The Detection of Clinically Significant Prostate Cancer in Chinese Biopsy Naïve Men. The Role of Mpmri and Targeted Biopsy and Risk Stratification Using PSA Density

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Kai Zhang Zijian Song S. Remmers Rui Chen Gang Zhu Monique J Roobol


Objective To evaluate the performance of the systematic (SBx) and targeted prostate biopsy (TBx) in detecting prostate cancer (PCa) and significant prostate cancer (csPCa) and including upfront risk stratification with PSA Density (PSAD) in a biopsy naïve cohort of Chinese men.

Methods A total of 348 men from two medical centers were available for analyses.  All men underwent a mpMRI scan based on an elevated PSA and/or abnormal digital rectal examination (DRE). A total of 150 men received both SBx and TBx prostate biopsy (PIRADS >= 3). In these men the detection ratio was calculated as the PCa and csPCa prevalence of the TBx strategy divided by the prevalence of PCa and csPCa of the SBx + TBx strategy. For PSAD analyses the percentage missed csPCa were plotted against the clinically relevant thresholds of PSAD (range 0.01 – 0.20).

Results In the men with PIRADS >= 3, a total of 89 PCa cases (59 being csPCa) were detected. The TBx alone strategy detected 74 of all PCa, leading to a detection ratio of 0.83 (95% CI 0.74-0.90). For csPCa these numbers were 48 of the total 59 csPCa cases, i.e a detection ratio of  0.81 (95% CI 0.69-0.90).With the focus on avoiding missing csPCa diagnoses a  cut-off of PSA D 0.10 seemed optimal in this cohort, leading to a reduction of 15% of all referrals, missing 6% of all PCa and 2% of csPCa. A similar cut-off of PSAD holds if also men with PIRADS >= 2 were included.

Conclusion In this Chinese cohort of biopsy naïve men a TBx approach can aid in improved detection of csPCa. Omitting SBx would results in missing csPCa cases. An upfront risk stratification step with the use of PSAD is advised although the optimal PSAD cut-off in Asian men most likely differs from the generally advised cut-off of 0.15 ng/ml/ml.

Keywords: Targeted biopsy, MRI, Prostate carcinoma, PSA density, Diagnosis

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How to Cite
ZHANG, Kai et al. The Detection of Clinically Significant Prostate Cancer in Chinese Biopsy Naïve Men. The Role of Mpmri and Targeted Biopsy and Risk Stratification Using PSA Density. Medical Research Archives, [S.l.], v. 9, n. 8, aug. 2021. ISSN 2375-1924. Available at: <>. Date accessed: 25 june 2024. doi:
Research Articles


