CC BY 4.0 · Journal of Gastrointestinal and Abdominal Radiology 2024; 07(03): 183-202
DOI: 10.1055/s-0043-1778636
Special Issue Articles
Review Article

Pearls and Pitfalls in Applying PI-RADS 2.1

1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
Priyanka Prajapati
1   Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts, United States
,
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.

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.



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/)

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  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 9 Fine SW. Variants and unusual patterns of prostate cancer: clinicopathologic and differential diagnostic considerations. Adv Anat Pathol 2012; 19 (04) 204-216
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 19 Guneyli S, Ward E, Thomas S. et al. Magnetic resonance imaging of benign prostatic hyperplasia. Diagn Interv Radiol 2016; 22 (03) 215-219
  • 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
  • 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
  • 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
  • 23 Schieda N, Lim CS, Zabihollahy F. et al. Quantitative prostate MRI. J Magn Reson Imaging 2021; 53 (06) 1632-1645
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 30 Semple JE. Surgical capsule of the benign enlargement of the prostate. Its development and action. BMJ 1963; 1 (5346): 1640-1643
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 50 Sankineni S, Brown AM, Fascelli M. et al. Lymph node staging in prostate cancer. Curr Urol Rep 2015; 16 (05) 30
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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