PI-RADS: what is new and how to use it

The Diagnostic Value of bpMRI in Prostate Cancer: Benefits and Limitations Compared to mpMRI

Prostate cancer is the second most common cancer in men and a leading cause of death worldwide. Early detection is vital, as it often presents with vague symptoms such as nocturia and poor urinary stream. Diagnostic tools like PSA tests, ultrasound, PET-CT, and mpMRI are essential for prostate cancer management. The PI-RADS system helps assess malignancy risk based on imaging. While mpMRI, which includes T1, T2, DWI, and dynamic contrast-enhanced imaging (DCE), is the standard, bpMRI offers a contrast-free alternative using only T2 and DWI. This reduces costs, acquisition time, and the risk of contrast-related side effects but has limitations in detecting higher-risk PI-RADS 3 and 4 lesions. This study compared bpMRI's diagnostic accuracy to mpMRI, focusing on prostate volume and PI-RADS scoring. Both methods showed strong inter-rater agreement for prostate volume (ICC 0.9963), confirming bpMRI's reliability in this aspect. However, mpMRI detected more complex conditions, such as periprostatic fat infiltration and iliac lymphadenopathy, which bpMRI missed. While bpMRI offers advantages like reduced cost and no contrast use, it is less effective for higher-risk lesions, making mpMRI more comprehensive.

Management of Patients With a Negative Multiparametric Prostate MRI Examination: AJR Expert Panel Narrative Review

Multiparametric MRI (mpMRI) of the prostate aids risk stratification of patients with elevated PSA levels. Although most clinically significant prostate cancers are detected by mpMRI, insignificant cancers are less evident. Thus, multiple international prostate cancer guidelines now endorse routine use of prostate MRI as a secondary screening test before prostate biopsy. Nonetheless, management of patients with negative mpMRI results (defined as PI-RADS category 1 or 2) remains unclear. This AJR Expert Panel Narrative Review summarizes the available literature on patients with an elevated screening PSA level and a negative prostate mpMRI result and provides guidance for these patients' management. Systematic biopsy should not be routinely performed after a negative mpMRI examination in patients at average risk but should be considered in patients at high risk. In patients who undergo PSA screening rather than systematic biopsy after negative mpMRI, clear triggers should be established for when to perform a repeat MRI examination. Patients with a negative MRI result followed by negative biopsy should follow their health care practitioners' preferred guidelines concerning subsequent PSA screening for the patient's risk level. Insufficient high-level data exist to support routine use of adjunctive serum or urine biomarkers, artificial intelligence, or PSMA PET to determine the need for prostate biopsy after a negative mpMRI examination.

Magnetic Resonance Fingerprinting: A Review of Clinical Applications

ABSTRACT

Magnetic resonance fingerprinting (MRF) is an approach to quantitative magnetic resonance imaging that allows for efficient simultaneous measurements of multiple tissue properties, which are then used to create accurate and reproducible quantitative maps of these properties. As the technique has gained popularity, the extent of preclinical and clinical applications has vastly increased. The goal of this review is to provide an overview of currently investigated preclinical and clinical applications of MRF, as well as future directions. Topics covered include MRF in neuroimaging, neurovascular, prostate, liver, kidney, breast, abdominal quantitative imaging, cardiac, and musculoskeletal applications.

Systematic Review and Narrative Synthesis of Economic Evaluations of Prostate Cancer Diagnostic Pathways Incorporating Prebiopsy Magnetic Resonance Imaging

Context

Prebiopsy magnetic resonance imaging (MRI) of the prostate has been shown to increase the accuracy of the diagnosis of clinically significant prostate cancer. However, evidence is still evolving about how best to integrate prebiopsy MRI into the diagnostic pathway and for which patients, and whether MRI-based pathways are cost effective.

Objective

This systematic review aimed to assess the evidence for the cost effectiveness of prebiopsy MRI-based prostate cancer diagnostic pathways.

Evidence acquisition

INTERTASC search strategies were adapted and combined with terms for prostate cancer and MRI, and used to search a wide range of databases and registries covering medicine, allied health, clinical trials, and health economics. No limits were set on country, setting, or publication year. Included studies were full economic evaluations of prostate cancer diagnostic pathways with at least one strategy including prebiopsy MRI. Model-based studies were assessed using the Philips framework, and trial-based studies were assessed using the Critical Appraisal Skills Programme checklist.

