Korean J Radiol.  2018 Apr;19(2):193-200. 10.3348/kjr.2018.19.2.193.

Prostate Imaging-Reporting and Data System Version 2: Beyond Prostate Cancer Detection

• Park SY
• Cho NH
• Jung DC
• Oh YT

• KMID: 2404915
• DOI: http://doi.org/10.3348/kjr.2018.19.2.193

Abstract

The main purpose of Prostate Imaging-Reporting and Data System Version 2 (PI-RADSv2) is to effectively detect clinically significant prostate cancers (csPCa) using multiparametric magnetic resonance imaging. Since the first introduction of PI-RADSv2, researchers have validated its diagnostic performance in identifying csPCa, and these promising data have influenced biopsy and treatment schemes. However, in this article, we focused on the potential of PI-RADSv2 in relation to various aspects of PCa such as Gleason score, tumor volume, extraprostatic extension, lymph node metastasis, and postoperative biochemical recurrence, beyond prostate cancer detection.

Keyword

PI-RADS; Prostate cancer; Magnetic resonance imaging; Recurrence; Prognosis

MeSH Terms

Biopsy
Information Systems*
Lymph Nodes
Magnetic Resonance Imaging
Neoplasm Grading
Neoplasm Metastasis
Passive Cutaneous Anaphylaxis
Prognosis
Prostate*
Prostatic Neoplasms*
Recurrence
Tumor Burden

Figure

• 

  Fig. 1 69-year-old man with serum PSA level of 18.6 ng/mL and biopsy-proven GS 6 PCa. A. T2WI showed focal hypointense area in anterior TZ of prostate gland (arrow). PI-RADSv2 score on T2WI was 5. B, C. High b-value DWI and ADC map consistently showed focal area of diffusion restriction at corresponding site (arrow). Final PI-RADSv2 score on DWI was 5. Thus, final PI-RADSv2 score was 5 for TZ lesion. D. In surgical specimen, GS 7 PCa was confirmed (dotted area). This is case of GS upgrading, which was suspected by PI-RADSv2. ADC = apparent diffusion coefficient, DWI = diffusion-weighted imaging, GS = Gleason score, PCa = prostate cancer, PI-RADSv2 = Prostate Imaging-Reporting and Data System Version 2, PSA = prostate-specific antigen, TZ = transition zone, T2WI = T2-weighted imaging

• 

  Fig. 2 DWI and ADC maps of two different patients. A, B. 53-year-old man with serum PSA level of 7.6 ng/mL and PCa. High b-value DWI and ADC map showed focal area of diffusion restriction, measuring 0.9 cm, in left PZ of prostate gland (arrow). DWI and final PI-RADSv2 scores were 4 each. Mean tumor ADC was 0.91 × 10-3 mm2/s. Surgery revealed GS 6 PCa. C, D. 65-year-old man with serum PSA level of 13.2 ng/mL and PCa. High b-value DWI and ADC map showed focal area of diffusion restriction, measuring 1.0 cm, in left PZ of prostate gland (arrow). DWI and final PI-RADSv2 scores were 4 each. Mean tumor ADC was 0.71 × 10-3 mm2/s. Surgery revealed GS 7 PCa. These are cases of PCa with different GS, whose PI-RADSv2 scores were same, but tumor ADCs were different. PZ = peripheral zone

• 

  Fig. 3 67-year-old man with serum PSA level of 22.4 ng/mL and PCa. A, B. High b-value DWI and ADC map showed focal, indistinct area of mild diffusion restriction in right PZ of prostate gland (arrow). DWI score was 2. C. DCE MRI showed diffuse, gradual enhancement around corresponding site (arrow), which is suggestive of negative findings. Thus, final PI-RADSv2 score on DWI was 2 for PZ lesion. D. In surgical specimen, GS 6 PCa with tumor volume of 0.8 cm3 was confirmed (dotted area). According to Epstein criteria, this is case of csPCa underestimated by PI-RADSv2. CsPCa = clinically significant prostate cancer, DCE = dynamic contrast-enhanced, MRI = magnetic resonance imaging

