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• W3016653559 abstract "HomeRadiologyVol. 296, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialVariation of PI-RADS Interpretations between Experts: A Significant LimitationLaurent Milot Laurent Milot Author AffiliationsFrom the Body and VIR Radiology Department, Hospices Civils de Lyon, Hôpital Edouard Herriot 5, place D’Arsonval, 69003 Lyon, France.Address correspondence to the author (e-mail: [email protected]).Laurent Milot Published Online:Apr 21 2020https://doi.org/10.1148/radiol.2020192650MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Westphalen et al in this issue.Dr Milot is a body radiologist with specific clinical and research expertise in abdominal and genitourinary MRI. After many years as associate professor of radiology in Toronto, Canada, he is now the associate head of the Department of Diagnostic and Vascular and Interventional Radiologic Imaging at the Edouard Herriot Hospital in Lyon, France.Download as PowerPointOpen in Image Viewer Prostate cancer is a common disease of markedly variable prognoses. Screening for prostate cancer carries a risk of overdetection of indolent cancers, which can lead to overtreatment. However, underdetection of more aggressive cancers can lead to cancer-related morbidity and death.Multiple strategies have been explored in the hope of finding the optimal balance between overdiagnosis and underdiagnosis. Multiparametric MRI has emerged as an essential imaging tool for patients at risk for prostate cancer. This is due to the combination of morphologic information (high-spatial-resolution T2-weighted imaging) and functional imaging capability (especially diffusion-weighted imaging, linked to cancer grade). However, reporting of prostate MRI results can be difficult, especially how much to emphasize different components of the MRI scan for determining final recommendations.To overcome this issue, the Prostate Imaging Reporting and Data System (PI-RADS) has been proposed and updated by the American College of Radiology and the European Society of Urogenital Radiology. The second version of PI-RADS includes standardized guidelines for interpretation and reporting (1). The algorithm recommends reporting of separate scores for each sequence (diffusion-weighted imaging, T2-weighted imaging, dynamic contrast material–enhanced MRI, etc) and then the reporting of a composite score reflecting the likelihood (probability) of prostate cancer according to lesion and in a given patient. The scores range from 1 (very low probability of cancer) to 5 (very high probability of cancer).Due to its practical use and relatively straightforward implementation, PI-RADS was quickly adopted into clinical practice. Since then, some studies have raised concern over the variability of prostate MRI reporting and performances in the diagnosis of prostate cancer (2). Awareness of such variability is necessary to understand the true role and limitations of prostate MRI as a means of diagnosing prostate cancer.In this issue of Radiology, Westphalen and colleagues (3) evaluated the positive predictive value (PPV) of PI-RADS in the detection of clinically significant prostate cancers and its variability across expert centers, each of which included at least one member of the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel (which represents an international panel of experts). A secondary end point was to identify influencing factors explaining this variability. The key findings were that the PPV of PI-RADS varied significantly across centers and was low overall.Westphalen et al (3) evaluated a large cohort of 3449 patients from 26 centers with a total of 5082 lesions. There were 1698 clinically significant cancers in 2082 men with cancer. All patients were adult men with suspected prostate cancer (elevated prostate-specific antigen level or abnormal digital rectal examination) or untreated biopsy-proven tumor. The patients underwent prostate MRI examination, which was performed and interpreted according to the PI-RADS recommendations, followed by MRI-targeted biopsy. Scans were interpreted as part of standard clinical care at the individual centers. Biopsy results were used as the reference standard. The main factor evaluated in the study was the variability in PPV, namely the fact that a positive prostate MRI scan helps identify a clinically significant cancer. To quantify and test for variation across centers, the authors used a robust and refined statistical model. This model enabled the estimation of the potential effects of many patient- and center-related parameters on the results.For the practicing radiologist, the most clinically useful finding reported in this article was the low PPV of PI-RADS across all centers: the PPV was 15% for a PI-RADS score of 3, 39% for a PI-RADS score of 4, and 72% for a PI-RADS score of 5. Not surprisingly, results were better for lesions located in the peripheral zone than for lesions located in the transition zone. Transition zone lesions are known to be more challenging to evaluate. Interestingly, the authors found no effect of field strength (1.5 T vs 3 T) on the PPV.Other important findings from this study included the high variation in PPV between sites—even after adjusting for baseline patient characteristics. Another important finding is the high percentage (24%) of men in whom the clinically significant cancer was found with the systematic biopsy and not with the MRI-guided biopsy, which is in line with results from other trials (4).Westphalen et al used biopsy rather than prostatectomy specimens as the reference standard. The choice to use biopsies as the reference standard is similar to the real practice situation, where