Evidence synthesis

A total of 6593 records were screened after removing duplicates, and eight full-text papers, reporting on seven studies (two model based) were included in this review. Included studies were judged to have a low-to-moderate risk of bias. All studies reported cost-effectiveness analyses based in high-income countries but had significant heterogeneity in diagnostic strategies, patient populations, treatment strategies, and model characteristics. Prebiopsy MRI-based pathways were cost effective compared with pathways relying on ultrasound-guided biopsy in all eight studies.

Conclusions

Incorporation of prebiopsy MRI into prostate cancer diagnostic pathways is likely to be more cost effective in than that into pathways relying on prostate-specific antigen and ultrasound-guided biopsy. The optimal prostate cancer diagnostic pathway design and method of integrating prebiopsy MRI are not yet known. Variations between health care systems and diagnostic approaches necessitate further evaluation for a particular country or setting to know how best to apply prebiopsy MRI.

Patient summary

In this report, we looked at studies that measured the health care costs and benefits and harms to patients of using prostate magnetic resonance imaging (MRI), to decide whether men need a prostate biopsy for possible prostate cancer. We found that using prostate MRI before biopsy is likely to be less costly for health care services and probably has better outcomes for patients being investigated for prostate cancer. It is still unclear what the best way to use prostate MRI is.

Diagnosis and Pathologic Reporting of Prostate Cancer in the Era of MRI-Targeted Prostate Biopsy

Historically, the detection of prostate cancer relied upon a systematic yet random sampling of the prostate by transrectal ultrasound guided biopsy. This approach was a nontargeted technique that led to the under detection of cancers at biopsy and the upgrading of cancers at radical prostatectomy. Multiparametric MRI-targeted prostate biopsy allows for an image-directed approach to the identification of prostate cancer. MRI-targeted biopsy of the prostate is superior for the detection of clinically significant prostate cancer. As this technique has become more prevalent among urologists, pathologists need to recognize how this development impacts cancer diagnosis and reporting.

Combination of PI-RADS score and PSAD can improve the diagnostic accuracy of prostate cancer and reduce unnecessary prostate biopsies

OBJECTIVES

The purpose of this study is to evaluate the diagnostic accuracy of the clinical variables of patients with prostate cancer (PCa) and to provide a strategy to reduce unnecessary biopsies.

PATIENTS AND METHODS

A Chinese cohort that consists of 833 consecutive patients who underwent prostate biopsies from January 2018 to April 2022 was collected in this retrospective study. Diagnostic ability for total PCa and clinically significant PCa (csPCa) was evaluated by prostate imaging-reporting and data system (PI-RADS) score and other clinical variables. Univariate and multivariable logistic regression analyses were performed to figure out the independent predictors. Diagnostic accuracy was estimated by plotting receiver operating characteristic curves.

RESULTS

The results of univariate and multivariable analyses demonstrated that the PI-RADS score (P < 0.001, OR: 5.724, 95% CI: 4.517-7.253)/(P < 0.001, OR: 5.199, 95% CI: 4.039-6.488) and prostate-specific antigen density (PSAD) (P < 0.001, OR: 2.756, 95% CI: 1.560-4.870)/(P < 0.001, OR: 4.726, 95% CI: 2.661-8.396) were the independent clinical factors for predicting total PCa/csPCa. The combination of the PI-RADS score and PSAD presented the best diagnostic performance for the detection of PCa and csPCa. For the diagnostic criterion of "PI-RADS score ≥ 3 or PSAD ≥ 0.3", the sensitivity and negative predictive values were 94.0% and 93.1% for the diagnosis of total PCa and 99.2% and 99.3% for the diagnosis of csPCa, respectively. For the diagnostic criterion "PI-RADS score >3 and PSAD ≥ 0.3", the specificity and positive predictive values were 96.8% and 92.6% for the diagnosis of total PCa and 93.5% and 82.4% for the diagnosis of csPCa, respectively.

CONCLUSIONS

The combination of the PI-RADS score and PSAD can implement the extraordinary diagnostic performance of PCa. Many patients may safely execute active surveillance or take systematic treatment without prostate biopsies by stratification according to the PI-RADS score and the value of PSAD.

