Upgraded PI-RADS 3 Prostate Lesions Are Less Likely to Harbor Clinically Significant Cancer (2024)

Multiparametric MRI Improves Lesion Detection Based on Volume, Shape and Extraprostatic Features

Dr. Yilmaz and colleagues examined data from 454 men with suspected or known prostate cancer who underwent MRI/US fusion-guided biopsy. They obtained MRIs on a 3T scanner for each participant with T2-weighted imaging, diffusion-weighted imaging (including high b-value images and Apparent diffusion coefficient maps), and dynamic contrast-enhanced imaging sequences.

The investigators found that clinically significant prostate cancer rates differed notably among lesions in categories 5, 4 and 3—77%, 37%, and 14%, respectively.

“While there was no difference in clinically significant prostate cancer rates for category 4 TZ lesions, we have noted differences between nonupgraded and upgraded lesions for category 4 peripheral zone lesions and category 3 TZ lesions,” said principal investigator Baris Turkbey, MD, head of the Molecular Imaging Branch’s MRI and Artificial Intelligence Resource sections.

The difference amounted to a detection rate of just 4% in upgraded PI-RADS 3 transition zone lesions (i.e T2W score of 2 upgraded by the diffusion weighted score), versus 20% for nonupgraded PI-RADS 3 lesions (i.e. T2W score of 3).

“Considering these results, we may expect to observe an increased number of unnecessary biopsies for upgraded category 3 lesions,” Dr. Turkbey said. “Further prospective research is definitely needed to evaluate this.”

Imaging features on MRI like relative lesion volume, surface-to-volume ratio and extraprostatic extension scores of 2 and 3 were predictors of clinically significant prostate cancer, the investigative team found. Utilizing these factors could enhance the stratification of lesions, they said, suggesting that the next iteration of PI-RADS guidelines might benefit from considering these findings.

“Importantly, lesion PI-RADS categories and extraprostatic extension scores were also included in the multivariable analysis,” Dr. Yilmaz noted. “This means that the imaging features we identified are not driven by PI-RADS categories and extraprostatic extension scores and are independent predictors of harboring clinically significant prostate cancer.”

Current Iteration of PI-RADS Provides Appropriate Risk Stratification

In an accompanying editorial, Vicky Goh, MD, FRCR, a professor and chair of clinical cancer imaging at King’s College London, commented on the “balancing act” radiologists must perform to prevent overtreatment of indolent cancers while ensuring appropriate detection of clinically significant cancers.

“Given this trade-off of poorer specificity albeit with increased sensitivity, the jury remains out on the added value in substratification within PI-RADS 3 and PI-RADS 4,” Dr. Goh wrote. “There is an ongoing debate on whether the more objective assessment of shape and other radiomic and artificial intelligence approaches can improve the prediction of clinically significant prostate cancer.”

Until now, the lack of well-designed prospective studies and external validation has raised concerns about generalizability, noted Dr. Goh. She said that, despite limitations acknowledged by the authors, the study is an important step.

Both the authors and Dr. Goh touted the excellence of targeted biopsy versus systemic biopsy in MRI-defined lesions—in fact, the study by Dr. Yilmaz’s team excluded systematic biopsy results, including samples and reports from targeted biopsies only.

“Multiparametric MRI has a high negative predictive value, meaning that an individual with a negative MRI result is very unlikely to have the disease,” Dr. Goh explained. “A negative MRI finding can obviate unnecessary biopsy, and many prospective trials have demonstrated that an MRI-directed pathway is superior to a systematic ultrasound biopsy pathway in reducing the detection rate of clinically insignificant cancer and in confirming clinically significant disease.”

“Nevertheless,” she added, citing the multifocal nature of disease within the prostate, “clinically significant cancers can remain undetected in up to 26% of patients.”

Further Studies Necessary to Continue Identifying Markers for Prostate Cancer

Medical science is in a continual state of evolution, Dr. Yilmaz emphasized, and structured reporting systems like PI-RADS benefit from ongoing investigation and refinement.

“Envisioning a transition from subjective criteria to objective, reproducible, quantitative measures might be the key to addressing this challenge,” Dr. Yilmaz said. “Our study is an initial step towards this objective, and further research is imperative to continue this progression.”

For More Information

Access the Radiology study, “Prospective Evaluation of PI-RADS Version 2.1 for Prostate Cancer Detection and Investigation of Multiparametric MRI–derived Markers,” and the accompanying editorial, “PI-RADS and Multiparametric MRI: The Shape of Things to Come for Prostate Cancer.”

