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14 A History of Reporting Standards for Prostate Magnetic Resonance Imaging: PI-RADS, PRECISE…
141
across readers was 93% for EPE using the 3-point
score versus 77% using the Likert scale. They
concluded that a Likert scale was potentially
more difcult to teach, convey, and report on than
a 3-point system with stringently dened criteria
and outcome measures [72].
Some have suggested that incorporating standardised EPE reporting into PI-RADS would be
helpful and further improve the uniformity of
mpMRI interpretations [43, 71]. Yet, one surprising aspect of the aforementioned studies was how
poor mpMRI is at predicting EPE [22, 23, 72,
73]. Even in the case of gross visible extension,
only a limited number of cases demonstrated
EPE pathologically. False-positive EPE ndings
may be due to inammation, desmoplastic reaction, and trauma-related changes from biopsy
that can lead to irregularities in the apparent margin of the tumour, [71] while false negatives may
also occur since EPE is commonly microscopic
and thus, below the detection threshold of
mpMRI [74]. However, a recent paper by
Ponsiglione et al. demonstrated that assessing
image quality using a dedicated scoring system
and only attempting to interpret adequate quality
scans can greatly improve the accuracy of both
these proposed EPE scoring systems [73].
Additionally, metastatic disease carries a
much worse prognosis and different treatment
options compared to organ-conned or locally
advanced PCa. Therefore, an international expert
panel created the METastasis Reporting and Data
System for Prostate Cancer guidelines in 2016.
These recommendations help to promote standardisation for whole-body MRI scans in
advanced PCa and to provide comprehensive
tumour characterisation both before treatment
and over time [75].
Standards forImage Quality
In 2020, a joint ESUR and EAU Section of
Urological Imaging (ESUI) consensus meeting
stressed the importance of prostate MRI image
quality [76]. Challenges around image quality
can be broadly subdivided into issues of quality
assurance (i.e. measures introduced to ensure
MRI scans are optimal quality) and quality control (i.e. radiologists assessing scan quality) [77,
78]. The growing interest in prostate MRI has led
to signicant heterogeneity in imaging protocols
and a variety of scanners and settings worldwide
[79, 80]. This has rendered quality assurance difcult and consequently led to a large focus on
improving quality control, although experts stress
the need for both initiatives [13, 76].
The Prostate Imaging Quality (PI-QUAL)
score was proposed in 2020 as the rst standardised scoring system to evaluate the quality of
prostate MRI [26]. As shown in Table 14.4,
PI-QUAL provides an overall score that ranges
from 1-to-5 by combining the PI-RADS technical
recommendations with a set of more subjective
Table 14.4 PI-QUAL scoring sheet for assessing prostate MRI image quality
PI-QUAL
score Criteria Clinical implications
1 All mpMRI sequences are below the minimum
standard of diagnostic quality
2 Only one mpMRI sequence is of acceptable diagnostic
3 At least two mpMRI sequences are taken together are
4 Two or more mpMRI sequences are independently of
5 All mpMRI sequences are of optimal diagnostic quality
ADC apparent diffusion coefcient, DCE dynamic contrast- enhanced, DWI diffusion-weighted imaging, mpMRI multi-
parametric magnetic resonance imaging, PI-RADS prostate imaging reporting and data system, T2- WI T2-weighted
imaging
a
Therefore, reports should not include PI-RADS or Likert scores
quality
of diagnostic quality
diagnostic quality
It is NOT possible to rule in all signicant
a
lesions
It is NOT possible to rule out all signicant
a
lesions
It is possible to rule in all signicant lesions
It is NOT possible to rule out all signicant
lesions
It is possible to rule in all signicant lesions
It is possible to rule out all signicant
lesions
142
C. Englman et al.
criteria, which assess the reporter’s ability to visualise specic anatomical landmarks and assess the
presence of artefacts across all sequences. After
conceiving the scoring system, Giganti etal. retrospectively applied PI-QUAL scores to MRIs
obtained in the PRECISION trial, a multicentre
randomised controlled trial that demonstrated
mpMRI-targeted biopsy was superior to standard
TRUS-guided biopsy for the detection of PCa [5].
Fifty-eight out of 252 (23%) mpMRI scans, chosen at random from each of the 22 centres in this
trial, were evaluated by two experienced radiologists, in consensus, blinded to pathology results.
