Prostate Biopsy Decision Node Framework A guide for clinical decision-making

Prostate Biopsy Decision Node Framework

A guide for clinical decision-making

1. Entry Point: Patient Assessment

Input Required:

• Clinical suspicion (PSA, DRE, risk calculators)
• MRI status (PI-RADS category, lesion location, number)
• Biopsy history (naïve vs repeat)
• Clinical context (family history, BRCA, prior atypia, ASAP, HGPIN)

2. Decision Nodes

Condition: No prior biopsy, MRI performed

If PI-RADS 4–5 (high suspicion):

Decision: Combined Targeted + Systematic Biopsy (≥2 targeted cores per lesion + 10–12 systematic cores).

Rationale: Maximizes detection of clinically significant PCa; systematic acts as safety net against MRI-occult disease.

Source: AUA 2023 [1], NCCN 2025 [2], EAU 2024 [3].

If PI-RADS 3 (equivocal):

Decision: Combined Targeted + Systematic Biopsy.

Rationale: Intermediate-risk lesion; targeted cores increase yield, systematic protects against MRI under-calling.

Source: NCCN [2], EAU [3].

If PI-RADS 1–2 (low suspicion):

Decision: Consider deferring biopsy with shared decision-making unless high-risk clinical features (PSA density >0.15, strong family history, BRCA mutation).

Rationale: Low likelihood of clinically significant PCa; minimize overdiagnosis.

Source: AUA [1], NCCN [2].

Condition: Patient had ≥1 prior negative biopsy

If MRI shows PI-RADS 4–5 lesion:

Decision: Multiple Targeted Biopsy (≥3 cores per lesion) ± limited systematic sampling.

Rationale: MRI-directed sampling improves yield in men with prior negative biopsy; systematic may be omitted in expert centers.

Source: EAU 2024 [3], PRECISION & FUTURE trials [4, 5].

If MRI shows PI-RADS 3 lesion:

Decision: Targeted + Systematic.

Rationale: To avoid under-detection; equivocal lesions need comprehensive sampling.

Source: NCCN [2], AUA [1].

If MRI negative but clinical suspicion remains high (PSA rising, family history):

Decision: Saturation Biopsy (20–24 cores, transperineal approach preferred).

Rationale: Captures MRI-invisible cancers; improves yield in persistent suspicion.

Source: AUA [1], NCCN [2].

Indications:

• ≥2 prior negative biopsies with persistent suspicion
• PSA progression with negative MRI
• Considered in select high-risk cohorts (genetic mutations, young patients)

Decision: Saturation (≥20 cores, preferably transperineal).

Rationale: Improves detection of clinically significant cancer in MRI-negative but high-risk patients.

Source: EAU 2024 [3], NCCN 2025 [2].

ASAP/HGPIN on prior biopsy:

Decision: Repeat biopsy with targeted + systematic sampling.

Rationale: High risk of missed clinically significant cancer.

Source: NCCN [2].

Active Surveillance patient (known low-risk cancer):

Decision: MRI-targeted biopsy of index lesion + confirmatory systematic biopsy at baseline, then targeted-only for follow-up.

Rationale: Reduce sampling burden, but maintain safety early on.

Source: AUA 2023 [1], EAU [3].

• 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). Available at: nccn.org
• European Association of Urology (EAU) Guidelines on Prostate Cancer (2024 Update). Available at: uroweb.org
• Kasivisvanathan, V., et al. "MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis." *New England Journal of Medicine*, 2018. The PRECISION trial.
• Wegelin, O., et al. "The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies." *European Urology*, 2018.