Response to the Letter by Carey and Kommu: ‘Generating a consensus on the follow‐up of multifocal high‐grade prostate intraepithelial neoplasia’

I appreciate the interest of Carey and Kommu in establishing a consensus on the follow-up of multifocal high-grade intraepithelial neoplasia (HGPIN) in the context of a negative prostate biopsy, at a time when early diagnosis of prostate cancer (PCa) has become focused on clinically significant PCa (csPCa), owing to the widespread use of MRI and targeted biopsies of lesions with a Prostate Imaging-Reporting and Data System (PI-RADS) score ≥3 [1]. In Europe, we benefit from excellent PCa guidelines, which assign grades of recommendation based on the most recent scientific evidence across most clinical scenarios. In the latest 2026 version, repeat biopsies after detection of atypical small acinar proliferation (ASAP) and HGPIN are addressed in section 5.7.1, page 51. This is addressed in only a brief paragraph and cites references that are not contextualised within the MRI era: ‘In a contemporary series of biopsies, the likelihood of finding a csPCa after follow-up biopsy after a diagnosis of atypical small acinar proliferation and high-grade prostatic intraepithelial neoplasia (PIN) was only 6–8%, not significantly different from follow-up biopsies after a negative biopsy [476, 477]. Therefore, routine re-biopsies in this setting are not required’ [2]. Following our paper referenced in this ‘Letter to the Editor’, which was the first analysis of prostate re-biopsy in men with previous HGPIN and MRI evaluation, at least two further studies have addressed when prostate biopsy should be repeated after identifying HGPIN in the context of a negative prostate biopsy, confirming our findings [3, 4]. We hope that in the next edition of the European PCa guidelines, the recommendation to repeat prostate biopsy will be updated to reflect current practice, in which predictive factors for csPCa persist, particularly high PI-RADS and other independent predictive variables that allow individual risk stratification, as defined in the Barcelona csPCa risk calculator (https://bcnrc.com), derived from the Barcelona MRI predictive model (BCN-MRI PM). The author has no conflict of interest associated with this submission. Research data are not shared.