Overall, mpMRI quality was of sufcient diagnostic quality (PI-QUAL≥3) for 55 scans (95%)
and of good or optimal diagnostic quality
(PI-QUAL≥4) for 35 scans (60%). Fifty-ve out
of 58 (95%) scans were of diagnostic quality for
T2-WI, followed by DWI (46/58 scans; 79%) and
DCE (38/58 scans; 66%) [26].
The use of the PI-QUAL score to assess
image quality can help to improve lesion detection, and it has now been incorporated into several studies [81–90]. Brembilla etal. found that
for PI-RADS 3 scans, those of suboptimal quality (PI-QUAL≤3), were more likely to undergo a
biopsy and less likely to harbour csPCa [81].
This is in line with a study by Karanasios etal.
that found for both negative (PI-RADS 1 and 2)
and indeterminate (PI-RADS 3) scans, those of
suboptimal quality were more likely to proceed
to biopsy and had a reduced ability to rule in or
rule out csPCa [82]. Others have assessed
PI-QUAL’s reproducibility, and results for agreement, as assessed by Cohen’s kappa (κ), have
ranged from slight [83], to moderate [84–87], to
substantial [88, 89], and even excellent [90].
Additionally, PI-QUAL can be used to improve
image quality and a recent multicentre study
using prostate MRIs from 71 scanners across 42
centres globally demonstrated that basic evaluation and modications to MRI protocols using
PI-QUAL led to substantial improvements in
image quality [91].
As with all scoring systems, limitations with
PI-QUAL have been reported [78, 92]. Currently,
PI-QUAL cannot be applied to bpMRI, despite
the growing number of centres that are using this
approach [93]. Although PI-QUAL considers all
sequences, for staging purposes, T2-WI is the
main sequence utilised for the detection of EPE
[73], and therefore, adequate image quality may
only be needed for this sequence, or it has been
pointed out that a scan with suboptimal image
quality could still be acceptable for detection in
cases of large PI-RADS 5 lesions [92]. Future
iterations of PI-QUAL are expected to address its
application for bpMRI and may also consider
adopting a simplied scale that groups scores
(i.e. PI-QUAL 1–2 vs. PI-QUAL 3 vs. PI-QUAL
4–5) since this has already shown promising
results [87, 90].
Reporting Cancer Recurrence
Both RP and RT are denitive treatments for
localised PCa. They offer long-term tumour control for most, yet for some patients, residual or
recurrent local disease can occur [94]. Previously,
the diagnosis of local relapse was largely based
on PSA levels or kinetics and BCR was observed
in about 50% of high-risk patients and about 10%
of low-risk patients within 15years following RP
[95]. For RT, BCR ranges from 15% for low-risk
patients to 67% for high-risk patients during
5years of follow-up [94]. However, now there is
robust evidence that mpMRI can detect and localise recurrence in patients after receiving initial
PCa treatment [96, 97]. Indeed, guidelines in the
United States now recommend the use of mpMRI
to assess for local recurrence in patients with
BCR after RP [98, 99].
In 2021, an international expert panel published the consensus-based Prostate Imaging for
Recurrence Reporting (PI-RR) guidelines for
MRI assessment to detect PCa local recurrence
after RP and RT. [24] This includes a 5-point
overall suspicion score with separate scales for
assessing DWI and DCE imaging after RT and
RP (see Fig. 14.1 and Table14.5). PI-RR also
includes technical recommendations like those
recommended in PI-RADS v2.1 [18, 100].
However, PI-RR adds specic considerations for
local recurrence. For example, PI-RR indicates
that after RP, T2-WI should be performed in all
14 A History of Reporting Standards for Prostate Magnetic Resonance Imaging: PI-RADS, PRECISE…
143
Fig. 14.1 PI-RR scoring system for reporting local
recurrence of prostate cancer after surgery or radiation
therapy. For MRI scans following radiotherapy, DWI and
DCE imaging are both considered dominant sequences
that jointly determine the overall score. For MRI scans
following radical prostatectomy, DCE imaging is considered the sole dominant sequence in this setting. DWI is
also scored on a 5-point scale but is not a dominant
three anatomic planes (axial, sagittal, and coronal) [24] compared to PI-RADS v2.1, which
allows for T2-WI in two planes (axial and either
sagittal or coronal) [18]. Moreover, for PI-RR,
the eld of view (FOV) must encompasses the
most common sites of recurrence, including the
seminal vesicle or retrovesical bed, vesicourethral anastomosis, and bladder neck [24, 101]. In
addition, PI-RR calls for performing at least one
large-FOV sequence (T1-WI or DWI) to assess
sequence in determining the overall score, and a DWI
score≥4 can upgrade an overall score from 2 to 3 or 3 to
4. T2-WI is also assessed with a 5-point scale, although
this sequence is used primarily for assessing anatomic
landmarks and does not inuence the overall PI-RR score.
