 ng/mL, respectively. 17.4% of patients had csPCa, while 27.5% had Gleason group 1. In univariable logistic analyses, we found that age, BMI, prostate size, PSAd, ADC, and 4Kscore were significant csPCa predictors (P < 0.05). PSAd showed the best prediction performance in terms of AUC (= 0.679). On multivariable analysis, PSAd and 4Kscore were associated with csPCa. The net benefit of PSAd combined with clinical features was superior to those of other parameters. Within patients with PSAd < 0.15, 4Kscore was a statistically significant predictor of csPCa (OR = 3.25, P = 0.032). PSAd and 4Kscore are better predictors of csPCa in patients with PIRADS 3 lesions compared to ADC. The predictive role of 4Kscore is higher in patients with low PSAd. These results can assist practitioners in the risk stratification of patients with equivocal lesions to determine the need of biopsy.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	1078-1439 1873-2496 1873-2496
DOI:	10.1016/j.urolonc.2024.05.025