Today’s world of prostate cancer diagnosis and treatment is not your grandfather’s world. Many factors have transformed it, such as new insights into cancer’s biology, or revolutionary treatment methods. Even so, today’s patients are as anxious as past generations. They worry about potentially painful tests, and they fear bad results. But, thanks to advanced imaging, fear is becoming a thing of the past. If there’s a key innovation that has improved life for patients, it’s 3T multiparametric MRI (3T mpMRI).

3T mpMRI is a powerful, noninvasive high-resolution imaging that gives your doctor a 3-D portrait of your prostate gland. Imagine that your doctor has Superman’s X-ray vision. When administered and interpreted by an expert team, this prostate scan gives your doctor accurate advance information. It gives your doctor a valuable advantage. He can now determine which next steps, if any, are necessary.

Dr. Dan Sperling, a pioneer in 3T mpMRI of the prostate, is a leading expert in 3T mpMRI, which has transformed the world of prostate cancer (PCa). He developed proprietary 3T Multi-Parametric MRI – BlueLaser™ solutions. As an early adopter of AI-integrated MRI imaging, Dr. Sperling—along with his experienced team—can offer you the most accurate tumor detection, targeted diagnosis (MRI-Guided Biopsy; prostate mapping, and treatment), and precision MRI-guided focal therapies.

In addition to the high-definition visual portrait of your prostate and the diagnostic performance of real-time MRI-guided targeted biopsy, two scoring systems based on imaging and biopsy samples guide treatment planning. If treatment is required, Dr. Sperling helps you navigate to a treatment that is tailored to your disease as well as your lifestyle. This means excellent cancer control while preserving the quality of life you want. Read on to learn the details of how 3T mpMRI has changed the field of PCa diagnosis and treatment.

For your personal situation, request a consultation.

Out with the old, in with the new: mpMRI rewrites diagnosis

Gone is the traditional diagnostic pathway that went straight from a suspicious PSA blood test result to a blind prostate biopsy using 12 or more needles guided by transrectal ultrasound (TRUS). Instead, the new standard of care follows a suspicious PSA test with mpMRI. The former rush-to-biopsy approach had a significant error rate, leading to overdiagnosis and overtreatment of insignificant PCa. In turn, many over-treated patients were left with urinary and sexual side effects. No wonder patients feared the PSA test and biopsy. Now, however, international data shows that when mpMRI is negative for PCa, biopsy can safely be avoided; monitoring then continues using combination PSA + mpMRI. With Sperling Prostate Center’s mpMRI as the cornerstone of today’s new patient-centered care, all signs of prostate problems, whether cancerous or not, are revealed. Diagnosis and treatment follow accordingly.

Limitations of PSA and blind TRUS biopsy

The PSA (prostate specific antigen) test is often misleading. Its chief limitation is that it is not cancer-specific. A higher-than-normal PSA is a message that something unusual is going on—but it could be any number of things besides cancer: irritation, infection, activity that stimulates the gland (e.g., bike riding, having sex), even a normal aging-related enlargement called BPH (benign prostatic hyperplasia). Don’t panic, and don’t rush to biopsy. Instead, follow a suspicious PSA with mpMRI for a visual evaluation.

Besides PSA, standard TRUS biopsy also has limitations. Unlike mpMRI, ultrasound cannot clearly distinguish normal prostate tissue from cancerous tissue. Since the tumor is not visible on ultrasound, the doctor doesn’t know where to aim. Instead, he/she uses 12 or more needles to randomly sample prostate tissue according to a systematic pattern. It’s called a blind biopsy. False negative rates (missing a tumor) are estimated at 15-46%. Diagnostic undergrading rates are as high as 40% (only picks up less aggressive cells, leading to undertreatment and risk of recurrence). On the other hand, Dr. Sperling’s MRI-targeted biopsy method uses real-time mpMRI to identify the location, size and shape of a suspected tumor. Then, only a few needles are placed, targeting the numbed prostate where the most dangerous cells are harbored. This greatly minimizes infection and bleeding risks associated with blind TRUS biopsy, while maximizing accurate diagnosis of the tumor’s true nature for treatment planning. Plus, minimalist real time MRI-targeted biopsies have faster recovery, minimal bleeding, and same-day return to routine benefits vs. 12+ needle biopsies.