DCE dynamic contrast-enhanced, DWI diffusionweighted imaging, PI-RR prostate imaging for recurrence
reporting
for metastatic disease in lymph nodes or bone
lesions [24].
Initial studies on PI-RR have shown promising
results concerning to the reproducibility and diagnostic performance of the system [102, 103].
Pecoraro etal. found excellent reproducibility of
the PI-RR overall score (intraclass correlation
coefcient = 0.87) and moderate-to-high accuracy (area under the curve range = 0.77–0.92)
[102]. Across four readers, the PPV of a PI-RR
144
Table 14.5 Assessment categories for scoring MRI sequences after radiation therapy and radical prostatectomy
according to PI-RR
T2- WI
score
1 Normal hypointense vesicourethral anastomosis and
2 Diffuse thickening of the vesicourethral anastomosis and/or
3 Symmetric focal or mass-like signal intensity in the
4 Asymmetric focal or mass-like iso/hyperintensity in the
5 Asymmetric focal or mass-like iso/hyperintensity in the
DWI
score Following radical prostatectomy/radiation therapy
1 No signal abnormality on high-b-value DWI and ADC map
2 Diffuse moderate hyperintensity on high-b- value DWI and/or diffuse moderate hypointensity on the ADC
3 Focal marked hyperintensity on high-b-value DWI or focal marked hypointensity on the ADC map, but
4 Focal marked hyperintensity on high-b-value DWI and marked hypointensity on the ADC map not on the
5 Focal marked hyperintensity on high-b-value DWI and marked hypointensity on the ADC map on the
DCE
score Following radical prostatectomy/radiation therapy
1 No enhancement
2 Diffuse or heterogenous enhancement
3 Focal or mass-like late enhancement
4 Focal or mass-like early enhancement not on the same side/site as the primary tumour, or tumour side/site
5 Focal or mass-like early enhancement on the same side/site as the primary tumour
After assessing each sequence, individual sequence scores can be put together to determine an overall PI-RR score
(Fig.14.1). PI-RR incorporates the relation between a lesion and the primary tumour location on pre-treatment imaging
as a key determinant of assigned scores. Additionally, unlike PI-RADS v2.1, PI-RR introduces a 5-point scale for
assessing DCE imaging based on the distribution (diffuse or heterogeneous vs. focal or mass-like) and timing (early vs.
delayed) of prostatic enhancement
ADC apparent diffusion coefcient, DCE dynamic contrast- enhanced, DWI diffusion-weighted imaging, MRI magnetic
resonance imaging, PI-RADS prostate imaging reporting and data system, PI-RR prostate imaging for recurrence reporting, T2-WI T2-weighted imaging
Pattern changes on MRI
Following radical prostatectomy Following radiation therapy
No abnormal signal intensity compared to
seminal vesicle bed remnants
thick-walled seminal vesicle remnants and/or coarse scar
tissue within the seminal vesicle beds
perianastomotic area or seminal vesicle bed(s)
perianastomotic area or seminal vesicle bed(s) not on the
same side as the primary tumour, or tumour side not known
perianastomotic area or seminal vesicle bed(s) on the same
side as the primary tumour
map
not on both
same side/site as the primary tumour, or side of the primary tumour not known
same side/site as the primary tumour
not known
the background
Linear, wedge- shaped, or diffuse moderate
hypointensity or residual BPH nodules
Focal or mass-like mild hypointensity not
at the primary tumour site; includes others
that do not qualify as 2, 4, or 5
Focal or mass-like moderate hypointensity
not at the same site as the primary tumour,
or location of primary tumour not known
Focal or mass-like marked hypointensity at
the same site as the primary tumour
C. Englman et al.
score of 3 or greater after either RT or PR was
high, although all readers were highly experienced, limiting the generalisability of the results.
