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. 2025 Sep 22;6(9):e70079.
doi: 10.1002/bco2.70079. eCollection 2025 Sep.

Multiparametric MRI combined with PSA density as a noninvasive rule-out strategy in active surveillance for prostate cancer

Publio Cesar Cavalcante Viana  1   2 , Marcelo Araújo Queiroz  2 , Fabio Oliveira Ferreira  3 , Adriano Basso Dias  4 , Natally Horvat  5 , Maurício Dener Cordeiro  6 , Claudio Bovolenta Murta  6 , Giuliano Betoni Guglielmetti  6 , Rafael Ferreira Coelho  6 , Leonardo Cardili  6 , José Pontes Jr  6 , William Carlos Nahas  6 , Giovanni Guido Cerri  1
Affiliations

Multiparametric MRI combined with PSA density as a noninvasive rule-out strategy in active surveillance for prostate cancer

Publio Cesar Cavalcante Viana et al. BJUI Compass. .

Abstract

Objective: To evaluate the diagnostic performance of multiparametric MRI (mpMRI), mpMRI combined with PSA density (PSAd) and combined biopsy (CBx) in detecting clinically significant prostate cancer (csPCa) in men undergoing active surveillance, using radical prostatectomy (RP) specimens as the reference standard.

Patients and methods: In this prospective single-centre study, 91 patients with low-risk prostate cancer under active surveillance underwent mpMRI, PSAd measurement, CBx and ultimately RP. mpMRI was reported using PI-RADS v2.0, and PSAd was dichotomised at 0.12 ng/ml/cm3. Diagnostic accuracy was compared using ISUP grade ≥2 and ≥3 thresholds. Radical prostatectomy pathology served as the reference standard.

Results: For detecting ISUP ≥3 cancer, mpMRI combined with PSAd achieved the highest sensitivity (93.3%) and negative predictive value (94.4%). CBx demonstrated the highest specificity (88.2%) and overall diagnostic balance (Youden index = 0.348). mpMRI alone showed intermediate performance. Differences in classification between strategies were statistically significant (McNemar p < 0.001).

Conclusions: mpMRI combined with PSAd provides high sensitivity and negative predictive value for ruling out aggressive prostate cancer, supporting its use as a non-invasive triage tool in active surveillance. CBx remains the most specific method for histological confirmation. These strategies should be used complementarily to optimise decision-making in active surveillance protocols.

Keywords: ISUP grade; PSA density; active surveillance; combined biopsy; mpMRI; prostate cancer; radical prostatectomy.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Study design and flowchart of the institutional active surveillance protocol and patient selection for radical prostatectomy (RP). RP = radical prostatectomy; mpMRI = multiparametric magnetic resonance imaging; PSAd = prostate‐specific antigen density; SBx = systematic biopsy; TBx = targeted biopsy; CBx = combined biopsy; ISUP = International Society of Urological Pathology; csPCa = clinically significant prostate cancer.
FIGURE 2
FIGURE 2
Stacked bar plots of reclassification outcomes (upgrade, downgrade and no change) for mpMRI, mpMRI + PSAd and CBx, using radical prostatectomy (RP) pathology as reference. Results are shown for both ISUP ≥2 and ISUP ≥3 thresholds. mpMRI + PSAd achieved the lowest upgrade rates but was associated with high downgrade rates and limited concordance. In contrast, CBx showed the highest overall concordance and the most balanced classification performance, particularly under the ISUP ≥3 threshold.
FIGURE 3
FIGURE 3
Diagnostic performance of mpMRI, mpMRI + PSAd and CBx across reference standards (CBx and RP) and ISUP thresholds (≥2 and ≥3). Bar charts display sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Youden index for each method under four different conditions: CBx as the reference with ISUP ≥2 and ≥3 (top row), and RP as the reference with ISUP ≥2 and ≥3 (bottom row). Shades of blue represent the different diagnostic strategies.
See this image and copyright information in PMC

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