Download PDF
CC BY 4.0 · Journal of Gastrointestinal and Abdominal Radiology
DOI: 10.1055/s-0043-1778636
Review Article

Pearls and Pitfalls in Applying PI-RADS 2.1

Ankur Pandey 
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
Soumyadeep Ghosh 
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
Priyanka Prajapati
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
Nabih Nakrour 
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
Mukesh Harisinghani
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
› Author Affiliations Funding None.
› Further Information
   Permissions and Reprints

Abstract

The use of Prostate Imaging Reporting and Data System (PI-RADS) with multiparametric magnetic resonance imaging (MRI) has significantly improved the detection of clinically significant prostate cancer (csPCa), but there are certain challenges that the reader may face. This review provides an overview of the pitfalls associated with the PI-RADS system for multiparametric prostate MRI (mpMRI), with suggestions/pearls to help overcome these pitfalls.

PI-RADS assessment is hindered by several causes of false positives (FPs) and false negatives (FNs). In addition, there is wide variability in the positive predictive value (PPV) of the PI-RADS system across different centers, highlighting the need for improvement. While the negative predictive value (NPV) for csPCa is generally high, variations exist.

This review discusses the pitfalls contributing to FNs, including MRI artifacts, such as susceptibility and motion artifacts. Techniques to optimize image acquisition, such as switching the phase encoding direction and reducing bowel peristalsis, are suggested to mitigate these artifacts. Improper b-value selection for diffusion-weighted imaging (DWI) is another pitfall, emphasizing the importance of using high b-values (≥1,400 s/mm2) to optimize neoplasm detection. Similarly, optimizing window settings to visualize csPCa, correctly positioning the endorectal coil, awareness of rare variants like mucinous adenocarcinoma and cribriform adenocarcinoma, and distinguishing central zone tumors from normal central zone are discussed.

This article highlights the common pitfalls causing FPs, such as benign pathologies like prostatitis, granulomatous prostatitis, prostatic abscess, stromal BPH nodules, extruded BPH nodules, and prostatic calcifications. It also discusses the pitfalls related to normal anatomical structures, including the central zone, anterior fibromuscular stroma, thickened surgical capsule, neurovascular bundle, and periprostatic venous plexus. Techniques for carefully evaluating these entities' morphology and distribution of signal abnormalities are described to avoid overdiagnosing these as PCa. The article also addresses the pitfalls related to postintervention changes, including postbiopsy hemorrhage and artifacts caused by the UroLift procedure, while providing recommendations for managing these challenges.

Finally, the pitfalls that may be encountered during staging, including evaluation for extraprostatic extension, and pelvic nodal and osseous metastases, are highlighted.

Keywords

magnetic resonance imaging - mpMRI - prostate - prostatic neoplasms - prostatitis - prostatic hyperplasia


