Contemporary Approach to Prostate Imaging and Data Reporting System Score 3 Lesions

Area of Science:

• Radiology
• Urology
• Oncology

Background:

• Prostate imaging has evolved, with PI-RADS (Prostate Imaging Reporting and Data System) becoming standard for assessing prostate cancer risk.
• PI-RADS 3 lesions present equivocal findings for clinically significant prostate cancer (csPCa), posing diagnostic challenges.
• Detection rates for csPCa in PI-RADS 3 lesions range from 10% to 35%.

Purpose of the Study:

• To review technical and clinical considerations for PI-RADS 3 lesions in prostate MRI.
• To discuss factors influencing PI-RADS scoring, including MRI quality and radiologist expertise.
• To explore the role of diffusion-weighted imaging (DWI) and biparametric MRI (bpMRI) in evaluating PI-RADS 3 lesions.

Main Methods:

• Review of PI-RADS v.2.1 updated definitions for peripheral zone (PZ) and transition zone (TZ) lesions.
• Analysis of the impact of MRI quality and radiologist experience on PI-RADS 3 lesion reporting.
• Evaluation of DWI's role in assessing TZ lesions and potential score upgrades.
• Consideration of bpMRI as an alternative for specific patient groups.

Main Results:

• PI-RADS 3 lesion reporting is influenced by MRI quality and radiologist expertise.
• Updated PI-RADS v.2.1 definitions affect scoring in the PZ and TZ.
• DWI can aid in assessing TZ lesions, potentially upgrading PI-RADS 2 lesions to 3.
• bpMRI may increase indeterminate cases requiring biopsy.

Conclusions:

• Managing patients with PI-RADS 3 (equivocal) prostate MRI findings remains a clinical challenge.
• Further research utilizing molecular/imaging markers and artificial intelligence is needed for better patient selection for biopsy.
• Standardizing assessment and improving diagnostic accuracy for PI-RADS 3 lesions are critical for optimal prostate cancer management.