Lesion size critical predictor of clinically significant prostate cancer within PI-RADS 4 category: Study

A new study published in the journal of Research and Reports in Urology showed that lesion size was a crucial predictor of clinically significant prostate cancer (CSPCa) in the PI-RADS 4 category.

When diagnosing prostate cancer (PCa), magnetic resonance imaging (MRI) is a crucial diagnostic technique. The frequency of CSPCa with PI-RADS 4 is 33–41%, whereas PI-RADS 5 is 62–79%, per the most recent guidelines. The PI-RADS v2.1 score corresponds with clinically significant prostate cancer. Despite just being 15 mm apart, there is a noticeable variation in risk between both groups.

To assist with risk stratification and patient counseling in the pre-biopsy scenario, this study by Ali Hooshyari and team attempts to identify a size threshold linked with CSPCa within the PI-RADS 4 group. This threshold may be employed in conjunction with other prostatic characteristics, such as PSA density. In the event of a negative biopsy, this may also help with surveillance of smaller PI-RADS 4 lesions and prevent needless repeat biopsies unless prompted by a size threshold.

The data from a total of 407 individuals who had transperineal prostate biopsies (TPPBs) between April 2022 and November 2023 were used in a retrospective analysis. For analysis, a subset of patients with PI-RADS 4 was included. The result was a ROC-AUC.

The findings of this study found that the PSA density was 0.20 (interquartile range 0.13–0.28) and the median age was 67 (interquartile range: 61–71). There was a link between the PI-RADS score and CSPCa: 10% for PI-RADS 1 and 2, 20% for PI-RADS 3, 60% for PI-RADS 4, and 80% for PI-RADS 5 (Pearson correlation = 0.51, p < 0.001).

The results showed that the Receiver Operating Characteristic Area Under the Curve (ROC-AUC) was 0.664 [0.579–0.7499]. 8.5 mm was the ideal cut-off point. CSPCa risk was 2.31 times greater in those with lesions bigger than 8.5 mm. When PI-RADS 4 lesions reach the statistically significant size threshold of 8.5 mm, the probability of CSPCa is 2.31 [1.31–4.07] times greater than for lesions that fall below this threshold. Therefore, the size of a PI-RADS 4 lesion is important and may actually be used to predict the likelihood of a positive biopsy for CSPCa.

Overall, the study emphasized the significance of considering PI-RADS 4 lesions in size-specific groups. This is a helpful tool for increasing the precision of patient counseling and optimizing follow-up or monitoring tactics when paired with PSA density.

Source:

Hooshyari, A., Scholtz, D., Maoate, K., Robertson, S., Vermeulen, L., De Andrade, L. G. M., Kawano, P., Gilling, P., Fraundorfer, M., & Vasconcelos Ordones, F. (2025). Does size matter? A retrospective study analysing the size of PI-RADS 4 lesions and its associated prostate cancer positivity with transperineal prostate biopsy. Research and Reports in Urology, 17, 49–57. https://doi.org/10.2147/rru.s499930