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Clinically Significant Prostate Cancer in Patients with PI-RADS 3 Lesions: Does Lesion Size Correlate?
Austin Freedman, BA1, Theodoros Karanikolas, BA1, Sandra Yu, BA2, Morgan Joseph, BS1, Kelli Aibel, MD1, Kara Watts, MD1, Stephen Reese, MD1.
1Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA, 2Albert Einstein College of Medicine, Bronx, NY, USA.
BACKGROUND: PI-RADS 3 lesions represent an equivocal risk category for clinically significant prostate cancer (csPCa). We evaluated predictors of csPCa in a diverse PI-RADS 3 cohort.
METHODS: We retrospectively identified men with PI-RADS 3 lesions only undergoing targeted ± systematic biopsy (2019-2024). Demographic, imaging, and pathologic variables were abstracted; both lesion- and patient-level analyses were performed. Multivariable logistic regression assessed predictors of PCa and csPCa (Grade Group ≥2) adjusted for age, race/ethnicity, prostate-specific antigen density (PSAD), and maximum lesion dimension (MLD). Generalized additive models assessed csPCa risk and Spearman rank correlations (ρ) evaluated associations between PSAD, MLD, total cancer length (TCL), and length of Gleason pattern 4 (LP4).
RESULTS: Among 182 patients (68% Black/Hispanic; median age 61 years; PSAD 0.13 ng/mL/cc; MLD 1.25 cm), PCa was detected in 96 (53%) patients (csPCa: 50 [27%]). MLD did not differ by diagnosis (p>0.5). 244 lesions were evaluated; despite comparable PCa yield among peripheral zone (PZ; 29% [58/202]) and transition zone (TZ; 17% [7/42]) lesions (p=0.127), the TZ exhibited a higher csPCa:PCa ratio than the PZ (100% [7/7] versus 59% [34/58]; p=0.027). On multivariable analysis, PSAD was a robust predictor of PCa (OR 1.37 per 0.1 units) and csPCa (OR 1.60 per 0.1 units) whereas MLD was not. PSAD also correlated with TCL (ρ=0.266, p<0.001) across the full cohort; MLD correlated with increased TCL (ρ=0.347) and LP4 (ρ=0.294) only among csPCa patients (p≤0.04).
CONCLUSIONS: In patients with PI-RADS 3 lesions, PSAD predicts csPCa and cancer length, whereas lesion size only correlates with cancer length in confirmed csPCa. TZ lesions demonstrate lower absolute yield but consistent significance. Pre-biopsy risk stratification should prioritize PSAD and lesion location over lesion size.
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