Impact of prostate mpMRI quality on diagnostic accuracy in prostate cancer: a prospective study

To prospectively evaluate the influence of multiparametric magnetic resonance imaging (mpMRI) quality, as assessed by the Prostate Imaging Quality (PI-QUAL) score, on diagnostic accuracy in men undergoing prostate biopsy after external mpMRI at a tertiary referral center.

From June 2024 to July 2025, a total of 246 consecutive patients referred for prostate biopsy after external mpMRI were prospectively enrolled. All patients underwent systematic biopsy with targeted biopsy when indicated. External mpMRI scans were centrally reviewed by expert uro-radiologists blinded to clinical and pathological data. Image quality and lesion grading were reassessed using PI-QUAL v2 and Prostate Imaging Reporting and Data System (PI-RADS) v2.1. Accuracy for clinically significant prostate cancer (csPCa; International Society of Urological Pathology [ISUP] grade ≥2) was assessed using receiver operating characteristic-derived area under the curve AUC before and after review, stratified by PI-QUAL (1-2 vs 3).

Median age and prostate-specific antigen (PSA) were 66.5 years (interquartile range [IQR] 61-73) and 6.6 ng/mL (IQR 4.8-9.7), respectively, and csPCa was detected in 128 patients (52%). After review, 49 (20%), 113 (46%), and 84 (34%) mpMRI scans were classified as PI-QUAL 1, 2, and 3, respectively. The proportion of indeterminate PI-RADS 3 findings was 27% for PI-QUAL 1, 15% for PI-QUAL 2, and 8% for PI-QUAL 3. PI-QUAL 3 scans demonstrated greater diagnostic accuracy than PI-QUAL 1-2 (AUC 0.79 vs 0.66, P = 0.01). Central review improved csPCa detection in both PI-QUAL 1-2 (AUC 0.63 vs 0.78, P < 0.01) and PI-QUAL 3 (AUC 0.77 vs 0.89, P < 0.01) scans.

High-quality mpMRI achieved approximately 15% higher diagnostic accuracy for csPCa and were associated with a lower prevalence of indeterminate findings than were low-quality MRI scans; centralized expert review reclassified nearly half of PI-RADS assessments. These findings support upfront high-quality mpMRI acquisition and PI-QUAL-based quality control to optimize diagnosis and reduce unnecessary procedures.