Real time, in-bore MRI-targeted biopsy is more accurate than TRUS or fusion-guided biopsy. Studies show that in-bore MRI-guided biopsy detects roughly 16-20% more clinically significant cancers (potentially life-threatening) while avoiding overdetection of clinically insignificant cancers (potentially non-life-threatening). Note: Insignificant PCa is frequently over-treated by surgery or radiation with risk of urinary, sexual or bowel side effects when less aggressive options have comparable success rates with minimal-to-no risk of side effects.

Thus, mpMRI excels at

• Clarifying PSA result,
• Determining if a biopsy is needed
• If needed, directing only a minimum number of needles precisely to the tumor under live MRI, with advantages (least invasive, fastest recovery, highest accuracy)

Be aware that “fusion biopsy”, wrongly called MRI-guided biopsy, does not substitute for real-time mpMRI because it incorporates previously captured (not live) MRI scans with real time blind TRUS.

Explaining 3T multiparametric MRI

To understand how 3T mpMRI works, let’s break it down.

“3T” stands for 3 Tesla. The strength of the magnet is measured in Tesla. Medical MRI was first done on 1.5T equipment, which all hospitals and imaging centers have. Now, 3T magnets are gradually replacing previous magnets because their higher power gives superior images. Image clarity is measured by what is called the signal to noise ratio, or SNR. Here’s a comparison between 1.5T and 3T.

Feature	1.5T MRI	3T MRI
Signal-to-Noise Ratio (SNR)	Lower SNR; may require endorectal coil for adequate resolution	Higher SNR (approximately twice that of 1.5T); allows for better image quality without coil
Scan Time	Longer scan times to achieve diagnostic image quality	Shorter scan times due to higher signal efficiency
Lesion Detectability	Good for detecting larger lesions; smaller lesions may be missed	Improved detection of small and anterior lesions; better differentiation of prostate zones

“Multiparametric” literally means multiple parameters, or imaging sequences. Dr. Sperling relies on three research-proven sequences that define a tumor’s characteristics. They are:

• T2 weighted MRI (here T stands for Time, not Tesla) shows the anatomy of the prostate, including its 3 inner zones, and any mass that could be significant PCa
• Diffusion weighted imaging (DWI) reveals normal tissue vs. tumor tissue. PCa tumor cells differ from healthy cells. They are so dense that they restrict the motion of water molecules. The DWI parameter shows the area(s) of cancer that restrict motion.
• Dynamic contrast-enhanced (DCE) parameter verifies the findings of the above two sequences by highlighting tumor blood flow. Tumors build chaotic blood vessels to supply their own needs for oxygen and nutrients, so this parameter identifies abnormal blood flow.

Dr. Sperling’s proprietary BlueLaser™ MRI protocol is done on his Center’s state-of-the-art 3T magnet. In addition to applying all three parameters, Dr. Sperling has been on the leading edge of using specialized AI software for a level of image-based detection faster and with higher accuracy than the human eye.

Prostate biopsy alternative: can MRI alone be enough?

Some patients wonder why a needle biopsy would be necessary since 3T mpMRI can reveal suspicious areas. They ask, “If you can see a tumor, why not just go ahead and develop a treatment plan?” It’s a good question, but it’s not that simple. There are many PCa cell lines, with several stages in a tumor’s development and aggression level. No two PCa tumors are identical, and no two patients have exactly the same anatomy or other clinical factors (age, family history, co-existing health conditions, etc.) There are also more treatment methods today than at any time in history, so Dr. Sperling customizes planning to each patient. Therefore, examining tumor cells under a microscope is necessary to assess their aggression level. Then, coupled with mpMRI results, a definitive diagnosis is given. Thus, a biopsy is needed in order to plan treatment. However, 3T mpMRI plays a key role before biopsy.