only a minority of patients would undergo radical prostatectomy.The findings of Westphalen et al are important for the practicing radiologist. Westphalen et al showed that PI-RADS version 2 has substantial limitations in the diagnosis of clinically significant cancers in at-risk patients, especially a low PPV. The PPVs found in this study are well in line with the low PPVs reported in meta-analyses (5). Marked variability in PPVs across experienced centers is another important point. This likely reflects the clinical challenge of prostate MRI interpretation along with a yet-to-be-perfected PI-RADS reporting system.Radiologists who interpret prostate MRI scans using the PI-RADS version 2 system must be aware that they are using an imperfect tool and that a positive finding at MRI does not always translate to a positive finding at pathologic examination. Westphalen et al showed that it is expected to have numerous false-positive findings in cases of PI-RADS 3 and 4 lesions, even when experts read the MRI scans.I believe that radiologists should regularly audit their interpretations. They should evaluate the PPVs of their site interpretations. The high variability in PPVs seen in the study by Westphalen et al suggests that the results may vary considerably. Internal audits may lead to improvement in clinical interpretive skills.Finally, the results from this study should encourage the imaging community to further evaluate their PI-RADS reporting tool. What threshold of false-positive findings is acceptable? The variable results between centers should lead to more initiatives to standardize prostate MRI interpretation. Additional education programs may be needed.Although the medical community is waiting for more novel and specific imaging tools for prostate evaluation (6), MRI is most likely to remain the imaging modality of choice in the evaluation of patients at risk for prostate cancer. In this setting, it is important for practicing radiologists to be aware of the limitations of the techniques and reporting scheme they use in practice. Westphalen and colleagues provide an important contribution in that regard.Disclosures of Conflicts of Interest: L.M. disclosed no relevant relationships.References1. Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS Prostate Imaging Reporting and Data System: 2015, Version 2. Eur Urol 2016;69(1):16–40. Crossref, Medline, Google Scholar2. 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(12):5204–5214. Crossref, Medline, Google Scholar3. Westphalen AC, McCulloch CE, Anaokar JM, et al. Variability of the Positive Predictive Value of PI-RADS for Prostate MRI Across 26 Centers: Experience of the Society of Abdominal Radiology Prostate Cancer Disease-Focused Panel. Radiology 2020;296:76–84. Link, Google Scholar4. Klotz L, Loblaw A, Sugar L, et al. Active Surveillance Magnetic Resonance Imaging Study (ASIST): Results of a Randomized Multicenter Prospective Trial. Eur Urol 2019;75(2):300–309. Crossref, Medline, Google Scholar5. Barkovich EJ, Shankar PR, Westphalen AC. A Systematic Review of the Existing Prostate Imaging Reporting and Data System Version 2 (PI-RADSv2) Literature and Subset Meta-Analysis of PI-RADSv2 Categories Stratified by Gleason Scores. AJR Am J Roentgenol 2019;212(4):847–854. Crossref, Medline, Google Scholar6. Hoffmann MA, Wieler HJ, Baues C, Kuntz NJ, Richardsen I, Schreckenberger M. The Impact of 68Ga-PSMA PET/CT and PET/MRI on the Management of Prostate Cancer. Urology 2019;130:1–12. Crossref, Medline, Google ScholarArticle HistoryReceived: Dec 1 2019Revision requested: Dec 11 2019Revision received: Dec 13 2019Accepted: Dec 16 2019Published online: Apr 21 2020Published in print: July 2020 FiguresReferencesRelatedDetailsCited ByAutomated Patient-level Prostate Cancer Detection with Quantitative Diffusion Magnetic Resonance ImagingAllison Y.Zhong, Leonardino A.Digma, TroyHussain, Christine H.Feng, Christopher C.Conlin, KarenTye, Asona J.Lui, Maren M.S.Andreassen, Ana E.Rodríguez-Soto, RoshanKarunamuni, JoshuaKuperman, Christopher J.Kane, RebeccaRakow-Penner, Michael E.Hahn, Anders M.Dale, Tyler M.Seibert2023 | European Urology Open Science, Vol. 47Accompanying This ArticleVariability of the Positive Predictive Value of PI-RADS for Prostate MRI across 26 Centers: Experience of the Society of Abdominal Radiology Prostate Cancer Disease-focused PanelApr 21 2020RadiologyRecommended Articles Introducing a Standard in Prostate Cancer Imaging EvaluationRadiology2021Volume: 302Issue: 3pp. 603-604Multiparametric MRI of the Prostate: Beyond Cancer Detection and StagingRadiology2021Volume: 299Issue: 3pp. 624-625Organized Chaos: Does PI-RADS Version 2 Work in the Transition Zone?Radiology2018Volume: 288Issue: 2pp. 492-494PI-RADS and Multiparametric MRI: The Shape of Things to Come for Prostate CancerRadiology2023Volume: 307Issue: 4Prostate-specific Membrane Antigen PET in Addition to Multiparametric Prostate MRI Triage in the Diagnosis of Prostate Cancer: The Future is AvidRadiology: Imaging Cancer2022Volume: 4Issue: 1See More RSNA Education Exhibits Prostate MR Imaging: How to Do and What to ReportDigital Posters2020Biochemical Recurrence of Prostate Cancer: Where Cancer Recurs, Where MRI Fails, and Where PSMA PET Fails?Digital Posters2022False-Negative Clinically Significant Prostate Cancers on Prostate Multiparametric MR Imaging: What Radiologists Should KnowDigital Posters2020 RSNA Case Collection Anterior transition zone prostate adenocarcinomaRSNA Case Collection2020Peripheral Zone Prostate Cancer with PseudocapsuleRSNA Case Collection2022Parasagittal meningiomaRSNA Case Collection2022 Vol. 296, No. 1 Metrics Altmetric Score PDF download" @default.
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