• 

  Fig. 4 54-year-old man with serum PSA level of 6.2 ng/mL and PCa. A, B. High b-value DWI and ADC map showed focal area of marked diffusion restriction, measuring 1.5 cm, in right PZ of prostate gland (arrow). Overt protrusion of lesion into right extraprostatic area was also seen. DWI score was consistently 5 as measured by two independent, experienced radiologists. C. T2WI also demonstrated focal hypointense lesion with high suspicion of right EPE (arrow). Thus, final PI-RADSv2 score on DWI was also consistently 5 for PZ lesion as measured by two independent, experienced radiologists. D. In surgical specimen, GS 8 PCa with right EPE was confirmed (dotted area). EPE = extraprostatic extension

• 

  Fig. 5 44-year-old man with serum PSA level of 22.0 ng/mL and PCa. A, B. High b-value DWI and ADC map showed focal area of marked diffusion restriction, measuring 1.1 cm, in right PZ of prostate gland (arrow). Broad tumor-capsule contact was also seen. DWI score was 4 and 5 as measured by two independent, experienced radiologists, respectively, due to different interpretation regarding definite EPE. C. T2WI also demonstrated focal hypointense lesion with broad tumor-capsule contact (arrow). Thus, final PI-RADSv2 score on DWI was also 4 and 5 as measured by two independent, experienced radiologists, respectively. D. In surgical specimen, GS 7 PCa without EPE was confirmed (dotted area).

• 

  Fig. 6 69-year-old man with serum PSA level of 19.7 ng/mL and PCa. A, B. High b-value DWI and ADC map showed focal area of marked diffusion restriction, measuring 1.8 cm, in right PZ of prostate gland (arrow). Overt protrusion of lesion into right extraprostatic area was also seen. DWI score was 5. C. DCE MRI also showed positive findings (arrow). Thus, final PI-RADSv2 score was 5. D. In surgical specimen, GS 9 PCa with right EPE was confirmed (dotted area). In this patient, normal-sized (e.g., short-axis diameter < 0.8 cm) pelvic lymph node metastasis was proven surgically.

Reference

1. Park SY, Jung DC, Oh YT, Cho NH, Choi YD, Rha KH, et al. Prostate cancer: PI-RADS version 2 helps preoperatively predict clinically significant cancers. Radiology. 2016; 280:108–116.

2. Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Diagnostic performance of prostate imaging reporting and data system version 2 for detection of prostate cancer: a systematic review and diagnostic meta-analysis. Eur Urol. 2017; 72:177–188.

3. Zhang L, Tang M, Chen S, Lei X, Zhang X, Huan Y. A meta-analysis of use of prostate imaging reporting and data system version 2 (PI-RADS V2) with multiparametric MR imaging for the detection of prostate cancer. Eur Radiol. 2017; 27:5204–5214.

4. van As NJ, Norman AR, Thomas K, Khoo VS, Thompson A, Huddart RA, et al. Predicting the probability of deferred radical treatment for localised prostate cancer managed by active surveillance. Eur Urol. 2008; 54:1297–1305.

5. Mehralivand S, Bednarova S, Shih JH, Mertan FV, Gaur S, Merino MJ, et al. Prospective evaluation of PI-RADS™ version 2 using the international society of urological pathology prostate cancer grade group system. J Urol. 2017; 198:583–590.

6. Martorana E, Pirola GM, Scialpi M, Micali S, Iseppi A, Bonetti LR, et al. Lesion volume predicts prostate cancer risk and aggressiveness: validation of its value alone and matched with prostate imaging reporting and data system score. BJU Int. 2017; 120:92–103.

7. Tan N, Lin WC, Khoshnoodi P, Asvadi NH, Yoshida J, Margolis DJ, et al. In-Bore 3-T MR-guided transrectal targeted prostate biopsy: prostate imaging reporting and data system version 2-based diagnostic performance for detection of prostate cancer. Radiology. 2017; 283:130–139.

8. Washino S, Okochi T, Saito K, Konishi T, Hirai M, Kobayashi Y, et al. Combination of prostate imaging reporting and data system (PI-RADS) score and prostate-specific antigen (PSA) density predicts biopsy outcome in prostate biopsy naive patients. BJU Int. 2017; 119:225–233.

