Recent guidelines suggest that biopsy may be omitted in some groups of patients with PI-RADS 3 lesions on mpMRI. In this study, we aimed to evaluate biopsy strategies involving prostate-specific antigen density (PSAd) to avoid unnecessary biopsy versus the risk of missing clinically significant prostate cancer (csPCa) in patients with PI-RADS 3 lesions. Data of 616 consecutive patients who underwent PSAd and mpMRI before prostate biopsy between January 2017 and January 2022 at a single center were retrospectively assessed. All of these patients underwent combined cognitive or fusion targeted biopsy of suspicious lesions and transrectal ultrasonography guided systematic biopsy. PI-RADS 3 based strategies with PSAd and mpMRI combination were created. For each strategy, avoided unnecessary biopsy, reduced ISUP Grade 1, and missed ISUP Grade ≥ 2 ratios were determined. Decision curve analysis (DCA) was used to statistically compare the net benefit of each strategy. DCA revealed that patients who had PI-RADS 3 lesions with PSAd ≥ 0.2, and/or patients who had PI-RADS 4 and 5 lesions had the most benefit, under the threshold probability level between 10% and 50%, which avoided 48.2% unnecessary prostate biopsies and reduced 51% of ISUP grade 1 cases, while missed 17.5% of ISUP grade ≥ 2 cases. (22.1% for ISUP grade 2 and 8.8% for ISUP grade ≥ 3). Strategy 1 (PI-RADS 4-5 and/or PSAd ≥ 0.2), 3 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15), and 7 (PI-RADS 4-5 and/or PI-RADS 3 if PSAd ≥ 0.15 and/or PI-RADS 2 if PSAd ≥ 0.2) were the next three best strategies. mpMRI combined with PSAd strategies reduced biopsy attempts in PI-RADS 3 lesions. Using these strategies, the advantage of avoiding biopsy and the risk of missing the diagnosis of csPCa can be discussed with the patient, and the biopsy decision can be made afterwards.

中文翻译：

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结合磁共振成像和前列腺特异性抗原密度的风险适应策略，对 PI-RADS 3“灰区”病变患者进行个体化活检决策

最近的指南建议，对于某些 mpMRI 上出现 PI-RADS 3 病变的患者组，可以省略活检。在这项研究中，我们的目的是评估涉及前列腺特异性抗原密度 (PSAd) 的活检策略，以避免 PI-RADS 3 病变患者中不必要的活检以及漏检具有临床意义的前列腺癌 (csPCa) 的风险。回顾性评估了 2017 年 1 月至 2022 年 1 月期间在单一中心连续接受 PSAd 和 mpMRI 的 616 名患者的数据。所有这些患者均接受了可疑病变的联合认知或融合靶向活检以及经直肠超声引导的系统活检。创建了基于 PI-RADS 3 的 PSAd 和 mpMRI 组合策略。对于每种策略，都确定了避免不必要的活检、减少 ISUP 1 级和错过 ISUP ≥ 2 级的比率。决策曲线分析（DCA）用于统计比较每种策略的净收益。 DCA 显示，具有 PI-RADS 3 病变且 PSAd ≥ 0.2 的患者和/或具有 PI-RADS 4 和 5 病变的患者获益最大，阈值概率水平在 10% 到 50% 之间，避免了 48.2%不必要的前列腺活检，减少了 51% 的 ISUP 1 级病例，同时漏诊了 17.5% 的 ISUP ≥ 2 级病例。 （ISUP 2 级为 22.1%，ISUP ≥ 3 级为 8.8%）。策略 1（PI-RADS 4-5 和/或 PSAd ≥ 0.2）、3（PI-RADS 4-5 和/或 PI-RADS 3，如果 PSAd ≥ 0.15）和 7（PI-RADS 4-5 和/或接下来的三个最佳策略是 PI-RADS 3（如果 PSAd ≥ 0.15）和/或 PI-RADS 2（如果 PSAd ≥ 0.2）。 mpMRI 与 PSAd 策略相结合减少了 PI-RADS 3 病变的活检尝试。使用这些策略，可以与患者讨论避免活检的优点和错过 csPCa 诊断的风险，并可以在事后做出活检决定。