MRI-derived real PSA density improves risk stratification for equivocal PI-RADS 3 prostate lesions

For PI-RADS 3 lesions, MRI-derived real PSA density (rPSAD) achieved AUC 0.846 (95% CI 0.767–0.924) for clinically significant prostate cancer — outperforming conventional PSAD. A sequential strategy flagged 53% cancer prevalence in the high-risk tier. Retrospective; n=116.

• Retrospective single-center study; 116 patients with PI-RADS 3 lesions who underwent multiparametric MRI and systematic biopsy; clinically significant prostate cancer (csPCa) prevalence was 17% (20/116).
• rPSAD independently predicted csPCa on multivariable analysis (adjusted OR 2.03 per 0.1 unit increase; 95% CI 1.48–2.78; p<0.001); a sequential PSAD/rPSAD strategy stratified patients into low- (9% csPCa), intermediate- (16%), and high-risk (53%) groups, with decision curve analysis favoring rPSAD over conventional PSAD across most threshold probabilities.
• Key limitations: retrospective, single-center design with small sample size (n=116) and no external validation; internal validation by bootstrap showed minimal optimism, but generalizability remains unproven.

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