Moreover, Ciccarese et al. found excellent
interobserver agreement (κ = 0.884, p < 0.001)
between two radiologists with 5 and 10years of
prostate MRI experience [103]. In their study on
patients post-RP, a PI-RR score of 3 or greater had
high sensitivity (85%) and PPV (73%) for recurrence but low specicity (33%) [103]. Multicentre
prospective studies that include radiologists with
varying levels of experience and expertise are
required for further validation and to guide clinical adoption of PI-RR moving forward [104].
14 A History of Reporting Standards for Prostate Magnetic Resonance Imaging: PI-RADS, PRECISE…
145
MRI After Focal Therapy
Several FT consensus meetings have stressed
the robust evidence that exists to support the
use of mpMRI in this setting [105–115]. MRI
not only has a role to play in FT planning and
targeted biopsies but also in patient follow-up
since PSA levels are unreliable in monitoring
for local recurrence given the variable reduction in prostate volume during treatment [116,
117], and recurrence rates following FT are as
high as 40% within 2years [118]. Paxton etal.
demonstrated the high sensitivity of mpMRI for
the detection of late recurrence [119]. In their
study with a mean follow-up of 49 months,
biopsy revealed recurrent disease in 83% of
patients with restricted diffusion and 63% of
those with hyperenhancement at the treatment
site. Moreover, the combination of restricted
diffusion and early enhancement had PPV of
100%.
Although PI-RR deals with local recurrence
after RP and RT, no standardised scoring system
had been designed for MRI assessment following
FT until the Prostate Imaging after Focal Ablation
(PI-FAB) score was proposed in 2023 [25]. As
shown in Fig. 14.2, PI-FAB involves a 3-point
scale for rating MRI sequences in sequential
order: (1) DCE sequences; (2) DWI, split into the
assessment of the high-b-value sequence rst and
then the apparent diffusion coefcient map; and
(3) T2-WI. A comparison with pre-treatment
DCE sequences is recommended, and key information such as the date of treatment, ablation
modality, tumour burden (including pre- treatment
Gleason score, maximum cancer core length, and
Fig. 14.2 PI-FAB scoring system for assessing the likelihood of local recurrence of prostate cancer after focal
therapy. Low signal intensity on T2-WI and high-b-value
sequence and no enhancement at the site of the original
tumour, receives a score of PI-FAB 1, which means it is
likely to represent brosis. High signal intensity on the
high-b-value sequence, focal enhancement (any size), and
low signal intensity on T2-WI and the ADC map equals a
PI-FAB score of 3 and indicates that there is a high suspicion for residual or recurrent disease. Whereas focal
enhancement alone (low signal intensity on T2-WI, low
signal intensity on the high-b-value sequence) can be
PI-FAB 1, 2, or 3: a linear enhancing area, not at the site
of the original tumour or the edge of the ablation cavity, is
likely to represent a vessel or inammation and equals
PI-FAB 1; an enhancing area≤ 3 mm at the site of the
original tumour is PI-FAB 2; and PI-FAB 3 is early focal
enhancement >3mm within the ablated zone/edge of the
ablation cavity or a PI-FAB 2 focus that has now increased
in size. ADC apparent diffusion coefcient, DCE dynamic
contrast-enhanced, DWI diffusion-weighted imaging,
MRI magnetic resonance imaging, PI-FAB prostate imaging after focal ablation, PSA prostate-specic antigen, T2-
WI T2-weighted imaging
146
C. Englman et al.
PSA), and post-treatment PSA kinetics should
always be provided by the referrer. Performance
of the PI-FAB scoring system still needs to be
evaluated across multiple readers, and Giganti
et al. have indicated their intention to trial the
scoring system on FT patient cohorts [25].