Publication History

Article published online:
11 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Barentsz JO, Richenberg J, Clements R. et al; European Society of Urogenital Radiology. ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22 (04) 746-757
    Google Scholar
  • 2 Turkbey B, Rosenkrantz AB, Haider MA. et al. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2. Eur Urol 2019; 76 (03) 340-351
    Google Scholar
  • 3 Becerra MF, Alameddine M, Zucker I. et al. Performance of multiparametric MRI of the prostate in biopsy naïve men: a meta-analysis of prospective studies. Urology 2020; 146: 189-195
    Google Scholar
  • 4 Westphalen AC, McCulloch CE, Anaokar JM. et al. Variability of the positive predictive value of PI-RADS for prostate MRI across 26 centers: experience of the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel. Radiology 2020; 296 (01) 76-84
    Google Scholar
  • 5 Moldovan PC, Van den Broeck T, Sylvester R. et al. What is the negative predictive value of multiparametric magnetic resonance imaging in excluding prostate cancer at biopsy? A systematic review and meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel. Eur Urol 2017; 72 (02) 250-266
    Google Scholar
  • 6 Sundaram KM, Rosenberg J, Syed AB, Chang ST, Loening AM. Assessment of T2-weighted image quality at prostate MRI in patients with and those without intramuscular injection of glucagon. Radiol Imaging Cancer 2023; 5 (03) e220070
    Google Scholar
  • 7 Metens T, Miranda D, Absil J, Matos C. What is the optimal b value in diffusion-weighted MR imaging to depict prostate cancer at 3T?. Eur Radiol 2012; 22 (03) 703-709
    Google Scholar
  • 8 Manetta R, Palumbo P, Gianneramo C. et al. Correlation between ADC values and Gleason score in evaluation of prostate cancer: multicentre experience and review of the literature. Gland Surg 2019; 8 (Suppl. 03) S216-S222
    Google Scholar
  • 9 Fine SW. Variants and unusual patterns of prostate cancer: clinicopathologic and differential diagnostic considerations. Adv Anat Pathol 2012; 19 (04) 204-216
    Google Scholar
  • 10 Yamada K, Kozawa N, Nagano H, Fujita M, Yamada K. MRI features of mucinous adenocarcinoma of the prostate: report of four cases. Abdom Radiol (NY) 2019; 44 (04) 1261-1268
    Google Scholar
  • 11 Westphalen AC, Coakley FV, Kurhanewicz J, Reed G, Wang ZJ, Simko JP. Mucinous adenocarcinoma of the prostate: MRI and MR spectroscopy features. AJR Am J Roentgenol 2009; 193 (03) W238-W243
    Google Scholar
  • 12 Truong M, Feng C, Hollenberg G. et al. A comprehensive analysis of cribriform morphology on magnetic resonance imaging/ultrasound fusion biopsy correlated with radical prostatectomy specimens. J Urol 2018; 199 (01) 106-113
    Google Scholar
  • 13 Seyrek N, Hollemans E, Schoots IG, van Leenders GJLH. Association of quantifiable prostate MRI parameters with any and large cribriform pattern in prostate cancer patients undergoing radical prostatectomy. Eur J Radiol 2023; 166: 110966
    Google Scholar
  • 14 Hoeks CMA, Barentsz JO, Hambrock T. et al. Prostate cancer: multiparametric MR imaging for detection, localization, and staging. Radiology 2011; 261 (01) 46-66
    Google Scholar
  • 15 Rais-Bahrami S, Nix JW, Turkbey B. et al. Clinical and multiparametric MRI signatures of granulomatous prostatitis. Abdom Radiol (NY) 2017; 42 (07) 1956-1962
    Google Scholar
  • 16 Bour L, Schull A, Delongchamps NB. et al. Multiparametric MRI features of granulomatous prostatitis and tubercular prostate abscess. Diagn Interv Imaging 2013; 94 (01) 84-90
    Google Scholar
  • 17 Hosseinzadeh K, Schwarz SD. Endorectal diffusion-weighted imaging in prostate cancer to differentiate malignant and benign peripheral zone tissue. J Magn Reson Imaging 2004; 20 (04) 654-661
    Google Scholar
  • 18 Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol 1984; 132 (03) 474-479
    Google Scholar
  • 19 Guneyli S, Ward E, Thomas S. et al. Magnetic resonance imaging of benign prostatic hyperplasia. Diagn Interv Radiol 2016; 22 (03) 215-219
    Google Scholar