9. Baco E, Rud E, Eri LM, Moen G, Vlatkovic L, Svindland A, et al. A randomized controlled trial to assess and compare the outcomes of two-core prostate biopsy guided by fused magnetic resonance and transrectal ultrasound images and traditional 12-core systematic biopsy. Eur Urol. 2016; 69:149–156.

10. Seo JW, Shin SJ, Taik Oh Y, Jung DC, Cho NH, Choi YD, et al. PI-RADS version 2: detection of clinically significant cancer in patients with biopsy gleason score 6 prostate cancer. AJR Am J Roentgenol. 2017; 209:W1–W9.

11. Abdollah F, Suardi N, Gallina A, Bianchi M, Tutolo M, Passoni N, et al. Extended pelvic lymph node dissection in prostate cancer: a 20-year audit in a single center. Ann Oncol. 2013; 24:1459–1466.

12. Park JJ, Kim CK, Park SY, Park BK, Lee HM, Cho SW. Prostate cancer: role of pretreatment multiparametric 3-T MRI in predicting biochemical recurrence after radical prostatectomy. AJR Am J Roentgenol. 2014; 202:W459–W465.

13. Weinreb JC, Barentsz JO, Choyke PL, Cornud F, Haider MA, Macura KJ, et al. PI-RADS prostate imaging - reporting and data system: 2015, version 2. Eur Urol. 2016; 69:16–40.

14. Fütterer JJ. Multiparametric MRI in the detection of clinically significant prostate cancer. Korean J Radiol. 2017; 18:597–606.

15. Maas MC, Fütterer JJ, Scheenen TW. Quantitative evaluation of computed high B value diffusion-weighted magnetic resonance imaging of the prostate. Invest Radiol. 2013; 48:779–786.

16. Ueno Y, Takahashi S, Kitajima K, Kimura T, Aoki I, Kawakami F, et al. Computed diffusion-weighted imaging using 3-T magnetic resonance imaging for prostate cancer diagnosis. Eur Radiol. 2013; 23:3509–3516.

17. Vargas HA, Akin O, Franiel T, Mazaheri Y, Zheng J, Moskowitz C, et al. Diffusion-weighted endorectal MR imaging at 3 T for prostate cancer: tumor detection and assessment of aggressiveness. Radiology. 2011; 259:775–784.

18. Chatterjee A, Watson G, Myint E, Sved P, McEntee M, Bourne R. Changes in epithelium, stroma, and lumen space correlate more strongly with gleason pattern and are stronger predictors of prostate ADC changes than cellularity metrics. Radiology. 2015; 277:751–762.

19. Park SY, Shin SJ, Jung DC, Cho NH, Choi YD, Rha KH, et al. PI-RADS version 2: quantitative analysis aids reliable interpretation of diffusion-weighted imaging for prostate cancer. Eur Radiol. 2017; 27:2776–2783.

20. Park SY, Oh YT, Jung DC, Cho NH, Choi YD, Rha KH, et al. Prediction of biochemical recurrence after radical prostatectomy with PI-RADS version 2 in prostate cancers: initial results. Eur Radiol. 2016; 26:2502–2509.

21. Woo S, Kim SY, Lee J, Kim SH, Cho JY. PI-RADS version 2 for prediction of pathological downgrading after radical prostatectomy: a preliminary study in patients with biopsy-proven Gleason Score 7 (3+4) prostate cancer. Eur Radiol. 2016; 26:3580–3587.

22. Ploussard G, Epstein JI, Montironi R, Carroll PR, Wirth M, Grimm MO, et al. The contemporary concept of significant versus insignificant prostate cancer. Eur Urol. 2011; 60:291–303.

23. Vargas HA, Akin O, Shukla-Dave A, Zhang J, Zakian KL, Zheng J, et al. Performance characteristics of MR imaging in the evaluation of clinically low-risk prostate cancer: a prospective study. Radiology. 2012; 265:478–487.

