The Prostate Imaging-Reporting and Data System (PIRADS) is a widely used tool in prostate cancer diagnostics, offering a standardized approach for evaluating multiparametric MRI (mpMRI) results. Despite its effectiveness, high PIRADS scores (4/5 or 5/5) that do not correlate with positive biopsy results present significant diagnostic challenges.

This retrospective cohort study included 40 patients from our institution with high PIRADS scores (4/5 or 5/5) but negative biopsy results. Patient data were analyzed to identify factors that may influence discrepancies between PIRADS scores and biopsy outcomes.

The analysis highlighted potential gaps in the current PIRADS scoring system, emphasizing the need for additional diagnostic parameters. Preliminary findings suggest that incorporating PSA density or exploring novel contrast agents could enhance the accuracy of prostate cancer diagnostics.

In this retrospective cohort study of 40 patients with elevated PIRADS 4/5 scores but negative prostate biopsies, no cases of malignancy were confirmed, even after repeat biopsies and further imaging. These findings suggest that benign conditions — particularly fungal prostatitis, granulomatous prostatitis, and prostate tuberculosis — can mimic the imaging features of prostate cancer and lead to false-positive PIRADS scores. Importantly, some patients responded to empirical antifungal therapy with fluconazole, supporting the hypothesis that fungal prostatitis may be an underrecognized contributor to elevated PSA and suspicious MRI findings.
The results highlight the need for greater clinical awareness of fungal prostatitis and suggest that its consideration could prevent unnecessary biopsies. Additionally, the findings underline the limitations of the current PIRADS system and support the potential benefits of integrating PSA density and exploring novel MRI contrast agents like mannitol to enhance diagnostic specificity.

Modifications to the PIRADS scoring system, such as integrating PSA density or employing new contrast agents, may address the challenges associated with high PIRADS scores and negative biopsy results. These adjustments could improve the reliability and clinical utility of mpMRI in prostate cancer evaluation. To improve diagnostic accuracy and reduce the number of unnecessary biopsies to render the patient pass the stressful experience with minimum tension.

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Kelalis, L., & Hanison, E. (1965). Biopsy Diagnosis of Granulomatous Prostatitis.   Urology International  , 25(1), 11-15.
Shukla, H. G., Gulurani, H., & Kaur, S. (2017). Granulomatous Prostatitis: A Rare Mimicker of Prostate Cancer.   Prostate International  , 12(1), 1-6.