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Two radiologists identified 218 TZ PI-RADS 3 lesions in 128 patients on MRI and measured mean ADC; a third radiologist correlated imaging findings with whole-mount histopathology. Lesions located in the anterior apex, anterior mid-gland, or middle apex were classified as Location-risk positive; lesions with mean ADC\u2009&lt;\u20090.800\u2009\u00d7\u200910\u207b\u00b3 mm\u00b2\/s were classified as ADC-risk positive. Four virtual biopsy strategies were compared (conventional, Location-based, ADC-based, and Location\u2009+\u2009ADC-based). Outcomes included cancer detection rate (CDR), biopsy burden (performed\/avoided), clinically significant prostate cancer (csPCa) yield (detected\/missed), positive predictive value (PPV), and net benefit on decision curve analysis (thresholds, 5\u201325%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Mean age was 68\u2009\u00b1\u20095.9 years (median, 69; range, 50\u201378). Among 218 lesions, 34 (16%) were csPCa. CDR was higher in location-risk positive than negative lesions (43% [28\/65] vs. 4% [6\/153];\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) and in ADC-risk positive than ADC-risk negative lesions (47% [15\/32] vs. 10% [19\/186];\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Compared with conventional biopsy, the Location\u2009+\u2009ADC-based strategy reduced biopsies by 62% while detecting 31 of 34 csPCa lesions (91%) and missing 3 of 34 csPCa lesions (9%). Both location-informed strategies showed higher net benefit than the conventional across the evaluated thresholds.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>For TZ PI-RADS 3 lesions, combining anatomical location with an ADC threshold reduces unnecessary biopsies while preserving csPCa detection.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00261-026-05662-3","type":"journal-article","created":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T01:17:27Z","timestamp":1782955047000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Location- and ADC-based stratification of transition zone PI-RADS 3 lesions to optimize biopsy indication"],"prefix":"10.1007","author":[{"given":"Yasuhiro","family":"Enjoji","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiromi","family":"Edo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroshi","family":"Kuwamura","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taiki","family":"Nozaki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroaki","family":"Kobayashi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keiichi","family":"Ito","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kosuke","family":"Miyai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susumu","family":"Matsukuma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hiroshi","family":"Shinmoto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,2]]},"reference":[{"key":"5662_CR1","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1001\/jamaoncol.2024.5497","volume":"11","author":"CA Hamm","year":"2025","unstructured":"Hamm CA, Asbach P, P\u00f6hlmann A et al (2025) Oncological safety of MRI-informed biopsy decision-making in men with suspected prostate cancer. 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