Conclusion
Over the past decades, remarkable advancements
in MRI for PCa have been made, and the indications for mpMRI have expanded greatly. The
number of consensus meetings and guidelines on
prostate MRI has also increased reecting the
growing interest in this area. Recommendations
on standardisation, structured reporting, and
scoring systems have been designed to reduce
variability in the acquisition, interpretation, and
reporting of scans. Select consensus meetings
and scoring systems that have been discussed in
this chapter are shown in Fig. 14.3 and summarised in Table14.6. Some of these recommendations are intended for routine clinical practice,
others have been created to facilitate better data
collection for research, and many serve both
these purposes. Some of the newer proposed
scoring systems will require further validation,
while almost all recommendations will develop
as more data are collected and scoring systems
will be rened with additional clinical
experience.
Fig. 14.3 Timeline of select prostate MRI consensus
meetings, recommendations, and scoring systems. AUA
American Urological Association, DRE digital rectal
examination, EAU European Association of Urology,
ESUI EAU Section of Urological Imaging, ESUR
European Society of Urogenital Radiology, MRI magnetic
resonance imaging, NICE National Institute for Health
and Care Excellence, PCa prostate cancer, PI-FAB pros-
tate imaging after focal ablation, PI-QUAL prostate imaging quality, PI-RADS prostate imaging reporting and data
system, PI-RR prostate imaging for recurrence reporting,
PRECISE prostate cancer radiological estimation of
change in sequential evaluation, PSA prostate-specic
antigen, START Standards of reporting for MRI-targeted
biopsy studies
14 A History of Reporting Standards for Prostate Magnetic Resonance Imaging: PI-RADS, PRECISE…
147
(continued)
of PCa
• T2-WI, DWI, and DCE provide the key sequences for prostate
No. of
participants Key radiologic message(s)
16 • Consensus meeting on detection, localisation, and characterisation
appropriateness
method
Europe RAND/UCLA
malignancy
MRI interpretation
• Suggested a 5-point Likert scale for likelihood of signicant
scans
• Encouraged pictorial reporting
• Three protocols recommended for detection, staging, and node
9 • Consensus meetings held to promote high- quality prostate MRI
Consensus meetings
and email
discussions
Europe and United
States
reporting
and bone assessment
• Developed the PI-RADS classication system for structured
16 • T2-WI, DWI, and DCE provide the key sequences for prostate
(no formal
consensus method)
United Kingdom Consensus meeting
diagnostic
MRI reporting
• High-quality 1.5-T MRI scans with pelvic phased- array coil are
• MRI can be used before biopsy
and group discussion
(no formal
consensus method)
recommended
studies
be reported separately using GS and MCCL
MRI-targeted biopsy studies
• Staging scans should be performed at least 10weeks after biopsy
• Use of a standardised scoring system and pictorial report are
• Histologic results of standard and MRI-targeted biopsies should
• Developed a checklist to improve the quality of reporting in
23 • List of recommendations for reporting MRI-targeted biopsy
RAND/UCLA
appropriateness
method
Europe, United
States, and Japan
• T2-WI is the dominant sequence for TZ lesions
• DCE scoring is simplied to negative or positive ndings
• Developed a 39-sector map of the prostate for lesion localisation
12 • DWI is the dominant sequence for PZ lesions
Consensus of
PI-RADS Steering
Committee expert
panel
Europe, United
States, and Canada
assessing the likelihood of radiological progression
a cohort of patients on AS
• Created the PRECISE scoring system—a 5-point scale for
• Developed a case report form and checklist of items for reporting
19 • Meeting on reporting serial MRI for AS
RAND/UCLA
appropriateness
method
Europe, United
States, and Canada
Dickinson etal.
2011 [27]
Meeting topic/
scoring system Authors, year Location Consensus method
5-point Likert
scale for
likelihood of
Table 14.6 Summary of select prostate MRI consensus meetings and scoring systems
signicant PCa
2012 [17]
PI-RADS Barentsz etal.
Kirkham etal.
2013 [28]
MRI for
detection,
staging, and
post-treatment
imaging of
prostate cancer
Moore etal.
2013 [20]
START
recommendations
on MRI-targeted
biopsy studies
2016 [19]
PI-RADS v2 Welnreb etal.
2017 [21]
PRECISE Moore etal.