24. Le JD, Tan N, Shkolyar E, Lu DY, Kwan L, Marks LS, et al. Multifocality and prostate cancer detection by multiparametric magnetic resonance imaging: correlation with whole-mount histopathology. Eur Urol. 2015; 67:569–576.

25. Kitzing YX, Prando A, Varol C, Karczmar GS, Maclean F, Oto A. Benign conditions that mimic prostate carcinoma: MR imaging features with histopathologic correlation. Radiographics. 2016; 36:162–175.

26. Vargas HA, Hötker AM, Goldman DA, Moskowitz CS, Gondo T, Matsumoto K, et al. Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference. Eur Radiol. 2016; 26:1606–1612.

27. Langer DL, van der Kwast TH, Evans AJ, Sun L, Yaffe MJ, Trachtenberg J, et al. Intermixed normal tissue within prostate cancer: effect on MR imaging measurements of apparent diffusion coefficient and T2--sparse versus dense cancers. Radiology. 2008; 249:900–908.

28. Wolters T, Roobol MJ, van Leeuwen PJ, van den Bergh RC, Hoedemaeker RF, van Leenders GJ, et al. A critical analysis of the tumor volume threshold for clinically insignificant prostate cancer using a data set of a randomized screening trial. J Urol. 2011; 185:121–125.

29. Ting F, van Leeuwen PJ, Delprado W, Haynes AM, Brenner P, Stricker PD. Tumor volume in insignificant prostate cancer: Increasing the threshold is a safe approach to reduce over-treatment. Prostate. 2015; 75:1768–1773.

30. Kryvenko ON, Epstein JI. Definition of insignificant tumor volume of gleason score 3 + 3 = 6 (grade group 1) prostate cancer at radical prostatectomy-is it time to increase the threshold? J Urol. 2016; 196:1664–1669.

31. Kattan MW, Wheeler TM, Scardino PT. Postoperative nomogram for disease recurrence after radical prostatectomy for prostate cancer. J Clin Oncol. 1999; 17:1499–1507.

32. Mottet N, Bellmunt J, Bolla M, Briers E, Cumberbatch MG, De Santis M, et al. EAU-ESTRO-SIOG guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol. 2017; 71:618–629.

33. Gupta RT, Spilseth B, Patel N, Brown AF, Yu J. Multiparametric prostate MRI: focus on T2-weighted imaging and role in staging of prostate cancer. Abdom Radiol (NY). 2016; 41:831–843.

34. Kayat Bittencourt L, Litjens G, Hulsbergen-van de Kaa CA, Turkbey B, Gasparetto EL, Barentsz JO. Prostate cancer: the European society of urogenital radiology prostate imaging reporting and data system criteria for predicting extraprostatic extension by using 3-T multiparametric MR imaging. Radiology. 2015; 276:479–489.

35. Lim CS, McInnes MDF, Lim RS, Breau RH, Flood TA, Krishna S, et al. Prognostic value of Prostate Imaging and Data Reporting System (PI-RADS) v. 2 assessment categories 4 and 5 compared to histopathological outcomes after radical prostatectomy. J Magn Reson Imaging. 2017; 46:257–266.

36. Krishna S, Lim CS, McInnes MDF, Flood TA, Shabana WM, Lim RS, et al. Evaluation of MRI for diagnosis of extraprostatic extension in prostate cancer. J Magn Reson Imaging. 2018; 47:176–185.

37. Matsuoka Y, Ishioka J, Tanaka H, Kimura T, Yoshida S, Saito K, et al. Impact of the Prostate Imaging Reporting and Data System, Version 2, on MRI diagnosis for extracapsular extension of prostate cancer. AJR Am J Roentgenol. 2017; 209:W76–W84.

38. McMahon CJ, Rofsky NM, Pedrosa I. Lymphatic metastases from pelvic tumors: anatomic classification, characterization, and staging. Radiology. 2010; 254:31–46.

39. Hövels AM, Heesakkers RA, Adang EM, Jager GJ, Strum S, Hoogeveen YL, 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; 63:387–395.

