Validation of the work using a wider range of PCa patients and MRI from multiple vendors

The gap

Evidence profile

Sourced from the limitations and future work and recommendations and future-work section of the source papers, classified as general, drawn from work published between 2025 and 2026, spanning 3 journals. Those papers have been cited 8 times in total.

Supporting evidence — 4 representative gaps

• Diagnostic Accuracy of Diffusion-Weighted Imaging and PSA for Prostate Carcinoma Using Histopathology as the Gold Standard: A Cross-Sectional Study (2026) · Journal of Medical Research and Surgery · doi

  The early and accurate detection of PCa is central to improving patient outcomes and reducing unnecessary treatment-related morbidity. Serum Prostate-Specific Antigen (PSA) has been the primary screening biomarker for several decades; however, including poor it suffers from well-recognized specificity, as PSA elevations may arise from benign prostatic hyperplasia (BPH), prostatitis, or other non-malignant conditions. Reliance on PSA alone to trigger biopsy has historically resulted in 40–65% of performed biopsies being redundant, exposing patients unnecessarily to the risks of bleeding, infection, pain, and psychological distress, while simultaneously leaving up to 30% of clinically significant PCa undetected due to the inherent sampling limitations of Transrectal Ultrasound (TRUS)-guided systematic biopsy. These shortcomings have catalyzed the search for non-invasive functional imaging techniques capable of more precisely characterizing prostatic lesions before a histopathological decision is made. J Med Res Surg, ISSN: 2582-9572 Page 57 of 62 Volume 7 • Issue 3 • 208Citation: Panhwer U, Shaikh A, Khattri Y, et al. Diagnostic Accuracy of Diffusion-Weighted Imaging and PSA for Prostate Carcinoma Using Histopathology as the Gold Standard: A Cross-Sectional Study. J Med Res Surg. 2026;7(3):57-62.

  generallimitationsevidence 5/5
  Keywords: imaging prostate prostatic biopsy surg early accurate detection central improving patient outcomes reducing unnecessary treatment
• European Society of Urogenital Radiology (ESUR) perspectives on the role of prostate MRI in active surveillance (2026) · Insights into Imaging · doi

  The success of AS hinges on oncological safety, accept- follow-up protocols to patients, and clear ability of pathways follow-up, and intervention. for Notwithstanding the increasing agreement on the inclu- sion criteria for AS (low-risk and favourable intermediate- risk PCa), the failure rate of AS remains considerable, with approximately 30% of patients requiring active treatment at 5 years [52]. That highlights the potential for further improvements in patient stratification. While its value is still uncertain, additional biomarkers such as tumour genomic profiles may supplement baseline MRI, biopsy Ursprung et al. Insights into Imaging (2026) 17:87 Page 10 of 13 Fig. 3 Report template for prostate MRI obtained during active surveillance, including PI-QUAL, PI-RADS and PRECISE scoring. For an example of a visual report, please refer to [47] Ursprung et al. Insights into Imaging (2026) 17:87 Page 11 of 13 and PSA to better characterise PCa progression risk and help identify patients most suitable for AS [53]. advanced disease Improved personalisation of AS strategies will also require adaptation to individual risk factors. Patients in the Black community are at an increased risk of developing PCa and experiencing disease progression [54]. Simulta- neously, they are less able to access diagnostic MRI as part of AS [55]. Similarly, Asian patients are at an increased risk of at presentation. Consequently, patients considered suitable for AS according to criteria developed in predominantly Caucasian populations may be at an increased risk of undergrading and understaging. This suggests that a one-size-fits-all approach to inclusion in AS and surveillance protocols compromises the onco- logical safety and efficacy of AS. Consequently, research in more diverse populations is essential, and guidelines need to take additional patient factors into account. Variations in the role of MRI during follow-up on AS across European guidelines mirror its rapid evolution. Future prospective research will determine to what degree a combination strategy of imaging and biomarker follow- up may help reduce the frequency of protocol biopsies. Furthermore, future research needs to define how follow- up schedules can adapt to the risk of progression and how repeat imaging is triggered to achieve a high sensitivity for progressive PCa with an acceptable specificity. Standar- disation in image acquisition and interpretation is of increased importance in AS, particularly as patients may undergo imaging on various equipment and in different centres. While lesions with a decreasing apparent diffu- sion coefficient may appear more conspicuous (PRECISE 4), quantitative maps obtained from diffusion-weighted or dynamic contrast-enhanced imaging vary considerably between protocols [56]. Furthermore, if MRI is intended to partly replace invasive biopsies, the clinical significance of progressing lesions that are undetected by MRI needs to be investigated [57]. Recent research highlighted the potential of artificial intelligence to address some of the unmet clinical needs in AS, including improved patient selection and personalis- ing the intensity of follow-up examinations by predicting progression to csPCa [58]. In conclusion, this report, prepared on behalf of the entire ESUR Prostate Working Group, provides practical guidance on the role of prostate MRI during active sur- veillance, emphasising the importance of the PRECISE v2 recommendations, while recognising that further work is required to enable personalised surveillance and harmo- nise international guidelines.

