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As the rate of clinically significant prostate cancer (csPCa) is positively correlated with PSA density (PSAd), a potential application for PSMA-guided biopsies may be men with negative MRI-first (PI-RADS-1-2) but increased PSAd. The PRIMARY scoring system, using the intraprostatic PSMA-pattern was developed and tested using [\n                      <jats:sup>68<\/jats:sup>\n                      Ga]Ga-PSMA-11 and proposed to be universal across PSMA-ligands, however no data on [\n                      <jats:sup>18<\/jats:sup>\n                      F]PSMA-1007 for biopsy guidance exists. Thus, the aim of this study was to evaluate the PRIMARY score for prostate biopsy guidance using [\n                      <jats:sup>18<\/jats:sup>\n                      F]PSMA-1007 in a prospective clinical setup.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      91 patients were prospectively enrolled for [\n                      <jats:sup>18<\/jats:sup>\n                      F]PSMA-1007 PET\/MRI, 86 of these for biopsy guidance after negative MRI or non-csPCa biopsies from PI-RADS 3\u20135 lesions and persistent suspicion of csPCa. Transperineal MRI\/ultrasound fusion target biopsies were performed predominantly from PRIMARY 3\u20135 lesions. Nine patients with PRIMARY 1\u20132 did not undergo target biopsies. CsPCa was defined as ISUP grade\u2009\u2265\u20092.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In a per patient analysis, 23.3% (20\/86) were diagnosed with csPCa. In line with previous studies, the rate of csPCa increased with higher PRIMARY score in a per lesion analysis, constituting 0% (0\/1), 0% (0\/8), 7.2% (7\/97), 60% (15\/25), and 60% (6\/10) for PRIMARY 1, 2, 3, 4, and 5 lesions, respectively. The 7.2% PRIMARY-3 lesions containing csPCa exhibited common characteristics such as anterior location or lack of well-defined separation from the peripheral zone.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>We evaluated the PRIMARY score for use with [\u00b9\u2078F]PSMA-1007 and identified benign features and potential \u201cred flags\u201d for PRIMARY-3 lesions. We found csPCa in 23.3% of patients with negative MRI or non-csPCa biopsies from PI-RADS 3\u20135 lesions and persistent suspicion of csPCa.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00259-026-08070-3","type":"journal-article","created":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T02:17:23Z","timestamp":1785291443000},"page":"7299-7312","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Prospective evaluation of the PRIMARY score using [18F]PSMA-1007 PET\/MRI in second-line prostate biopsies after negative MRI"],"prefix":"10.1007","volume":"53","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7676-2322","authenticated-orcid":false,"given":"Mads Ry\u00f8","family":"Jochumsen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lise","family":"Medrud","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andr\u00e9 H.","family":"Dias","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mette Abildgaard","family":"Pedersen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina","family":"Stilling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kirsten","family":"Bouchelouche","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Iversen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joan","family":"Fledelius","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lars Poulsen","family":"Tolbod","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louise Forsmann","family":"Gr\u00f8nnemark","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Vind-Kezunovic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Morten Heeb\u00f8ll","family":"Andersen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kasper Drimer","family":"Berg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,29]]},"reference":[{"key":"8070_CR1","doi-asserted-by":"publisher","unstructured":"Turkbey B, Rosenkrantz AB, Haider MA, Padhani AR, Villeirs G, Macura KJ, et al. 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