40. Briganti A, Abdollah F, Nini A, Suardi N, Gallina A, Capitanio U, et al. Performance characteristics of computed tomography in detecting lymph node metastases in contemporary patients with prostate cancer treated with extended pelvic lymph node dissection. Eur Urol. 2012; 61:1132–1138.

41. Harisinghani MG, Barentsz J, Hahn PF, Deserno WM, Tabatabaei S, van de Kaa CH, et al. Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med. 2003; 348:2491–2499.

42. Thoeny HC, Triantafyllou M, Birkhaeuser FD, Froehlich JM, Tshering DW, Binser T, et al. Combined ultrasmall superparamagnetic particles of iron oxide-enhanced and diffusion-weighted magnetic resonance imaging reliably detect pelvic lymph node metastases in normal-sized nodes of bladder and prostate cancer patients. Eur Urol. 2009; 55:761–769.

43. Birkhäuser FD, Studer UE, Froehlich JM, Triantafyllou M, Bains LJ, Petralia G, et al. Combined ultrasmall superparamagnetic particles of iron oxide-enhanced and diffusion-weighted magnetic resonance imaging facilitates detection of metastases in normal-sized pelvic lymph nodes of patients with bladder and prostate cancer. Eur Urol. 2013; 64:953–960.

44. Vag T, Heck MM, Beer AJ, Souvatzoglou M, Weirich G, Holzapfel K, et al. Preoperative lymph node staging in patients with primary prostate cancer: comparison and correlation of quantitative imaging parameters in diffusion-weighted imaging and 11C-choline PET/CT. Eur Radiol. 2014; 24:1821–1826.

45. Herlemann A, Wenter V, Kretschmer A, Thierfelder KM, Bartenstein P, Faber C, et al. 68Ga-PSMA positron emission tomography/computed tomography provides accurate staging of lymph node regions prior to lymph node dissection in patients with prostate cancer. Eur Urol. 2016; 70:553–557.

46. Hövels AM, Heesakkers RA, Adang EM, Jager GJ, Barentsz JO. Cost-analysis of staging methods for lymph nodes in patients with prostate cancer: MRI with a lymph node-specific contrast agent compared to pelvic lymph node dissection or CT. Eur Radiol. 2004; 14:1707–1712.

47. Briganti A, Larcher A, Abdollah F, Capitanio U, Gallina A, Suardi N, et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol. 2012; 61:480–487.

48. Cagiannos I, Karakiewicz P, Eastham JA, Ohori M, Rabbani F, Gerigk C, et al. A preoperative nomogram identifying decreased risk of positive pelvic lymph nodes in patients with prostate cancer. J Urol. 2003; 170:1798–1803.

49. Kim KH, Lim SK, Kim HY, Han WK, Choi YD, Chung BH, et al. Yonsei nomogram to predict lymph node invasion in Asian men with prostate cancer during robotic era. BJU Int. 2014; 113:598–604.

50. Paño B, Sebastià C, Buñesch L, Mestres J, Salvador R, Macías NG, et al. Pathways of lymphatic spread in male urogenital pelvic malignancies. Radiographics. 2011; 31:135–160.

51. Zhang J, Hricak H, Shukla-Dave A, Akin O, Ishill NM, Carlino LJ, et al. Clinical stage T1c prostate cancer: evaluation with endorectal MR imaging and MR spectroscopic imaging. Radiology. 2009; 253:425–434.

52. Park SY, Shin SJ, Jung DC, Cho NH, Choi YD, Rha KH, et al. PI-RADS version 2: preoperative role in the detection of normal-sized pelvic lymph node metastasis in prostate cancer. Eur J Radiol. 2017; 91:22–28.

53. Fuchsjäger MH, Pucar D, Zelefsky MJ, Zhang Z, Mo Q, Ben-Porat LS, et al. Predicting post-external beam radiation therapy PSA relapse of prostate cancer using pretreatment MRI. Int J Radiat Oncol Biol Phys. 2010; 78:743–750.

54. Zhang YD, Wu CJ, Bao ML, Li H, Wang XN, Liu XS, et al. MR-based prognostic nomogram for prostate cancer after radical prostatectomy. J Magn Reson Imaging. 2017; 45:586–596.