1. Schroder, F.H., J. Hugosson, M.J. Roobol, et al., Screening and prostate-cancer mortality in a randomized European study. N. Engl. J. Med., 2009. 360(13): p. 1320-8.
2. Schroder, F.H., J. Hugosson, M.J. Roobol, et al., Prostate-cancer mortality at 11 years of follow-up. N. Engl. J. Med., 2012. 366(11): p. 981-90.
3. Schroder, F.H., J. Hugosson, M.J. Roobol, et al., Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet, 2014. 384(9959): p. 2027-35.
4. Schoots, I.G., M.J. Roobol, D. Nieboer, et al., Magnetic resonance imaging-targeted biopsy may enhance the diagnostic accuracy of significant prostate cancer detection compared to standard transrectal ultrasound-guided biopsy: a systematic review and meta-analysis. Eur. Urol., 2015. 68(3): p. 438-50.
5. Zhang, K., C.H. Bangma, and M.J. Roobol, Prostate cancer screening in Europe and Asia. Asian journal of urology, 2017. 4(2): p. 86-95.
6. Alberts, A.R., M.J. Roobol, J.F.M. Verbeek, et al., Prediction of High-grade Prostate Cancer Following Multiparametric Magnetic Resonance Imaging: Improving the Rotterdam European Randomized Study of Screening for Prostate Cancer Risk Calculators. Eur. Urol., 2019. 75(2): p. 310-318.
7. Kasivisvanathan, V., A.S. Rannikko, M. Borghi, et al., MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N. Engl. J. Med., 2018. 378(19): p. 1767-1777.
8. Robertson, N.L., M. Emberton, and C.M. Moore, MRI-targeted prostate biopsy: a review of technique and results. Nature reviews. Urology, 2013. 10(10): p. 589-97.
9. Fascelli, M., S. Rais-Bahrami, S. Sankineni, et al., Combined Biparametric Prostate Magnetic Resonance Imaging and Prostate-specific Antigen in the Detection of Prostate Cancer: A Validation Study in a Biopsy-naive Patient Population. Urology, 2016. 88: p. 125-34.
10. Bhat, N.R., J.M. Vetter, G.L. Andriole, et al., Magnetic Resonance Imaging-Defined Prostate-Specific Antigen Density Significantly Improves the Risk Prediction for Clinically Significant Prostate Cancer on Biopsy. Urology, 2019. 126: p. 152-157.
11. Yanai, Y., T. Kosaka, H. Hongo, et al., Evaluation of prostate-specific antigen density in the diagnosis of prostate cancer combined with magnetic resonance imaging before biopsy in men aged 70 years and older with elevated PSA. Molecular and clinical oncology, 2018. 9(6): p. 656-660.
12. Kotb, A.F., S. Spaner, T. Crump, et al., The role of mpMRI and PSA density in patients with an initial negative prostatic biopsy. World J. Urol., 2018. 36(12): p. 2021-2025.
13. Mannaerts, C.K., M. Gayet, J.F. Verbeek, et al., Prostate Cancer Risk Assessment in Biopsy-naïve Patients: The Rotterdam Prostate Cancer Risk Calculator in Multiparametric Magnetic Resonance Imaging-Transrectal Ultrasound (TRUS) Fusion Biopsy and Systematic TRUS Biopsy. European urology oncology, 2018. 1(2): p. 109-117.
14. Bjurlin, M.A., N. Mendhiratta, J.S. Wysock, et al., Multiparametric MRI and targeted prostate biopsy: Improvements in cancer detection, localization, and risk assessment. Cent European J Urol, 2016. 69(1): p. 9-18.
15. Pokorny, M.R., M. de Rooij, E. Duncan, et al., Prospective study of diagnostic accuracy comparing prostate cancer detection by transrectal ultrasound-guided biopsy versus magnetic resonance (MR) imaging with subsequent MR-guided biopsy in men without previous prostate biopsies. Eur. Urol., 2014. 66(1): p. 22-9.
16. Ahmed, H.U., A. El-Shater Bosaily, L.C. Brown, et al., Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet, 2017. 389(10071): p. 815-822.
17. Elkhoury, F.F., E.R. Felker, L. Kwan, et al., Comparison of Targeted vs Systematic Prostate Biopsy in Men Who Are Biopsy Naive: The Prospective Assessment of Image Registration in the Diagnosis of Prostate Cancer (PAIREDCAP) Study. JAMA surgery, 2019. 154(9): p. 811-818.
18. Gross, M.D., B. Al Hussein Al Awalmlh, J.E. Shoag, et al. Race and Prostate Imaging: Implications for targeted biopsy and image-based prostate cancer interventions. BMJ Surg Interv Health Technologies.,2019 1:e000010. doi:10.1136/bmjsit-2019-000010.
19. Benson, M.C., I.S. Whang, C.A. Olsson, et al., The use of prostate specific antigen density to enhance the predictive value of intermediate levels of serum prostate specific antigen. J. Urol., 1992. 147(3 Pt 2): p. 817-21.
20. Washino, S., T. Okochi, K. Saito, et al., Combination of prostate imaging reporting and data system (PI-RADS) score and prostate-specific antigen (PSA) density predicts biopsy outcome in prostate biopsy naive patients. BJU Int., 2017. 119(2): p. 225-233.
21. Distler, F.A., J.P. Radtke, D. Bonekamp, et al., The Value of PSA Density in Combination with PI-RADS™ for the Accuracy of Prostate Cancer Prediction. J. Urol., 2017. 198(3): p. 575-582.
22. Yusim, I., M. Krenawi, E. Mazor, et al., The use of prostate specific antigen density to predict clinically significant prostate cancer. Sci. Rep., 2020. 10(1): p. 20015.
23. Han C., S.Liu, X.B.Qin, et al. MRI combined with PSA density in detecting clinically significant prostate cancer in patients with PSA serum levels of 4∼10 ng/mL: Biparametric versus multiparametric MRI.Diagnostic and Interventional Imaging.,2020. 101,235-244.
24. Chiu, P.K., C.F. Ng, A. Semjonow, et al., A Multicentre Evaluation of the Role of the Prostate Health Index (PHI) in Regions with Differing Prevalence of Prostate Cancer: Adjustment of PHI Reference Ranges is Needed for European and Asian Settings. Eur. Urol., 2019. 75(4): p. 558-561.
25. Roobol, M.J., E.W. Steyerberg, R. Kranse, et al., A risk-based strategy improves prostate-specific antigen-driven detection of prostate cancer. Eur. Urol., 2010. 57(1): p. 79-85.
26. Zhu, X., P.C. Albertsen, G.L. Andriole, et al., Risk-based prostate cancer screening. Eur. Urol., 2012. 61(4): p. 652-61.
27. Polanec, S., T.H. Helbich, H. Bickel, et al., Head-to-head comparison of PI-RADS v2 and PI-RADS v1. Eur. J. Radiol., 2016. 85(6): p. 1125-31.
28. Kasel-Seibert, M., T. Lehmann, R. Aschenbach, et al., Assessment of PI-RADS v2 for the Detection of Prostate Cancer. Eur. J. Radiol., 2016. 85(4): p. 726-31.
29. Vargas, H.A., A.M. Hotker, D.A. Goldman, et al., Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference. Eur. Radiol., 2016. 26(6): p. 1606-12.