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In 2013, another consensus meeting on pros­tate MRI led by Kirkham etal. took place in the United Kingdom [28]. One important recommen­dation was to wait at least 10 weeks before acquiring a post-biopsy scan to avoid MRI arte­facts. Secondly, since prostate MRI interpretation is difcult for inexperienced readers, and the learning curve is steep, the panel recommended that reporters should report at least 50 scans per year and regularly attend multidisciplinary meetings.

In 2012, the European Society of Urogenital Radiology (ESUR) proposed a standardised reporting system for prostate MRI called the Prostate Imaging Reporting and Data System (PI-RADS) [17]. Separate protocols for detec­tion, staging, and node and bone assessment were described. In terms of image interpretation and reporting, a PI-RADS score from 1 to 5 indicated the likelihood of a patient harbouring csPCa on each MRI sequence (T2-WI, DWI, DCE, and

Table 14.2 Comparison between use of a 5-point Likert scale and PI-RADS v2.1 for reporting prostate MRI

Once PCa has been diagnosed, it is also crucial to determine whether the cancer has spread beyond the prostatic capsule. EPE is an important indica­tor of PCa aggressiveness and is an independent predictor of biochemical recurrence (BCR)-free survival [67–70]. Although PI-RADS addresses various features of EPE such as tumour contact length, irregularity, bulging, gross extension, and loss of rectoprostatic angle, it does so in a vague way and does not assign relative predictive values to these features [71]. Therefore, in 2019 Mehralivand et al. proposed a 3-point grading system for predicting the likelihood of EPE: Grade 1 refers to tumours with a contact length≥1.5cm or contour bulge or irregularity; Grade 2 refers to tumours with a contact length≥1.5cm and contour bulge or irregularity; and Grade 3 refers to gross visible extension beyond the prostate [22]. They tested their scor­ing system on 553 patients who underwent mpMRI prior to RP and found Grade 1, Grade 2, and Grade 3 had sensitivities of 24%, 36%, and 66%, respectively, for the detection of EPE on histopathology [22]. They noted that incorporat­ing PSA level and Gleason score improved per­formance, but made no suggestions on how these should be added to the scoring system [22].

Other studies looked at the diagnostic perfor­mance of 5-point Likert scales for assessment of EPE [23, 72, 73]. In a study on 89 patients by Freifeld et al., whole-mount histopathology revealed organ-conned PCa, EPE, and SVI in 49%, 46%, and 18% of patients, respectively. They found that PPV for scores of 4 or 5 was 64% for EPE and 90% for SVI and the negative predictive value for scores of 1 or 2 was 87% for EPE and 93% for SVI.Reisaeter etal. compared Likert and 3-point EPE grading systems on more than 300 patients and found that the 3-point scale performed better [72]. The average sensitivity