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Updated: Nov 23, 2025
A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound
Published on: March 21, 2025
MRI features of the normal prostatic peripheral zone: the relationship between age and signal heterogeneity on T2WI,
Vlad Bura1, Iztok Caglic2, Ziga Snoj3
1Department of Radiology, County Clinical Emergency Hospital, Cluj-Napoca, Cluj, Romania.
Objectives:
To assess the multiparametric MRI (mpMRI) appearances of normal peripheral zone (PZ) across age groups in a biopsy-naïve population, where prostate cancer (PCa) was subsequently excluded, and propose a scoring system for background PZ changes.
Methods:
This retrospective study included 175 consecutive biopsy-naïve patients (40-74 years) referred with a suspicion of PCa, but with subsequent negative investigations. Patients were grouped by age into categories ≤ 54, 55-59, 60-64, and ≥ 65 years. MpMRI sequences (T2-weighted imaging [T2WI], diffusion-weighted imaging [DWI]/apparent diffusion coefficient [ADC], and dynamic contrast-enhanced imaging [DCE]) were independently evaluated by two uro-radiologists on a proposed 4-point grading scale for background change on each sequence, wherein score 1 mirrored PIRADS-1 change and score 4 represented diffuse background change. Peripheral zone T2WI signal intensity and ADC values were also analyzed for trends relating to age.
Results:
There was a negative correlation between age and assigned background PZ scores for each mpMRI sequence: T2WI: r = - 0.52, DWI: r = - 0.49, DCE: r = - 0.45, p < 0.001. Patients aged ≤ 54 years had mean scores of 3.0 (T2WI), 2.7 (DWI), and 3.1 (DCE), whilst patients ≥ 65 years had significantly lower mean scores of 1.7, 1.4, and 1.9, respectively. There was moderate inter-reader agreement for all scores (range κ = 0.43-0.58). Statistically significant positive correlations were found for age versus normalized T2WI signal intensity (r = 0.2, p = 0.009) and age versus ADC values (r = 0.33, p = 0.001).
Conclusion:
The normal PZ in younger patients (≤ 54 years) demonstrates significantly lower T2WI signal intensity, lower ADC values, and diffuse enhancement on DCE, which may hinder diagnostic interpretation in these patients. The proposed standardized PZ background scoring system may help convey the potential for diagnostic uncertainty to clinicians.
Key Points:
• Significant, positive correlations were found between increasing age and higher normalized T2-weighted signal intensity and mean ADC values of the prostatic peripheral zone. • Younger men exhibit lower T2-weighted imaging signal intensity, lower ADC values, and diffuse enhancement on dynamic contrast-enhanced imaging, which may hinder MRI interpretation. • A scoring system is proposed which aims towards a standardized assessment of the normal background PZ. This may help convey the potential for diagnostic uncertainty to clinicians.
Insights
Multiparametric MRI (mpMRI) shows normal prostate peripheral zone (PZ) changes with age. Younger men have lower signal intensity and ADC values, potentially impacting interpretation. A scoring system is proposed to aid clinicians.
Area of Science:
- Radiology
- Oncology
- Medical Imaging
Background:
- Prostate cancer (PCa) diagnosis relies on multiparametric MRI (mpMRI).
- Understanding normal peripheral zone (PZ) variations is crucial for accurate PCa detection.
- Age-related changes in the normal PZ can mimic or obscure suspicious lesions.
Purpose of the Study:
- To characterize age-related multiparametric MRI (mpMRI) appearances of the normal peripheral zone (PZ).
- To evaluate the utility of a proposed scoring system for background PZ changes.
- To identify mpMRI features in younger men that may complicate PCa diagnosis.
Main Methods:
- Retrospective analysis of 175 biopsy-naïve patients (40-74 years) with suspected PCa but negative investigations.
- mpMRI sequences (T2WI, DWI/ADC, DCE) were assessed using a 4-point grading scale for background PZ changes.
- Correlation analysis of age with PZ signal intensity, ADC values, and background scores.
Main Results:
- Significant negative correlation between age and background PZ scores across all mpMRI sequences (p < 0.001).
- Younger patients (≤ 54 years) showed higher mean background scores compared to older patients (≥ 65 years).
- Positive correlation between age and normalized T2WI signal intensity (r=0.2) and ADC values (r=0.33).
Conclusions:
- Normal PZ in younger men exhibits lower T2WI signal intensity, lower ADC values, and diffuse DCE enhancement, potentially hindering interpretation.
- The proposed scoring system for PZ background changes may assist clinicians in assessing diagnostic uncertainty.
- Age is a significant factor influencing the mpMRI appearance of the normal peripheral zone.
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