Biparametric MR signal characteristics can predict histopathological measures of prostate cancer

OBJECTIVES

The aim of this study was to establish a new data-driven metric from MRI signal intensity that can quantify histopathological characteristics of prostate cancer.

METHODS

This retrospective study was conducted on 488 patients who underwent biparametric MRI (bp-MRI), including T2-weighted imaging (T2W) and apparent diffusion coefficient (ADC) of diffusion-weighted imaging, and having biopsy-proven prostate cancer between August 2011 and July 2015. Forty-two of the patients who underwent radical prostatectomy and the rest of 446 patients constitute the labeled and unlabeled datasets, respectively. A deep learning model was built to predict the density of epithelium, epithelial nuclei, stroma, and lumen from bp-MRI, called MR-driven tissue density. On both the labeled validation set and the whole unlabeled dataset, the quality of MR-driven tissue density and its relation to bp-MRI signal intensity were examined with respect to different histopathologic and radiologic conditions using different statistical analyses.

RESULTS

MR-driven tissue density and bp-MRI of 446 patients were evaluated. MR-driven tissue density was significantly related to bp-MRI (p < 0.05). The relationship was generally stronger in cancer regions than in benign regions. Regarding cancer grades, significant differences were found in the intensity of bp-MRI and MR-driven tissue density of epithelium, epithelial nuclei, and stroma (p < 0.05). Comparing MR true-negative to MR false-positive regions, MR-driven lumen density was significantly different, similar to the intensity of bp-MRI (p < 0.001).

CONCLUSIONS

MR-driven tissue density could serve as a reliable histopathological measure of the prostate on bp-MRI, leading to an improved understanding of prostate cancer and cancer progression.

KEY POINTS

• Semi-supervised deep learning enables non-invasive and quantitative histopathology in the prostate from biparametric MRI. • Tissue density derived from biparametric MRI demonstrates similar characteristics to the direct estimation of tissue density from histopathology images. • The analysis of MR-driven tissue density reveals significantly different tissue compositions among different cancer grades as well as between MR-positive and MR-negative benign.

Imaging temporomandibular disorders: Reliability of a novel MRI-based scoring system

The aim of this study was to assess the inter- and intrarater reliability of a recently proposed scoring system for temporomandibular disorders (TMD), based upon radiological findings from magnetic resonance imaging (MRI). Patients with clinically suspected uni- or bilateral TMD, and subsequently conducted MRI examination of both temporomandibular joints, were included in this study. MRI data were independently evaluated by two experienced radiologists according to the DLJ scoring system proposed by Wurm et al., which includes assessment of the following categories: articular disk (prefix 'D'), direction of disk luxation (prefix 'L'), and osseous joint alterations (prefix 'J'). 60 patients (49 female and 11 male) were eligible for analysis. No significant differences were found between both observers regarding 'D' and 'L' scores (p = 0.13 and p = 0.59, respectively). Significant differences were found for the assessment of subtle osseous changes ('J0' category: p = 0.041; 'J1' category: p = 0.018). Almost perfect intra- and interrater agreements were found for 'D' and 'L' categories (intrarater and interrater agreements for 'D': κ = 0.92 and κ = 0.84, respectively; intrarater and interrater agreements for 'L': κ = 0.93 and κ = 0.89, respectively). However, the assessment of 'J' categories revealed only moderate interrater agreement (κ = 0.49). The DLJ scoring system based upon MRI findings is feasible for routine clinical TMD assessment, and may help to simplify interdisciplinary communication between radiologists and clinicians.

Coronary artery disease imaging reporting and data system (CAD-RADS): what radiologists need to know?

The aim of this work is to review Coronary Artery Disease Imaging Reporting and Data System (CAD-RADS) that was designed to standardize reporting language and improve the communication of data among radiologists and clinicians. Stenotic lesions are graded into 5 grades ranging from 0 (no stenosis) to 5 (total occlusion), where the highest grade represents the final score. The expert consensus platform has added 4 special modifiers (non-diagnostic, stent, graft, and vulnerability) to aid patient management through linking these scores with decision algorithm and treatment plan. Adherence to standard imaging protocol; knowledge of normal, variant, and anomalous anatomy; and skillful evaluation of stenosis are important for proper utilization of this reporting system. Lastly, radiologists should be aware of the inherited benefits, limitations, and common pitfalls of this classification system.

