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Observational Study
. 2023 Aug;33(8):5828-5839.
doi: 10.1007/s00330-023-09605-0. Epub 2023 Apr 13.

Low cancer yield in PI-RADS 3 upgraded to 4 by dynamic contrast-enhanced MRI: is it time to reconsider scoring categorization?

Emanuele Messina  1 , Martina Pecoraro  1 , Ludovica Laschena  1 , Marco Bicchetti  1 , Flavia Proietti  2 , Antonio Ciardi  1 , Costantino Leonardo  2 , Alessandro Sciarra  2 , Rossano Girometti  3 , Carlo Catalano  1 , Valeria Panebianco  4
Affiliations
Observational Study

Low cancer yield in PI-RADS 3 upgraded to 4 by dynamic contrast-enhanced MRI: is it time to reconsider scoring categorization?

Emanuele Messina et al. Eur Radiol. 2023 Aug.

Abstract

Objectives: To evaluate MRI diagnostic performance in detecting clinically significant prostate cancer (csPCa) in peripheral-zone PI-RADS 4 lesions, comparing those with clearly restricted diffusion (DWI-score 4), and those with equivocal diffusion pattern (DWI-score 3) and positive dynamic contrast-enhanced (DCE) MRI.

Methods: This observational prospective study enrolled 389 men referred to MRI and, if positive (PI-RADS 3 with PSA-density [PSAD] ≥ 0.15 ng/mL/mL, 4 and 5), to MRI-directed biopsy. Lesions with DWI-score 3 and positive DCE were classified as "PI-RADS 3up," instead of PI-RADS 4. Univariable and multivariable analyses were implemented to determine features correlated to csPCa detection.

Results: Prevalence of csPCa was 14.5% and 53.3% in PI-RADS categories 3up and 4, respectively (p < 0.001). MRI showed a sensitivity of 100.0%, specificity 40.9%, PPV 46.5%, NPV 100.0%, and accuracy 60.9% for csPCa detection. Modifying the threshold to consider MRI positive and to indicate biopsy (same as previously described, but PI-RADS 3up only when associated with elevated PSAD), the sensitivity changed to 93.9%, specificity 57.2%, PPV 53.0%, NPV 94.8%, and accuracy 69.7%. Age (p < 0.001), PSAD (p < 0.001), positive DWI (p < 0.001), and PI-RADS score (p = 0.04) resulted in independent predictors of csPCa.

Conclusions: Most cases of PI-RADS 3up were false-positives, suggesting that upgrading peripheral lesions with DWI-score 3 to PI-RADS 4 because of positive DCE has a detrimental effect on MRI accuracy, decreasing the true prevalence of csPCa in the PI-RADS 4 category. PI-RADS 3up should not be upgraded and directed to biopsy only if associated with increased PSAD.

Key points: • As per PI-RADS v2.1 recommendations, in case of a peripheral zone lesion with equivocal diffusion-weighted imaging (DWI score 3), but positive dynamic contrast-enhanced (DCE) MRI, the overall PI-RADS score should be upgraded to 4. • The current PI-RADS recommendation of upgrading PI-RADS 3 lesions of the peripheral zone to PI-RADS 4 because of positive DCE decreased clinically significant prostate cancer detection rate in our series. • According to our results, the most accurate threshold for setting indication to prostate biopsy is PI-RADS 3 or PI-RADS 3 with positive DCE both associated with increased PSA density.

Keywords: Biopsy; Multiparametric magnetic resonance imaging; Prostatic neoplasms.

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Conflict of interest statement

R. Girometti is a Deputy Editor of European Radiology. He has not taken part in the review or selection process of this article.

V. Panebianco is a member of the European Radiology Scientific Editorial Board. She has not taken part in the review or selection process of this article.

The remaining authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Figures

Fig. 1
Fig. 1
Study flowchart showing the outline of its different phases: enrollment, intervention, and outcomes. PCa, prostate cancer; MRI, magnetic resonance imaging; MRDB, MRI-directed biopsy
Fig. 2
Fig. 2
A 73-year-old man with clinical suspicion of prostate cancer (PSA total value of 6.3 ng/mL, PSA density of 0.09 ng/mL2, positive family history of prostate cancer). a T2WI acquired on the axial plane showing a hypointense nodular lesion on a wider wedge-shaped alteration on the apical-right posterior peripheral zone, with post-contrast enhancement on early DCE images (b), with restricted diffusion at b-value 2000 (c) and normal ADC value (d), classified as PI-RADS 3up. e, f The lesion was biopsied using MRI-TRUS TBx. Histopathology proved the absence of neoplastic disease, with an inflammatory pattern. PSA, prostate-specific antigen; T2WI, T2-weighted imaging; DCE, dynamic contrast-enhanced; TBx, targeted biopsy
Fig. 3
Fig. 3
A 62-year-old man with clinical suspicion of prostate cancer (PSA total value of 12.9 ng/mL, PSA density of 0.18 ng/mL2). a T2WI acquired on the axial plane showing hypointense nodular lesion on the mid-left posterior peripheral zone, with mild post-contrast enhancement on DCE images (b), with marked restriction diffusion at b-value 2000 (c) and low ADC value (d), classified as PI-RADS 4. e, f The lesions was biopsied using MRI-TRUS TBx. Histopathology confirmed the presence of clinically significant prostate cancer, ISUP 3 (GS 4 + 3). PSA, Prostate-specific antigen; T2WI, T2-weighted imaging; DCE, dynamic contrast-enhanced; TBx, targeted biopsy; ISUP, International Society of Urogenital Pathology; GS, Gleason score
Fig. 4
Fig. 4
ROC analysis for the performance of MRI and PI-RADS score, in detecting prostate cancer (outcome 1) and clinically significant prostate cancer (outcome 2), for both more and less experienced readers. ROC, receiver operating curve; PI-RADS, Prostate Imaging—Reporting and Data System
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