The evolving role of biparametric MRI in prostate cancer detection

In this video, Veeru Kasivisvanathan, MBBS, BSc, FRCS, MSc, PGCert, PhD, discussed the clinical and logistical considerations for adopting biparametric MRI (bpMRI) in prostate cancer diagnosis. Compared with multiparametric MRI (mpMRI), bpMRI eliminates the need for gadolinium contrast, reducing demands on staffing, equipment, and consumables. This makes bpMRI implementation more feasible for many centers. The main institutional barriers are ensuring adequate scanner quality and securing radiologist consensus on moving to a bpMRI protocol. Once these issues are addressed, Kasivisvanathan noted, most centers should be able to adopt the approach.

Regarding biopsy decisions, he emphasized that systematic biopsy added little value in his study, as nearly all clinically significant cancers were already detected through targeted biopsy. He advised that suspicious areas seen on bpMRI—particularly those evident on T2-weighted and diffusion-weighted imaging—should be prioritized for targeted biopsy, consistent with PI-RADS scoring. However, lesions showing only contrast enhancement in mpMRI were rarely clinically significant, leading him to recommend caution in pursuing contrast-only abnormalities.

Kasivisvanathan also highlighted how bpMRI aligns with evolving diagnostic strategies. MRI-first pathways are now supported by level 1 evidence and incorporated into guidelines for men with suspected prostate cancer. Risk calculators that integrate MRI findings can further refine biopsy decisions and patient counseling, provided they are validated in comparable populations. Finally, he noted the potential role of artificial intelligence (AI). Current AI algorithms can process both bpMRI and mpMRI, and forthcoming trials, such as the PARADIGM study, will prospectively assess whether AI can maintain or enhance detection of clinically significant cancers while supporting streamlined MRI approaches.

Overall, Kasivisvanathan sees bpMRI as a resource-efficient, evidence-supported imaging strategy that can be integrated with modern diagnostic tools to optimize prostate cancer detection while minimizing unnecessary interventions.

REFERENCE

1. Ng ABCD, Asif A, Agarwal R, et al. Biparametric vs multiparametric MRI for prostate cancer diagnosis: The PRIME diagnostic clinical trial. JAMA. 2025 Sep 10:e2513722. doi:10.1001/jama.2025.13722