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Synopsis of the PI-RADS v2 Guidelines for Multiparametric ...

Platinum Priority EditorialReferring to the article published on pp. 16 40 of this issueSynopsis of the PI-RADS v2 Guidelines for MultiparametricProstate Magnetic Resonance imaging and Recommendationsfor UseJelle O. Barentsza,*,y, Jeffrey C. Weinrebb,y, Sadhna Vermac, Harriet C. Thoenyd,Clare M. Tempanye, Faina Shternf, Anwar R. Padhanig, Daniel Margolish, Katarzyna J. Macurai,Masoom A. Haiderj, Francois Cornudk, Peter L. ChoykelaDepartment of Radiology and Nuclear Medicine Radboudumc, Nijmegen, The Netherlands;bYale School of Medicine, New Haven, CT, USA;cUniversity ofCincinnati, Cincinnati, OH, USA;dHarvard University, Boston, MA, USA;eUniversity Hospital of Bern, Bern, Switzerland;fAdMeTech Foundation, Boston, MA,USA;gPaul Strickland Scanner Centre, Mount Vernon Hospital, Northwood, Middlesex, UK;hUniversity of California, Los Angeles, CA, USA;iJohns HopkinsUniversity, Baltimore, MD, USA;jUniversity of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada;kRene Descartes University, Paris, France;lNational Institutes of Health, Bethesda, MD, USAR apid technical advances have enabled multiparametricmagnetic resonance imaging (mpMRI) combined withmagnetic resonance (MR) targeted biopsy

the key images for detecting significant cancers, especially in the TZ. 1.3. Diffusion weighted imaging DWI reflects and measures the random motion of water

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1 Platinum Priority EditorialReferring to the article published on pp. 16 40 of this issueSynopsis of the PI-RADS v2 Guidelines for MultiparametricProstate Magnetic Resonance imaging and Recommendationsfor UseJelle O. Barentsza,*,y, Jeffrey C. Weinrebb,y, Sadhna Vermac, Harriet C. Thoenyd,Clare M. Tempanye, Faina Shternf, Anwar R. Padhanig, Daniel Margolish, Katarzyna J. Macurai,Masoom A. Haiderj, Francois Cornudk, Peter L. ChoykelaDepartment of Radiology and Nuclear Medicine Radboudumc, Nijmegen, The Netherlands;bYale School of Medicine, New Haven, CT, USA;cUniversity ofCincinnati, Cincinnati, OH, USA;dHarvard University, Boston, MA, USA;eUniversity Hospital of Bern, Bern, Switzerland;fAdMeTech Foundation, Boston, MA,USA;gPaul Strickland Scanner Centre, Mount Vernon Hospital, Northwood, Middlesex, UK;hUniversity of California, Los Angeles, CA, USA;iJohns HopkinsUniversity, Baltimore, MD, USA;jUniversity of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada;kRene Descartes University, Paris, France.

2 LNational Institutes of Health, Bethesda, MD, USAR apid technical advances have enabled multiparametricmagnetic resonance imaging (mpMRI) combined withmagnetic resonance (MR) targeted biopsy to becomevaluable tools for early detection of clinically significantprostate cancer (PCa) while reducing overdiagnosis ofindolent PCa[1 6]. There has been concern, however, thatthe widespread implementation and acceptance of mpMRIcould be impaired by a lack of standardisation of imageacquisition, interpretation and reporting guidance, andinter- and intraobserver variability that could result in poorclinical test performance in daily practise[7].To expedite clinical evaluation and large-scale imple-mentation of mpMRI, in May 2010 AdMeTech Foundation sInternational Prostate MRI Working Group recommendeddevelopment of standards of clinical performance byestablishing a prostate imaging reporting and assessmentsystem using BI-RADS (Breast imaging and ReportingArchiving Data System) as a model.

3 Dickinson et al[8]attempted to develop criteria for standardised acquisitionand interpretation of mpMRI, but they noted that it wasextremely difficult to define such criteria, even amongexperts in the field, and that reliable implementation intodaily clinical practice remained problematic. To overcomethese limitations, the European Society of UrogenitalRadiology (ESUR) developed consensus-based guidelinesfor prostate mpMRI, including clinical indications, minimaland optimal imaging acquisition protocols, and a structuredcategory assessment system known as the Prostate Imagingand Reporting and Data System ( PI-RADS ) version 1 ( PI-RADS v1)[9].Since its publication in 2012, the PI-RADS v1 system hasachieved some acceptance, especially in Europe, and hasbeen validated in prospective studies, randomised trials,and systematic analyses.

4 A recent systematic review andmeta-analysis[10]evaluating 14 published studies usingPI-RADS v1 showed pooled sensitivity and specificity of 78%(95% confidence interval [CI], 72 89%) and 79% (95% CI: 68 86%), respectively, for detecting significant PCa, demon-strating that mpMRI significantly changes the risk distribu-tion of men with newly diagnosed PCa towards an increasedprevalence of high-risk disease. Improved risk managementwith better identification of significant versus insignificantcancers may lead to more specific and individualisedtreatment options and less overtreatment of PI-RADS v1, it was not specified exactly how tocombine the scores from each MRI sequence to derive anoverall category assessment. This led to confusion in itsEUROPEAN UROLOGY 69 (2016) 41 49available at homepage: of original article: *Corresponding author.