1. As already described, imaging before biopsy determines if a biopsy is needed. Studies show that 30-40% of men will have a negative MRI and can safely avoid biopsy at the time—but monitoring is ongoing with future PSA + MRI.
2. If imaging shows an area suspicious for clinically significant PCa that requires treatment, Dr. Sperling uses real-time mpMRI to target a minimal number of biopsy needles into the core of the area. This approach has minimal risk of biopsy-related side effects yet gives the most accurate diagnosis. It is superior to fusion-guided biopsy because the MRI is live and real time.

It’s important to note that professional medical societies like the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) emphasize the importance of shared decision-making between doctor and patient. At the Sperling Prostate Center, Dr. Sperling and team review each mpMRI result with you, so you understand your PCa risk level. Based on your images and your personal preference, Dr. Sperling helps you navigate to an appropriate treatment choice that will feel right.

Key tests every man should know

Let’s return to the concept that each patient’s PCa is truly unique to that individual. No longer is there a cookie-cutter approach to treating PCa. In addition to imaging and mpMRI-targeted biopsy, there are additional sophisticated tests for biomarkers. These are biological substances in blood, urine, tissue and tumor cells that offer additional information about PCa risk, giving important clues for matching treatment to disease. Note that genomic tests need tissue samples because they analyze the presence or absence of gene variants that influence tumor behavior, helping predict PCa risk level. Here are key approved or certified tests you should know about.

Blood sample tests	PSA density (PSA-D) Using the same blood sample for a PSA test, PSA-D is more specific for PCa. Combined with mpMRI, the PSA-D score increases the probability that PCa is present. Prostate Health Index (PHI) More specific for PCa than PSA 4K Score Predicts risk of aggressive PCa before biopsy
Urine sample tests (after prostate massage by doctor)	PCA3 Helps decide on repeat biopsy in men with previous negative biopsy SelectMDxClarifies risk level for high-grade PCa
Tissue sample tests (biopsy or prostate specimen after surgery)	ConfirmMDx Helps rule out PCa in men with negative biopsy Oncotype DXAssess aggression level in early stage PCa based on genomic analysis ProlarisEvaluate tumor aggression and mortality risk based on genomic analysis DecipherUses prostatectomy specimen analysis to predict risk of recurrence and metastasis after surgery, guides treatment decisions

negative mpMRI (PI-RADS 1–2, low PSA density) may allow men to defer biopsy.

Which test or combination of tests gives the most accurate prostate cancer results?

This table offers an at-a-glance comparison to test accuracy rates. Sensitivity means correctly identifies patients who have PCa. Specificity means correctly identifies patients who do NOT have PCa. csPCa means clinically significant prostate cancer, the most important PCa to detect.

Method	Sensitivity (%)	Specificity (%)	Notes
PSA (≥4 ng/mL cutoff)	20–80	20–40	High false-positive rate; detects many benign conditions.
mpMRI (PI-RADS ≥3)	80-95	40-70	Good for detecting clinically significant cancer (csPCa); expert readers are more accurate than less experienced readers
MRI-targeted biopsy (fusion or cognitive guidance based on prior MRI scans)	85-95	70-90	More accurate than systematic TRUS biopsy for csPCa; misses some low-grade cancers.
Systematic TRUS biopsy	60-80	50-70	Lower yield for csPCa; can miss anterior or small lesions.
mpMRI + real time MRI-targeted biopsy	90-97	70-90	Highest detection rate for csPCa; reduces overdiagnosis of insignificant cancer.

Thus, mpMRI followed by in-bore targeted biopsy delivers the highest accuracy while sparing healthy tissue.