148
contour bulge or irregularity
contour bulge or irregularity
urologic team
consistently high diagnostic quality
only
• Quality assessment checks of MRI scanners to guarantee scans of
• Scans should be reported by trained and experienced radiologists
especially at lower T2-WI scores
• DCE is still recommended, although bpMRI is acknowledged
• Greater emphasis placed on DWI for overall lesion scoring,
• Modications of sector map to include 41 prostatic regions
retrospectively to a cohort of 553 patients
– Grade 1=tumours with a contact length≥1.5cm or
– Grade 2=tumours with a contact length≥1.5cm and
into clinical practice
performance tests with histopathology feedback, compare their
– Grade 3=gross visible extension beyond the prostate
• For interpretation performance, radiologists should use self-
C. Englman et al.
interpretation with expert-reading, and use external performance
assessments
before interpreting prostate MRI
quality, which was then used to evaluate 58 scans from 22 centres
that participated in the PRECISION trial
• Radiologists must also attend theoretical and hands-on courses
– 1=all MR sequences are below the minimum standard
– 3=scan is of sufcient diagnostic quality
– 5=all sequences are of optimal diagnostic quality
• 95% of scans in PRECISION were PI-QUAL≥3
No. of
participants Key radiologic message(s)
15 • Prostate MRI requests should be made in consultation with the
appropriateness
method
United Kingdom RAND/UCLA
Brizmohun
Appayya etal.
2018 [13]
15 • Distinction between typical and atypical nodules in the TZ
Consensus of
PI-RADS Steering
Committee expert
panel
Europe, United
States, and Canada
2019 [18]
N/A 14 • Proposal for 3-point scale for EPE, which was then applied
Europe and United
States
Mehralivand
etal. 2019 [22]
Europe Delphi process 44 • Reporting of image quality should be performed and implemented
De Rooij etal.
2020 [76]
United Kingdom N/A 5 • Proposal for 5-point scale for evaluating prostate MRI image
2020 [26]
Meeting topic/
scoring system Authors, year Location Consensus method
Table 14.6 (continued)
National
implementation
of MRI for
prostate cancer
detection
PI-RADS v2.1 Turkbey etal.
3-point scale for
EPE
ESUR/ESUI on
quality
requirements for
prostate MRI
PI-QUAL Score Giganti etal.
14 A History of Reporting Standards for Prostate Magnetic Resonance Imaging: PI-RADS, PRECISE…
individual level, and there should be a re-evaluation after a
specied time
suspicion of local recurrence of PCa following RP or RT
and to facilitate data collection and outcome monitoring for
research
therapy
(split into high-b-value sequence and then ADC map); and T2-WI
interpretation of prostate mpMRI performed in patients with
suspect PCa
• 3 levels of certication agreed on
• Panel agreed that this process should be performed at an
• PI-RR scores are intended to be used in routine clinical practice
• Involves rating MRI sequences in sequential order: DCE; DWI
this assessment
• Essential that the pre-treatment scan is also available to help with
149
No. of
participants Key radiologic message(s)
13 • Agreed on the need for an evaluation process relating to the
appropriateness
method
United Kingdom RAND/UCLA
Barrett etal.
2021 [120]
17 • Consensus panel proposed a scoring system to be used to assess
Face-to-face and
online discussions
(no formal
consensus method)
Europe and United
States
2021 [24]
United Kingdom N/A 8 • Proposal for 3-point scale for reporting prostate MRI after focal
2023 [25]
Meeting topic/
scoring system Authors, year Location Consensus method
Credentialing for
prostate MRI
reporting
PI-RR Score Panebianco etal.
PI-FAB Score Giganti etal.
ADC apparent diffusion coefcient, AS active surveillance, bpMRI biparametric MRI, DCE dynamic contrast-enhanced, DWI diffusion-weighted image, EPE extraprostatic
extension, ESUI European Association of Urology Section of Urological Imaging, ESUR European Society of Urogenital Radiology, GS Gleason score, MCCL maximum cancer
core length, mpMRI multiparametric MRI, MRI magnetic resonance imaging, N/A not applicable, no. number, PCa prostate cancer, PI-FAB prostate imaging after focal ablation,
PI-QUAL prostate imaging quality, PI-RADS prostate imaging reporting and data system, PI-RR prostate imaging for recurrence reporting, PRECISE prostate cancer radiologic
estimation of change in sequential evaluation, PZ peripheral zone, RAND RAND Corporation, START Standards of reporting for MRI-targeted biopsy studies, T tesla, T2-WI
T2-weighted image, TZ transition zone, UCLA University of California, Los Angeles, v version
150
C. Englman et al.
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