5 Department of Radiology, Radboud University Nijmegen Medical Centre, PO Box 9101, Nijmegen, 6500 HB, The Barentsz).yThese authors are co-first #2015 European Association of Urology. Published by Elsevier All rights , and variable approaches were used. Thiscontributed to the variability of PI-RADS v1 performance[10].Toimprovethisperformance ,Vache etal[11]suggestedrefinement of the weighting given to each individual early 2012, a joint steering committee of the AmericanCollege of Radiology, ESUR, and AdMeTech Foundationagreed to collaborate on the development of an improvedPI-RADS version 2 ( PI-RADS v2). The PI-RADS v2 documentwas released online in December 2014[12]. The specificaims were to establish Guidelines for minimum acceptabletechnical parameters for prostate mpMRI, to simplify andstandardise the terminology and content of mpMRI reports,to develop assessment categories that summarise the levelsof suspicion or risk of having significant PCa, to reducevariability in imaging interpretations, to educate andenhance communication with referring clinicians, to enablestandardised data collection for outcomes monitoring, andto facilitate quality assurance and research with the overallaims of improving patient outcomes.

6 PI-RADS v2 is intendedto be a living document that evolves as clinical experienceand scientific validation data complete PI-RADS v2 document includes informa-tion regarding clinical considerations and technical speci-fications for mpMRI, normal anatomy and benign findings, Guidelines and caveats for assessment and reporting ofprostate mpMRI examinations, figures illustrating relevantfindings on MR images, a diagram for mapping of findings,report templates, and a lexicon of terminology. An onlineatlas of findings and cases is also being developed as alearning and reference tool ( ). This paper provides ashort description of PI-RADS v2. It provides discussion ofsome of the key differences and improvements comparedwith PI-RADS v1 (Table 1) and is focussed on the assessmentcriteria for detection and diagnosis of significant PCa onmpMRI examinations and clinical uses and v2 is not intended to be a comprehensive PCadiagnosis manual; it should be used in conjunction withother resources.

7 Its intended clinical application is for thediagnostic evaluation and risk assessment of patients withsuspected PCa prior to or after transrectal ultrasound(TRUS) biopsy. It has not been developed for detectingsuspected recurrent PCa following considerations for image acquisitionThe prostate mpMRI acquisition protocol should alwaysinclude T2-weighted (T2W) and T1-weighted (T1W)sequences, diffusion weighted imaging (DWI), and dynamiccontrast-enhanced imaging (DCE) sequences. Technologistsperforming the examination and/or supervising radiologistsshould undertake quality control of images. If image qualityof a pulse sequence is compromised because of patientmotion or another reason, measures should be taken torectify the problem and, if possible, the sequence should mpMRI at both and 3 T has become wellestablished, and satisfactory technical results have beenobtained at both magnetic field strengths; however, mostmembers of the PI-RADS steering committee prefer, use,and recommend 3 T for prostate MRI.

8 Performing mpMRI atmagnetic field strengths< T is not advised. At this time,there is no consensus among experts concerning thepotential benefits of the use of endorectal coils for cancerdetection, and their use varies according to the clinicalsituation, local expertise, and available equipment. Takingthese factors into consideration, the supervising radiologistshould optimise imaging protocols to obtain the best andmost consistent image quality possible on the MRI scannerused at the particular institution or T1-weighted imagesT1W images are used primarily to determine the presenceof postbiopsy haemorrhage within the prostate and seminalvesicles and to delineate the gland boundary. T1W imagesmay also be useful for detection of nodal and skeletalmetastases (the latter in the context of preliminary tumourstaging when a highly suspicious prostatic lesion isdetected, before biopsy confirmation).

9 T2-weighted imagesT2W images are used to discern prostatic zonal anatomy; toassess abnormalities within the gland, especially in thetransition zone (TZ); and to evaluate the patient for seminalvesicle invasion or extraprostatic extension. The quality ofthese images should be as high as possible because they areTable 1 Comparison of Prostate imaging and Reporting and Data System versions 1 and 2PI-RADS v1PI-RADS v2A sum score of 3 15 (20 with MRSI) for T2W + DWI +DCE (+ MRSI) is suggested1 5 point dominant score: For peripheral zone, DWI is dominant For transition zone, T2W is dominantEqual role for DCE (5-point scale)Secondary role for DCE (positive or negative)For DWI: ADC images are mandatoryFor DWI: ADC and high b-value images (b value>1400) are mandatory27-Sector map39-Sector mapMRSI can be includedSize is not used for T2W + DWIMRSI is not includedSize (>15 mm) is used for T2W + DWI to separate PI-RADS scores 4 and 5 ADC = apparent diffusion coefficient; DCE = dynamic contrast-enhanced imaging .

10 DWI - diffusion weighted imaging ; MRSI = magnetic resonance spectroscopicimaging; PI-RADS = Prostate imaging and Reporting and Data System; T2W = T2-weighted imaging ; v = UROLOGY 69 (2016) 41 4942the key images for detecting significant cancers, especiallyin the Diffusion weighted imagingDWI reflects and measures the random motion of watermolecules, the so-called Brownian motion, which becomesimpeded focally when cancer is present. DWI is a keycomponent of prostate mpMRI examinations, especially fordetection of significant cancers in the peripheral zone (PZ).Diffusion weighted (DW) images are used to calculateapparent diffusion coefficient (ADC) maps (with monoexpo-nential fitting of DW images acquired at b values 1000 s/mm2). High b-value images ( 1400 s/mm2) shouldbe obtained (by direct acquisition or computed from thesource DWI images) to facilitate detection of clinicallysignificant PCa.


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