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Volume 25, Issue 2 (March 2023) 25, 217–222; 10.4103/aja2022112

Improving the understanding of PI-RADS in practice: characters of PI-RADS 4 and 5 lesions with negative biopsy

Wang, Yu-Hao1,*; Liang, Chao1,*; Zhu, Fei-Peng2; Zhou, Tian-Ren1; Li, Jie1; Wang, Zeng-Jun1,; Liu, Bian-Jiang1

1Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China

2Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China

Correspondence: Dr. ZJ Wang (zengjunwang@njmu.edu.cn); Dr. BJ Liu (bjliu@njmu.edu.cn)

Received: 21 May 2022; Accepted: 15 December 2022; published online: 24 January 2023


The Prostate Imaging Reporting and Data System (PI-RADS) has good ability to identify the nature of lesions on prostate magnetic resonance imaging (MRI). However, some lesions are still reported as PI-RADS 4 and 5 but are biopsy-proven benign. Herein, we aimed to summarize the reasons for the negative prostate biopsy of patients who were assessed as PI-RADS 4 and 5 by biparameter MRI. We retrospectively sorted out the prostate MRI, treatment, and follow-up results of patients who underwent a biparameter MRI examination of the prostate in The First Affiliated Hospital of Nanjing Medical University (Nanjing, China) from August 2019 to June 2021 with PI-RADS 4 and 5 but a negative biopsy. We focused on reviewing the MRI characteristics. A total of 467 patients underwent transperineal prostate biopsy. Among them, biopsy pathology of 93 cases were negative. After follow-up, 90 patients were ruled out of prostate cancer. Among the 90 cases, 40 were considered to be overestimated PI-RADS after review. A total of 22 cases were transition zone (TZ) lesions with regular appearance and clear boundaries, and 3 cases were symmetrical lesions. Among 15 cases, the TZ nodules penetrated the peripheral zone (PZ) and were mistaken for the origin of PZ. A total of 17 cases of lesions were difficult to distinguish from prostate cancer. Among them, 5 cases were granulomatous inflammation (1 case of prostate tuberculosis). A total of 33 cases were ambiguous lesions, whose performance was between PI-RADS 3 and 4. In summary, the reasons for “false-positive MRI diagnosis” included PI-RADS overestimation, ambiguous images giving higher PI-RADS, diseases that were really difficult to distinguish, and missed lesion in the initial biopsy; and the first two accounted for the most.

Keywords: biopsy; negative; PI-RADS 4 and 5; prostate cancer

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Asian Journal of Andrology CN 31-1795/R ISSN 1008-682X  Copyright © 2023  Shanghai Materia Medica, Chinese Academy of Sciences.  All rights reserved.