  • 20 Ling D, Lee JKT, Heiken JP, Balfe DM, Glazer HS, McClennan BL. Prostatic carcinoma and benign prostatic hyperplasia: inability of MR imaging to distinguish between the two diseases. Radiology 1986; 158 (01) 103-107
    Google Scholar
  • 21 Li H, Sugimura K, Kaji Y. et al. Conventional MRI capabilities in the diagnosis of prostate cancer in the transition zone. AJR Am J Roentgenol 2006; 186 (03) 729-742
    Google Scholar
  • 22 McNeal JE, Redwine EA, Freiha FS, Stamey TA. Zonal distribution of prostatic adenocarcinoma. Correlation with histologic pattern and direction of spread. Am J Surg Pathol 1988; 12 (12) 897-906
    Google Scholar
  • 23 Schieda N, Lim CS, Zabihollahy F. et al. Quantitative prostate MRI. J Magn Reson Imaging 2021; 53 (06) 1632-1645
    Google Scholar
  • 24 Hoeks CMA, Hambrock T, Yakar D. et al. Transition zone prostate cancer: detection and localization with 3-T multiparametric MR imaging. Radiology 2013; 266 (01) 207-217
    Google Scholar
  • 25 Akin O, Sala E, Moskowitz CS. et al. Transition zone prostate cancers: features, detection, localization, and staging at endorectal MR imaging. Radiology 2006; 239 (03) 784-792
    Google Scholar
  • 26 Bonde AA, Korngold EK, Foster BR. et al. Prostate cancer with a pseudocapsule at MR imaging: a marker of high grade and stage disease?. Clin Imaging 2016; 40 (03) 365-369
    Google Scholar
  • 27 Hong CG, Yoon BI, Choe HS, Ha US, Sohn DW, Cho YH. The prevalence and characteristic differences in prostatic calcification between health promotion center and urology department outpatients. Korean J Urol 2012; 53 (05) 330-334
    Google Scholar
  • 28 Vargas HA, Akin O, Franiel T. et al. Normal central zone of the prostate and central zone involvement by prostate cancer: clinical and MR imaging implications. Radiology 2012; 262 (03) 894-902
    Google Scholar
  • 29 Purysko AS, Baroni RH, Giganti F. et al. PI-RADS version 2.1: a critical review, from the AJR special series on radiology reporting and data systems. AJR Am J Roentgenol 2021; 216 (01) 20-32
    Google Scholar
  • 30 Semple JE. Surgical capsule of the benign enlargement of the prostate. Its development and action. BMJ 1963; 1 (5346): 1640-1643
    Google Scholar
  • 31 Rosenkrantz AB, Taneja SS. Radiologist, be aware: ten pitfalls that confound the interpretation of multiparametric prostate MRI. AJR Am J Roentgenol 2014; 202 (01) 109-120
    Google Scholar
  • 32 Guerra A, Flor-de-Lima B, Freire G, Lopes A, Cassis J. Radiologic-pathologic correlation of prostatic cancer extracapsular extension (ECE). Insights Imaging 2023; 14 (01) 88
    Google Scholar
  • 33 Panebianco V, Barchetti F, Barentsz J. et al. Pitfalls in interpreting mp-MRI of the prostate: a pictorial review with pathologic correlation. Insights Imaging 2015; 6 (06) 611-630
    Google Scholar
  • 34 Kundra V, Silverman PM, Matin SF, Choi H. Imaging in oncology from the University of Texas M. D. Anderson Cancer Center: diagnosis, staging, and surveillance of prostate cancer. AJR Am J Roentgenol 2007; 189 (04) 830-844
    Google Scholar
  • 35 Panebianco V, Giganti F, Kitzing YX. et al. An update of pitfalls in prostate mpMRI: a practical approach through the lens of PI-RADS v. 2 guidelines. Insights Imaging 2018; 9 (01) 87-101
    Google Scholar
  • 36 Rosenkrantz AB, Kopec M, Kong X. et al. Prostate cancer vs. post-biopsy hemorrhage: diagnosis with T2- and diffusion-weighted imaging. J Magn Reson Imaging 2010; 31 (06) 1387-1394
    Google Scholar
  • 37 Barrett T, Vargas HA, Akin O, Goldman DA, Hricak H. Value of the hemorrhage exclusion sign on T1-weighted prostate MR images for the detection of prostate cancer. Radiology 2012; 263 (03) 751-757
    Google Scholar
  • 38 Zakian KL, Shukla-Dave A, Ackerstaff E, Hricak H, Koutcher JA. 1H magnetic resonance spectroscopy of prostate cancer: biomarkers for tumor characterization. Cancer Biomark 2008; 4 (4–5): 263-276
    Google Scholar
  • 39 Tamada T, Sone T, Jo Y. et al. Prostate cancer: relationships between postbiopsy hemorrhage and tumor detectability at MR diagnosis. Radiology 2008; 248 (02) 531-539
    Google Scholar
  • 40 White S, Hricak H, Forstner R. et al. Prostate cancer: effect of postbiopsy hemorrhage on interpretation of MR images. Radiology 1995; 195 (02) 385-390