Scoring systems: good to know

As mentioned previously, there are two systems to score PCa that predict the cancer’s risk level. One is based on mpMRI scans, the other is based on biopsy core samples.

PI-RADS (Prostate Imaging Reporting and Data System)

PI-RADS is a standardized rating scale for the likelihood that clinically significant prostate cancer (PCa) is present. It is a 5-number system, from least likely to most likely. The most recent version (PI-RADS 2.1) has clear criteria for administering and interpreting each parameter and generating a total score. It rules biopsy need in or out, and informs treatment strategy if PCa is diagnosed by biopsy. Studies show that expert readers like Dr. Sperling are more accurate than inexperienced readers.

PI-RADS 1	Clinically significant cancer is highly unlikely to be present. Very low risk.
PI-RADS 2	Clinically significant cancer is unlikely to be present. Low risk.
PI-RADS 3	Clinically significant cancer may or may not be present (gray zone). Intermediate risk.
PI-RADS 4	Clinically significant cancer is likely to be present. High risk.
PI-RADS 5	Clinically significant cancer is highly likely to be present. Very high risk.

What do PI-RADS scores mean?

The PI-RADS score can make the difference between biopsy not needed (PI-RADS 1 or 2) or biopsy needed (PI-RADS 3, 4 or 5). Studies show that, with mpMRI and PI-RADS, up to 50% of patients will not need a biopsy at the time of the scan.

Guidelines recommend a biopsy for PI-RADS scores of 4 (high risk) or 5 (very high risk). PI-RADS 3 lesions may warrant further investigation, like additional testing, before a biopsy, while scores of 1 and 2 typically do not require biopsy unless other risk factors are present. Dr. Sperling’s protocol includes a biopsy starting at PI-RADS 4, unless additional clinical factors suggest otherwise.

While the PI-RADS score guides treatment decision-making, before choosing a treatment it’s important to take other factors into account, such as tumor size (lesions greater than 8.5 mm carry higher risk), PSA-D, family history, and any biomarker tests that may have been done.

Dr. Sperling emphasizes the importance of timely targeted biopsy. The sooner clinically significant PCa is treated, the greater the likelihood of success, especially in cases of PI-RADS 4 and PI-RADS 5. For example, for PI-RADS 5 tumors, the 5-year metastasis free survival rate drops by 15-20%.

For PI-RADS 4 or PI-RADS 5 patients, when all clinical factors have been taken into account, Dr. Sperling will discuss if the patient is a candidate for a focal treatment (alternative to whole gland surgery or radiation). Focal treatment (destroy the tumor while sparing healthy prostate tissue) offers excellent cancer control with low to very low risk of urinary or sexual side effects. It leaves all treatment options open if PCa recurs. For more information, request a consultation.

Gleason scores and Grade Groups

Gleason scores describe cancer aggressiveness based on tissue patterns, complementing PI-RADS imaging. Designed by a pathologist who recognized 5 different patterns (grades) of PCa cells as seen under a microscope. Each pattern is given an individual grade from 1-5.

• 1 – Normal
• 2 – Not so normal (suspicious of cancer)
• 3 – Cancer (does not look dangerous)
• 4 – Cancer (suspicious of danger)
• 5 – Cancer (definitely dangerous)

However, the individual grade is not the same as the Gleason score. Gleason score is always shown as the sum of 2 grades (e.g., 3+4=7) based on the 2 largest proportions of the most aggressive pattern in each biopsy needle sample. Also, Gleason grades 1 and 2 are never reported, so the lowest Gleason score is 3+3=6, which sounds high even though it’s actually low. This can confuse patients, so a new 5-level Grade Group (GG) system was devised. Here is how the two systems stack up and what risk level they indicate.