Read previous RSNA News stories on prostate cancer:

  • Positioning MRI as an Effective Prostate Cancer Screening Tool
  • Deep Learning Reconstruction Can Lead to Better Image Quality and Increased Detection of Prostate Cancer
  • Advances in Prostate Cancer Diagnosis and Treatment Point to Improved Patient Outcomes
Upgraded PI-RADS 3 Prostate Lesions Are Less Likely to Harbor Clinically Significant Cancer (2024)

FAQs

Is PI-RADS 3 prostate cancer clinically significant? ›

Lesions on prostate MRI that are termed as 'intermediate' or 'equivocal on the presence of clinically significant cancer' are scored as PI-RADS category 3 lesions.

What stage is PI-RADS 3? ›

Prostate Imaging Reporting and Data System (PI-RADS)

The five scores include: PI-RADS 1: Very low. PI-RADS 2: Low. PI-RADS 3: Intermediate (undetermined)

Can PI-RADS 3 be benign? ›

Patients with PI-RADS 3 lesions were divided into three categories based on pathological biopsy results: benign, clinically insignificant disease (score Gleason = 6 or International Society of Urologic Pathologic (ISUP) 1) and clinically significant cancer (score Gleason ≥ 7 (3+4) or ISUP ≥ 2) according to target and ...

What is a PI-RADS lesion on the prostate? ›

PI-RADS is used to standardize interpretation of prostate MRI, improve early diagnosis and treatment, and reduce unnecessary biopsies. In the PI-RADS scale, each lesion is assigned a score from 1 to 5 indicating the likelihood of clinically significant cancer.

What are the odds of getting cancer in PI-RADS 3? ›

Conclusions: PIRADS 3 lesion indicates an equivocal likelihood of significant prostate cancer. In our series the overall PCa detection rate was 26.8% and 14.6% for clinically significant cancer in PIRADS 3 lesions. This evokes the question, if PIRADS 3 lesions could be surveilled only.

What does the number 3 mean in prostate cancer? ›

Grade Group 3 or 4 (Gleason score 4+3=7 or 8) PSA less than 20. The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0].

What is the Gleason score for PI-RADS 3? ›

Table 4
ScoreSignificance
2Clinically significant disease is unlikely to be present
3Clinically significant cancer is equivocal
4Clinically significant cancer is likely to be present
5Clinically significant cancer is highly likely to be present
1 more row

What is the difference between PI-RADS 3 and 4? ›

PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present) PI-RADS 2: low (clinically significant cancer is unlikely to be present) PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal) PI-RADS 4: high (clinically significant cancer is likely to be present)

How accurate is a PI-RADS score? ›

Lesion level analysis results in pooled cancer detection rates of 3% for PI-RADS 1, 9% for PI-RADS 2, 34% for PI-RADS 3, 70% for PI-RADS 4, 97% for PI-RADS 5. Patient level analysis results in pooled cancer detection rates of 32% for PI-RADS 1, 17% for PI-RADS 2, 27% for PI-RADS 3, 77% for PI-RADS 4, 97% for PI-RADS 5.

Is it better to have prostate removed or radiation? ›

Both treatments work well. With either treatment, the chance of your cancer spreading is low. Both treatments have side effects, such as bladder, bowel, and erection problems. Radiation therapy is more likely to cause bowel problems.

What is a clinically significant lesion on the prostate? ›

A doctor determines that prostate cancer is clinically significant when it is aggressive, likely to spread if not addressed and presents a risk to the patient. In these cases, doctors recommend the patient undergo immediate treatment.

What percentage of prostate lesions are cancerous? ›

The range of clinically significant prostate cancer in the current review article was relatively wide, with a frequency of 4.5-27.2% of PI-RADS 3 lesions; however, most of the studies suggested a frequency of less than 10%.

What is the positive predictive value of PI-RADS 3? ›

Across all centers, the estimated PPV was 35% (95% confidence interval [CI]: 27%, 43%) for a PI-RADS score greater than or equal to 3 and 49% (95% CI: 40%, 58%) for a PI-RADS score greater than or equal to 4. The interquartile ranges of PPV at these same PI-RADS score thresholds were 27%–44% and 27%–48%, respectively.

What is clinically significant prostate cancer? ›

A doctor determines that prostate cancer is clinically significant when it is aggressive, likely to spread if not addressed and presents a risk to the patient. In these cases, doctors recommend the patient undergo immediate treatment.

What is a PI-RADS 3 abnormality? ›

PI-RADS 2: low (clinically significant cancer is unlikely to be present) PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal) PI-RADS 4: high (clinically significant cancer is likely to be present) PI-RADS 5: very high (clinically significant cancer is highly likely to be present)

What is the PSA density for PI-RADS 3? ›

The optimal cut-off value of PSAD to investigate clinically significant prostate cancer in our population in patients with PI-RADS 3 score is 0.11 ng/ml/cc.

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