Abstract
I read with great interest the study by Avolio et al. evaluating the role of tumor volume ratio (TVR) in predicting clinically significant prostate cancer (csPCa) in patients undergoing transperineal prostate biopsy (PBx). The authors are to be commended for addressing an important clinical question and proposing a practical, imaging-based metric to improve biopsy decision-making in the era of multiparametric magnetic resonance imaging.
The study highlights TVR as an independent predictor of csPCa, with stronger predictive value than prostate-specific antigen density (PSAD) in multivariate analysis. Notably, a TVR cutoff of 0.23 would have avoided 46% of PBx procedures. However, it would have missed 26 cases of csPCa, which the authors describe as 10% of the overall cohort. While numerically correct, this presentation underrepresents the clinical impact: 21% of csPCa cases (26/119) would have been missed—an arguably substantial proportion.
Furthermore, according to the European Association of Urology guidelines, a missed csPCa rate of 5%–10% is generally considered acceptable when using risk-based biopsy strategies. 1 Yet, in this study, none of the tested TVR thresholds met this criterion: the proportion of missed csPCa cases ranged from 16% to 39% (see article’s Table 3). This raises concern regarding the clinical applicability of TVR as a standalone decision-making tool, particularly when aiming to adhere to contemporary standards of cancer detection safety.
Although TVR outperformed PSAD in multivariate analysis, PSAD remains a well-established and easy-to-calculate parameter in routine practice. 2 Exploring whether a combined metric or decision model integrating both TVR and PSAD could enhance predictive performance—especially in equivocal Prostate Imaging Reporting and Data System (PI-RADS) 3 lesions—may be a valuable next step.
I also encourage the authors to provide additional subgroup analyses, such as International Society of Urological Pathology (ISUP) grade stratification of missed csPCa cases and tumor zone localization, to better contextualize biopsy deferral risk.
Overall, this study contributes meaningfully to personalized PCa diagnostics. I congratulate the authors and look forward to further multicenter validation of TVR and its integration into clinical practice.
Sincerely.