| Summary: | The risk of misclassifying clinically significant prostate cancer (csPCa) by multiparametric magnetic resonance imaging is consistent, also using the updated PIRADS score and although different definitions of csPCa, patients with Gleason Grade group (GG) ≥ 3 have a significantly worse prognosis. This study aims to develop a machine learning model predicting csPCa (i.e., any GG ≥ 3 lesion at target biopsy) by mpMRI radiomic features and analyzing similarities between GG groups. One hundred and two patients with 117 PIRADS ≥ 3 lesions at mpMRI underwent target+systematic biopsy, providing histologic diagnosis of PCa, 61 GG < 3 and 56 GG ≥ 3. Features were generated locally from an apparent diffusion coefficient and selected, using the LASSO method and Wilcoxon rank-sum test (<i>p</i> < 0.001), to achieve only four features. After data augmentation, the features were exploited to train a support vector machine classifier, subsequently validated on a test set. To assess the results, Kruskal–Wallis and Wilcoxon rank-sum tests (<i>p</i> < 0.001) and receiver operating characteristic (ROC)-related metrics were used. GG1 and GG2 were equivalent (<i>p</i> = 0.26), whilst clear separations between either GG[1,2] and GG ≥ 3 exist (<i>p</i> < 10<inline-formula><math xmlns="http://www.w3.org/1998/Math/MathML" display="inline"><semantics><msup><mrow></mrow><mrow><mo>−</mo><mn>6</mn></mrow></msup></semantics></math></inline-formula>). On the test set, the area under the curve = 0.88 (95% CI, 0.68–0.94), with positive and negative predictive values being 84%. The features retain a histological interpretation. Our model hints at GG2 being much more similar to GG1 than GG ≥ 3.
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