Prostate Imaging Reporting and Data System (PI-RADS): What the radiologists need to know?

We aim to review the new modifications in MR imaging technique, image interpretation, lexicon, and scoring system of the last version of Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1) in a simple and practical way. This last version of PI-RADS v2.1 describes the new technical modifications in the protocol of Multiparametric MRI (MpMRI) including T2, diffusion-weighted imaging (DWI), and dynamic contrast enhancement (DCE) parameters. It includes also; new guidelines in the image interpretation specifications in new locations (lesions located in the central zone and anterior fibromuscular stroma), clarification of T2 scoring of lesions of the transition zone, the distinction between DWI score 2 and 3 lesions in the transition zone and peripheral zone, as well as between positive and negative enhancement in DCE. Biparametric MRI (BpMRI) along with simplified PI-RADS is gaining more acceptances in the assessment of clinically significant prostatic cancer.

Prostate MRI characteristics in patients with inflammatory bowel disease

PURPOSE

Previous studies have indicated an increased risk of prostate carcinoma (PCa) associated with inflammatory bowel disease (IBD). Prostate MRI of IBD patients could be expected to show a mixture of inflammation as well as higher than normal rates of PCa, which could impact interpretation and MRI performance. The purpose of this study is to evaluate the characteristics of prostate MRI in patients with IBD.

METHODS

3140 patients with prostate MRI were evaluated. Coexisting IBD, PI-RADS score, and pathological results of prostate lesions (clinically significant PCa [csPCa]: Gleason score [GS] 7+, Non-csPCa: benign or GS 6) were assessed. The distribution of PI-RADS scoring and pathological result was assessed by chi-square test.

RESULTS

71 patients had IBD (IBD group), whereas the remaining 3069 patients did not (Non-IBD group). The proportion of abnormal MRI (PI-RADS 3, 4 or 5) was 51 % (36/71) in IBD group and 47 % (1436/3069) in Non-IBD groups (p = 0.513). Total of 1285 patients underwent biopsy or prostatectomy. The proportion of csPCa at pathology was 35 % (12/34) in IBD group and 56 % (699/1251) in non-IBD groups (p = 0.017). The positive predictive value of abnormal MRI for csPCa was significantly lower in IBD group (39 %, 19/31) compared to Non-IBD group (63 %, 657/1047) (p = 0.007).

CONCLUSION

The proportion of csPCa at pathology and positive predictive value of abnormal MR for csPCa were lower in patients with IBD group compared to Non-IBD group.

PI-RADSv2.1: Current status

Multiparametric magnetic resonance imaging (mpMRI) has played an increasing role in the detection and local staging of prostate cancer over the last 15 years. Prostate mpMRI, due to various factors, is prone to high inter-reader variability necessitating standardized reporting guidelines that provide accurate and actionable information to the ordering clinician. The Prostate Imaging-Reporting and Data System version 2.1 (PI-RADSv2.1) was released in March 2019 as an update to PI-RADSv2.0 with the hope of further standardizing the reporting process of prostate mpMRI, improving the detection of clinically significant cancer, reducing the biopsy rate of indolent tumors, and decreasing inter-reader variability. Early data show an improved performance of PI-RADSv2.1 over PI-RADSv2.0. Updates included in PI-RADSv2.1 and its current experience in clinic will be reviewed in this review.

Biomarkers in the setting of benign prostatic hyperplasia-induced lower urinary tract symptoms: what an interventional radiologist needs to know

With increasing evidence to support prostate artery embolization (PAE) in the treatment of benign prostatic hyperplasia (BPH)-induced lower urinary tract symptoms (LUTS), Interventional Radiologists have begun to play an important role in the management of these patients. One area of knowledge needed when developing a PAE practice is knowledge of prostate-specific antigen (PSA) and other biomarkers utilized to detect prostate cancer in this population and what role they should play in the work up and follow-up of patients presenting with presumed BPH-induced LUTS. Furthermore, understanding how to evaluate presumed BPH-induced LUTS and stratify the risk of prostate cancer is an important skill to develop. The goal of this review is to provide Interventional Radiologists who have begun or aim to begin a PAE practice with the information they need to know regarding PSA levels and prostate cancer risk stratification for this patient population.