Grade Group (GG)	2-number Gleason Equivalent	PCa Risk Level
Grade Group 1	Gleason score ≤ 6	Low
Grade Group 2	Gleason score 3 + 4 = 7	Intermediate favorable
Grade Group 3	Gleason score 4 + 3 = 7	Intermediate unfavorable
Grade Group 4	Gleason score 8	High
Grade Group 5	Gleason score 9–10	Very high

IMPORTANT: When mpMRI is done before biopsy, the PI-RADS score is based on the probability that significant PCa is present, which then indicates need for a biopsy. PI-RADS is therefore not the same as a diagnosis, which can only be obtained by biopsy. The biopsy then gives a Gleason score or Grade Group, and it is the diagnosis that determines treatment choices. However, information from the MRI scan itself is important for planning treatment because of the visual portrait it provides that a biopsy alone can’t. One way to think of it is mpMRI and biopsy-proven PCa work hand-in-hand. The mpMRI shows the size, shape and location of the tumor, and the biopsy says how dangerous the cells are. Like putting puzzle pieces together to get an entire picture, assembling all the information (mpMRI, biopsy, biomarker/genomic data, other risk factors, and patient preference/lifestyle) gives the doctor and patient a high degree of confidence in forming a treatment plan tailored to the patient’s disease and quality of life.

If a patient’s PCa is diagnosed as localized—that is, still contained in the prostate—here are general treatment guidelines for each risk level up to Gleason 8/GG 4. (GG 4 and 5 are not included here because they require more aggressive treatment.) Ultimately, the doctor will determine best management choice(s) for each case.

GG	Gleason Score	Common Treatment Options	10-Year PCa-Specific Survival Rate*
GG 1	≤ 6 (3+3)	Active surveillance Focal therapy Whole gland treatment	>99%
GG 2	3+4=7	Active surveillance Focal therapy Whole gland treatment	~95–99%
GG 3	4+3=7	Focal therapy Aggressive whole gland treatment	~85–95%

^*The 10-year survival averages shown are specific for PCa, not all-cause mortality.

When a high Gleason score meets a high PI-RADS score

In cases where GG 4 or 5 is accompanied by PI-RADS 5, treatment planning must be based on thorough diagnostic factors to rule out advanced or metastatic disease, which may require both local as well as systemic treatment. For patients considering nerve-sparing prostatectomy, precise imaging is necessary to rule out tumor involvement close to the nerves.

Choosing an MRI-guided prostate center

National PCa patient education/advocacy groups recommend that patients carefully research imaging facilities and their medical staff before selecting one. Three qualifies to look for are accurate imaging, experienced reader(s) for skilled interpretation, and patient-centered care. Consider confirming

• The center does over 200 prostate MRIs per year
• The scanners are 3T magnets equipped for multiparametric imaging
• The readers use PI-RADS 2.1 to score images
• The radiologists have fellowship-level training
• The facility adheres to infection-control protocols

Questions to ask

• “How many MRI-targeted biopsies does your team perform yearly?”
• “What focal therapies are available on-site?”
• “How soon will I receive my PI-RADS report?”
• “Who explains results and next steps to me?”

Much information is available on the internet. For instance, search for “top-rated prostate cancer testing services” or “top-rated prostate imaging facilities.” Visit facility websites to explore their services and access physician and team profiles. Look for physician board certification and licensure, patient testimonials and outcome data.

Frequently asked questions

Q: Can mpMRI replace biopsy?
A: PCa can only be definitively diagnosed by a biopsy to take tissue samples. However, A negative mpMRI (PI-RADS 1–2) plus low PSA density (PSA-D) may let many men safely defer biopsy (but continue to monitor using PSA, PSA-D, and mpMRI as scheduled), but high-risk features still warrant tissue confirmation.

Q: How soon can I return to daily activities after an in-bore MRI-guided biopsy?
A: Most patients resume normal routines, including work and light exercise, within 24 hours because only a few targeted cores are taken.

Q: Is MRI safe if I have metal implants or a pacemaker?
A: Modern MRI-conditional devices are generally compatible, but always provide implant documentation so the safety team can confirm eligibility.

 
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.