  generalfuture workevidence 5/5
  Keywords: risk patients follow imaging progression increased protocols active patient report prostate surveillance precise guidelines needs
• European Society of Urogenital Radiology (ESUR) perspectives on the role of prostate MRI in active surveillance (2026) · Insights into Imaging · doi

  - Positive core ratio ≤ 50% - Cancer involvement ≤ 50%/core Offer: Cambridge Prognostic Group 1 and 2: cT1/2 AND ISUP GG 1 AND PSA ≤ 20 ng/mL OR cT1/2 AND ISUP GG 2 AND PSA ≤ 10 ng/mL Consider: Cambridge Prognostic Group 3: cT1/2 AND ISUP GG 2 AND PSA 10–20 ng/mL OR cT1/2 AND ISUP GG 3 Do not offer: Cambridge Prognostic Group 4–5: any of: ≥ cT3, ISUP GG 4/5, PSA > 20 ng/mL Inclusion: (Very) low risk: cT1/cT2a, ISUP GG 1, PSA < 10 ng/mL Favourable intermediate risk: one risk factor of cT2b/cT2c, ISUP GG 2, PSA 10–20 ng/mL AND < 50% biopsy cores positive Exclusion: cT3–cT4, ISUP GG 4 or 5, PSA > 20 ng/mL, unfavourable histology by the high negative predictive value of prostate MRI [33, 34]. Nonetheless, the optimal management of patients with negative MRI who are at a high risk of prostate cancer needs additional investigation [35]. These findings support MRI as a stratification tool, particularly in light of emerging data showing significant genomic differences between lesions sampled via MRI- targeted versus systematic biopsy [36], which may impact long-term outcomes and eligibility for AS. Despite growing evidence, MRI implementation remains incon- sistent. International consensus efforts, such as the Delphi process led by Bruinsma et al, have highlighted the per- sistent heterogeneity in terminology, risk definitions, and diagnostic workup prior to AS [37]. Cultural and practice- including physician attitudes and based differences, patient preferences, further shape MRI utilisation, as shown in recent evaluations of decision-making behaviour [38, 39]. These findings underscore the need for stan- dardised, MRI-informed pathways to ensure appropriate selection and long-term safety in AS. MRI of the prostate during active surveillance Adherence to AS varies considerably between countries and among centres in single countries [40, 41]. While adherence is particularly high in Nordic countries (e.g., in Sweden, 88% of patients diagnosed with low-risk PCa between 2020 and 2024 chose AS [42]), the latest available data from Germany show only 27% of eligible patients opt for AS [43]. The aim of AS is to differentiate the approximately 27% of patients experiencing disease pro- gression from those who can safely continue AS [11, 44]. Follow-up biopsies are key to identifying patients whose tumour was undergraded owing to sampling error at baseline or progressed. Nonetheless, biopsies are under- utilised [45]. Meta-analyses found that MRI alone is insufficiently accurate to supplant follow-up biopsies [11, 44]. However, its combination with other biomarkers may reduce the number of re-biopsies, making AS less onerous for patients [41]. Recommendations on the use and implications of serial MRI during AS vary, reflecting a paucity of evidence (Table 2). Standardised image acquisition and reporting are equally relevant in the diagnostic and AS setting. Therefore, the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) panel developed expert recommendations on conducting and interpreting serial MRI in 2016 [46], and these recommendations have been recently updated (PRECISE v2) [47]. The PRECISE score evaluates the degree of radiological change over time. A PRECISE score of 1 indicates Ursprung et al. Insights into Imaging (2026) 17:87 Page 6 of 13 Table 2 EAU and country-specific recommendations on MRI during follow-up

  generalrecommendationsevidence 5/5
  Keywords: isup risk patients prostate biopsies recommendations precise cancer cambridge prognostic group high countries follow positive
• A Multiparametric MRI and Baseline-Clinical-Feature-Based Dense Multimodal Fusion Artificial Intelligence (MFAI) Model to Predict Castration-Resistant Prostate Cancer Progression (2025) · Cancers · cited 8× · doi

  validation of the work using a wider range of PCa patients and MRI from multiple vendors - investigation of the impact of the tumor location on the model's performance - exploration of how the structural information from different anatomical regions of the prostate influences quantitative imaging analyses - development of regression models as a complement to existing classification models - systematic comparisons of different ROI delineation strategies to optimize the accuracy and reproducibility of the model

  generalfuture-work sectionevidence 5/5
  Keywords: validation work using wider range pca patients mri

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