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Eur Urol. 2017 Aug;72(2):250-266. doi: 10.1016/j.eururo.2017.02.026. Epub 2017 Mar 21.

What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy? A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel.

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Hospices Civils de Lyon, Department of Urinary and Vascular Radiology, Hôpital Edouard Herriot, Lyon, France.
Department of Urology, University Hospitals Leuven, Leuven, Belgium; Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium.
European Association of Urology Guidelines Office, Brussels, Belgium.
Department of Urology, Coimbra University Hospital, Coimbra, Portugal.
Bladder Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
Department of Radiation Therapy, CHU Grenoble, Grenoble, France.
Patient Advocate, Hasselt, Belgium.
Academic Urology Unit, University of Sheffield, Sheffield, UK.
Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy.
Department of Urology, University of Bern, Inselspital, Bern, Switzerland.
Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK.
Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands.
N.N. Blokhin Cancer Research Center, Moscow, Russia.
University of Warwick, Cancer Research Centre, Coventry, UK.
Department of Radiology & Nuclear Medicine, Erasmus MCUniversity Medical Center, Rotterdam, The Netherlands; Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany.
Division of Gastroenterology and Cochrane UGPD Group, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, Canada.
Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK.
Department of Urology, University Hospital, St. Etienne, France.
Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK.
Hospices Civils de Lyon, Department of Urinary and Vascular Radiology, Hôpital Edouard Herriot, Lyon, France; Université Lyon 1, faculté de médecine Lyon Est, Lyon, France. Electronic address:



It remains unclear whether patients with a suspicion of prostate cancer (PCa) and negative multiparametric magnetic resonance imaging (mpMRI) can safely obviate prostate biopsy.


To systematically review the literature assessing the negative predictive value (NPV) of mpMRI in patients with a suspicion of PCa.


The Embase, Medline, and Cochrane databases were searched up to February 2016. Studies reporting prebiopsy mpMRI results using transrectal or transperineal biopsy as a reference standard were included. We further selected for meta-analysis studies with at least 10-core biopsies as the reference standard, mpMRI comprising at least T2-weighted and diffusion-weighted imaging, positive mpMRI defined as a Prostate Imaging Reporting Data System/Likert score of ≥3/5 or ≥4/5, and results reported at patient level for the detection of overall PCa or clinically significant PCa (csPCa) defined as Gleason ≥7 cancer.


A total of 48 studies (9613 patients) were eligible for inclusion. At patient level, the median prevalence was 50.4% (interquartile range [IQR], 36.4-57.7%) for overall cancer and 32.9% (IQR, 28.1-37.2%) for csPCa. The median mpMRI NPV was 82.4% (IQR, 69.0-92.4%) for overall cancer and 88.1% (IQR, 85.7-92.3) for csPCa. NPV significantly decreased when cancer prevalence increased, for overall cancer (r=-0.64, p<0.0001) and csPCa (r=-0.75, p=0.032). Eight studies fulfilled the inclusion criteria for meta-analysis. Seven reported results for overall PCa. When the overall PCa prevalence increased from 30% to 60%, the combined NPV estimates decreased from 88% (95% confidence interval [95% CI], 77-99%) to 67% (95% CI, 56-79%) for a cut-off score of 3/5. Only one study selected for meta-analysis reported results for Gleason ≥7 cancers, with a positive biopsy rate of 29.3%. The corresponding NPV for a cut-off score of ≥3/5 was 87.9%.


The NPV of mpMRI varied greatly depending on study design, cancer prevalence, and definitions of positive mpMRI and csPCa. As cancer prevalence was highly variable among series, risk stratification of patients should be the initial step before considering prebiopsy mpMRI and defining those in whom biopsy may be omitted when the mpMRI is negative.


This systematic review examined if multiparametric magnetic resonance imaging (MRI) scan can be used to reliably predict the absence of prostate cancer in patients suspected of having prostate cancer, thereby avoiding a prostate biopsy. The results suggest that whilst it is a promising tool, it is not accurate enough to replace prostate biopsy in such patients, mainly because its accuracy is variable and influenced by the prostate cancer risk. However, its performance can be enhanced if there were more accurate ways of determining the risk of having prostate cancer. When such tools are available, it should be possible to use an MRI scan to avoid biopsy in patients at a low risk of prostate cancer.


Multiparametric magnetic resonance imaging; Prostate biopsy; Prostate cancer; Risk stratification

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