INCREASING prostate volume is associated with significantly lower prostate cancer detection rates using MRI–ultrasound (MRI–US) fusion-guided biopsy, according to a new study, highlighting the need to consider gland size when planning diagnostic strategies.
MRI–US fusion biopsy has become an important tool in prostate cancer diagnosis, combining multiparametric MRI findings with targeted ultrasound-guided sampling. However, enlarged prostate glands may present diagnostic challenges due to reduced specificity of prostate-specific antigen (PSA), anatomical changes within the transition zone, and potential difficulties achieving accurate tissue sampling.
Researchers investigated whether prostate volume influences cancer detection outcomes following fusion biopsy, analysing data from 1,203 patients who underwent MRI–US fusion-guided biopsy between 2014 and 2023. Patients were grouped according to prostate size, ranging from less than 30 mL to 120 mL or greater, and detection rates for overall prostate cancer and clinically significant prostate cancer (csPCa) were assessed.
Prostate Volume Affects MRI–Ultrasound Biopsy Accuracy
Overall, prostate cancer was detected in 62.0% of patients, with 39.5% diagnosed with clinically significant disease. However, detection rates declined progressively as prostate volume increased.
Patients with prostates smaller than 30 mL had the highest overall cancer detection rate at 82.3%. This fell to 67.1% in prostates measuring 30–54.9 mL, 50.2% in 55–79.9 mL, 48.5% in 80–119.9 mL, and just 28.9% in prostates measuring 120 mL or more.
A similar pattern was observed for clinically significant prostate cancer detection, which decreased from 59.4% in the smallest prostate group to 24.4% among patients with the largest glands.
Cancer Detection Declines Across PI-RADS Categories
Further analysis showed that prostate volume remained an independent predictor of cancer detection after adjustment for other factors. Detection rates decreased with increasing gland size across all PI-RADS categories, suggesting that larger prostates may reduce the sensitivity of MRI-guided diagnostic approaches.
Among patients with PI-RADS 5 lesions, cancer detection decreased from 87.1% in prostates below 50 mL to 69.2% in prostates above 100 mL. Similar reductions were observed for PI-RADS 4 and PI-RADS 3 lesions.
The study also found that larger prostates were associated with a greater proportion of anterior lesions and fewer positive digital rectal examinations, potentially contributing to diagnostic difficulty.
Findings Highlight Need for Tailored Biopsy Strategies
The authors concluded that prostate volume should be incorporated into clinical decision-making when assessing patients undergoing MRI–US fusion biopsy. Larger glands may require adapted sampling approaches to improve cancer detection and reduce the risk of missed clinically significant disease.
These findings emphasise the importance of personalised diagnostic pathways for men with enlarged prostates and suspected prostate cancer.
Reference
Franz T et al. Are big prostates a challenge? Correlation between prostate volume and detection rate in fusion biopsy of the prostate. Adv Urol. 2026;DOI: 10.1155/aiu/5999882.
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