    Google Scholar
  • 41 Das AK, Leong JY, Roehrborn CG. Office-based therapies for benign prostatic hyperplasia: a review and update. Can J Urol 2019; 26 (4, Suppl 1): 2-7
    Google Scholar
  • 42 NeoTract, Inc. UroLift® System UL400 Instructions for Use UroLift System UL400. Accessed February 23, 2024 at: https://in.urolift.com/wp-content/uploads/2022/09/India-IFU-for-UroLift-System.pdf
  • 43 Benidir T, Austhof E, Ward RD. et al. Impact of prostate urethral lift device on prostate magnetic resonance image quality. J Urol 2023; 209 (04) JU0 000000000003156
    Google Scholar
  • 44 Park KJ, Kim MH, Kim JK. Extraprostatic tumor extension: comparison of preoperative multiparametric MRI criteria and histopathologic correlation after radical prostatectomy. Radiology 2020; 296 (01) 87-95
    Google Scholar
  • 45 Diaz TA, Benson B, Clinkenbeard A, Long JR, Kawashima A, Yano M. MRI evaluation of patients before and after interventions for benign prostatic hyperplasia: an update. AJR Am J Roentgenol 2022; 218 (01) 88-99
    Google Scholar
  • 46 Mehralivand S, Shih JH, Harmon S. et al. A grading system for the assessment of risk of extraprostatic extension of prostate cancer at multiparametric MRI. Radiology 2019; 290 (03) 709-719
    Google Scholar
  • 47 Le Nobin J, Rosenkrantz AB, Villers A. et al. Image guided focal therapy for magnetic resonance imaging visible prostate cancer: defining a 3-dimensional treatment margin based on magnetic resonance imaging histology co-registration analysis. J Urol 2015; 194 (02) 364-370
    Google Scholar
  • 48 Soylu FN, Peng Y, Jiang Y. et al. Seminal vesicle invasion in prostate cancer: evaluation by using multiparametric endorectal MR imaging. Radiology 2013; 267 (03) 797-806
    Google Scholar
  • 49 Yang Z, Laird A, Monaghan A, Seywright M, Ahmad I, Leung HY. Incidental seminal vesicle amyloidosis observed in diagnostic prostate biopsies–are routine investigations for systemic amyloidosis warranted?. Asian J Androl 2013; 15 (01) 149-151
    Google Scholar
  • 50 Sankineni S, Brown AM, Fascelli M. et al. Lymph node staging in prostate cancer. Curr Urol Rep 2015; 16 (05) 30
    Google Scholar
  • 51 Hövels AM, Heesakkers RAM, Adang EM. et al. The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis. Clin Radiol 2008; 63 (04) 387-395
    Google Scholar
  • 52 Pedersen CK, Babu AS. Understanding the lymphatics: an updated review of the N category of the AJCC 8th edition for urogenital cancers. AJR Am J Roentgenol 2021; 217 (02) 368-377
    Google Scholar
  • 53 Muteganya R, Goldman S, Aoun F, Roumeguère T, Albisinni S. Current imaging techniques for lymph node staging in prostate cancer: a review. Front Surg 2018; 5: 74
    Google Scholar
  • 54 Thoeny HC, Froehlich JM, Triantafyllou M. et al. Metastases in normal-sized pelvic lymph nodes: detection with diffusion-weighted MR imaging. Radiology 2014; 273 (01) 125-135
    Google Scholar
  • 55 Kitajima K, Murphy RC, Nathan MA. et al. Detection of recurrent prostate cancer after radical prostatectomy: comparison of 11C-choline PET/CT with pelvic multiparametric MR imaging with endorectal coil. J Nucl Med 2014; 55 (02) 223-232
    Google Scholar
  • 56 Pasoglou V, Larbi A, Collette L. et al. One-step TNM staging of high-risk prostate cancer using magnetic resonance imaging (MRI): toward an upfront simplified “all-in-one” imaging approach?. Prostate 2014; 74 (05) 469-477
    Google Scholar
  • 57 Woo S, Kim SY, Kim SH, Cho JY. Identification of bone metastasis with routine prostate MRI: a study of patients with newly diagnosed prostate cancer. AJR Am J Roentgenol 2016; 206 (06) 1156-1163
    Google Scholar
  • 58 Tanaka T, Yang M, Froemming AT. et al. Current imaging techniques for and imaging spectrum of prostate cancer recurrence and metastasis: a pictorial review. Radiographics 2020; 40 (03) 709-726
    Google Scholar
  • 59 Vargas HA, Schor-Bardach R, Long N. et al. Prostate cancer bone metastases on staging prostate MRI: prevalence and clinical features associated with their diagnosis. Abdom Radiol (NY) 2017; 42 (01) 271-277
    Google Scholar