Prostate Biopsy Decision Assistant

Created by Dr. Sharad Maheshwari, imagingsimplified@gmail.com

1. PSA & Prostate Volume

Total PSA (ng/mL)

Free PSA (ng/mL)

Prostate Volume (cc)

2. MRI Findings (PI-RADS Score)

PI-RADS 1-2 (Low) PI-RADS 3 (Equivocal) PI-RADS 4-5 (High)

3. Other Clinical & Risk Factors

Digital Rectal Exam (DRE)

Normal Abnormal (nodule/induration)

High-Risk Patient Profile

Factors like family history, BRCA mutation, or African ancestry.

Yes No

Recommendation

Calculated PSA Density:

Calculated PSA Ratio (Free/Total):

Source:

1. Initial Biopsy Adequacy

Adequate (e.g., ≥12 systematic cores) Inadequate (e.g., too few cores, no targeted sampling)

2. Multiparametric MRI Findings

PI-RADS 1-2 (No lesion) PI-RADS 3 (Equivocal lesion) PI-RADS 4-5 (Suspect lesion)

3. PSA Density & Biomarkers

PSA Density (ng/mL/cm³)

Second-line Biomarker Risk Low Risk (e.g., low PHI, 4Kscore) High Risk (e.g., high PHI, positive PCA3)

4. PSMA PET-CT Findings

Used for "mystery" cases with persistent suspicion.

Negative Positive (focal uptake)

Recommendation

Source:

• AUA/SUO Guideline for Early Detection of Prostate Cancer (2023). Available at: auanet.org
• NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Prostate Cancer (Version 2.2025).
• European Association of Urology (EAU) Guidelines on Prostate Cancer (2024 Update).
• PRECISION trial: Kasivisvanathan, V., et al. "MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis." *New England Journal of Medicine*, 2018.
• FUTURE trial: Wegelin, O., et al. "The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques..." *European Urology*, 2018.