CLASSIFICATION PI-RADS v2

FOR DUMMIES

Garrouche N., Gamaoun W., Yaacoub W, Arifa N.

Jemni H.
Radiology service CHU Sahloul of Sousse

Main author:
nadagarrouche@[Link]

Electronic educational presentation

Francophone Congress of Radiology 2017
INTRODUCTION
PI-RADS = Prostate Imaging and Reporting and
DataSystem
Introduced by the European Society of Radiology
Urogenital (ESUR)
the ESUR proposes recommendations
consensual to standardize practices with
an evaluation score (PI-RADS) and report
standardized
Two versions established until:
version 1 in 2012
Version 2 in 2015
PEDAGOGICAL OBJECTIVES
Identify the key sequences in
the interpretation of prostate MRIs

Identify the key lesions in the areas

peripheral and transitional zone of the prostate

Establish a correct classification of

prostatic lesions according to the PI system
RADS v2
 PROSTATIC RADIOANATOMY
The prostate can be divided into 5 compartments.
4 glandular zones and 1 non-zone
glandular

Glandular Zones Non-glandular zone

Peripheral Zone (PZ) fibro-muscular zone

Central Zone (CZ) anterior (AS)
Transitional Zone (TZ)
Glandular zone peri-
urethral
Radiologically, two areas are interesting to
evaluate
The peripheral area and the central area composed
of the transitional zone and of the periurethral tissue

AS

Prostatic urethra
TZ TZ
PZ PZ

CZ

ejaculatory ducts
 RADIO-ANATOMY OF THE PROSTATE
EN IRM
From top to bottom, the gland is divided into 3 levels:

The Base (includes parts of PZ, CZ, and TZ)

• the average part (includes parts of PZ,
TZ)
• the Apex (essentially comprises parts of
PZ+++ > TZ)
 Sagittal Coronale

Radio-Anatomy of the prostate in MRI obtained by a 1.5 T MRI

The sagittal and coronal T2 sequences show the division of the prostate.
in 3 levels in the cranio-caudal direction

Source image: Department of Radiology

University of New Mexico Hospital
In MRI, the transition zone is inseparable from the
central zones of prostatic hypertrophy
benign and the two associated areas are
considered as the central gland.

The peripheral zone is in hyper signal T2.

IRM (rich in glandular tissue)

Central lagging (TZ+CZ) is often heterogeneous.

with areas of hypersignal T2 (glandular tissue)
and others in hyposignal T2 (hypertrophic nodules)
fibrous
 THE PI-RADS SYSTEM
Designed to improve detection, localization,
characterization and stratification of risk in the
patients with suspected prostate cancer
The goals:
Establish a strict minimum acceptable for the parameters
techniques during the realization of the MRI
Simplifier et standardiser la terminologie et le contenu
reports in prostate MRI
Facilitate the use of MRI data for the
targeted biopsies
Develop cancer risk categories
prostate-related and adjust the management
Facilitate interdisciplinary communication
 PI-RADS Scale
very
5-point scale based on the PI-RADS 1 weak
probability of the combination
T2, diffusion and DCE
correlates with the presence of cancer weak
PI-RADS 2
clinically significant

intermediate
Calculated by adding the scores PI-RADS 3
of each of the 3 techniques
for each lesion
PI-RADS High
4
Prostate biopsies
will be considered for the
PI-RADS 4 or 5 lesions and PI- very high
RADS
avoided for the lesions 5
PI-RADS 1 and 2
 IRM PROTOCOL
Acquisition of the aortic bifurcation to the
pubic symphysis

T2 axial and coronal sequences*: fat sat

Axial T1 sequence*
At least two functional sequences:
Diffusion Weighted Imaging (DWI)
Dynamic Contrast-Enhanced MRI (DCE-MRI)
Spectroscopy (MRSI)*

non-systematic
T2 SE
Offers the best definition of prostate anatomy
Allows for the detection, localization, and staging of
prostate cancer
The T2 sequence alone is sensitive but not specific.
The specificity will be improved by the MRI sequences.
functional (DWI and DCE)
Prostate cancer most often appears as
a round lesion, poorly defined in T2 hypointensity of the
peripheral zone (PZ).
Lesions of prostatitis, hemorrhage, atrophy,
scars and post-therapeutic lesions can
simulate cancer on T2 sequences.
 L L
* P * P
IO IO
UGD

C C
B

T2 coronal sequence: The prostate is located in a muscular tunnel.

composed of the levator ani muscles (L) and obturator muscles
internal (IO). the periprostatic venous plexus and the vascular-nerve elements
(*) separate these muscles from the prostatic capsule.
The Apex is separated from the penile bodies (B) by the urogenital diaphragm.
(UGD), containing the external urethral sphincter with the cavernous bodies (C).
 CZ ↓T2 homogeneous signal
intermediate

PZ ↑ T2 homogeneous signal
(greater than or equal to the intermediate
surrounding fat

AS ↓ T2
TZ ↓T2 ↓T1

Capsule and plexus ↑T2

perivenous
prostatic
Urethra ↑ T2
Score in T2: For the peripheral zone
Score 1 Uniform hypersignal
(normal)

Score 2 Linear, triangular or moderately diffuse hyposignal

Poorly defined contours

Score 3 Intermediate appearance between 2, 4, and 5

Score 4 Moderate, homogeneous, well-defined hyp signal

focal/limited mass to the prostate
1.5cm of major axis

Score 5 Moderate, homogeneous, well-defined hyposignal

focal/mass limited to the prostate
≥1.5cm of major axis
Or mass not limited to the prostate (extra-extension
prostatic
Score in T2: For the transitional zone
Score 1 Adenoma of the ZT with clear margins: "chaos
organized

Score 2 Encapsulated heterogeneous signal attenuation areas

but well-defined coming from the ZT/HBP

Score 3 Intermediate appearance between 2, 4, and 5

Score 4 Homogeneous signal attenuation areas poorly

delimited in moderate, homogeneous Hyposignal
1.5cm of major axis

Score 5 Homogeneous signal attenuation areas badly

delimited in moderate, homogeneous hyposignal,
≥1.5cm of major axis
Where
Mass not limited to the prostate (extra-
prostatic
DIFFUSION WEIGHTED MRI (DWI)

DWI helps to differentiate cancer from benign lesions,

notably the hemorrhagic areas post-biopsy in the
peripheral zone

DWI: it is the most useful sequence in functional MRI for

the detection of transitional zone cancers

several studies have shown the interest in sequences of

diffusion as the most effective sequence for improvement
performance in terms of prostate cancer detection

The addition of the DWI shows a greater specificity.

compared to the T2SE alone for cancer detection
 the DWI sequence also allows for:
1. the detection of lymphadenopathy
2. the detection of associated bone metastases

Acquisition:
axial plane
Value of b0, b100, 800-1400 s/mm2
Up to 2000 s/mm2

The DWI sequence with a b value

important (≥1,400 s/mm) associated with a
ADC mapping must be obtained and
interpreted in association with the T2SE sequences
for anatomical correspondence
 Score in DWI: For the area
peripheral and transitional
Score 1 Normal diffusion and ADC. No reduction in ADC nor
from hypersignal to high b

Score 2 ADC bassans focal character (indistinct)

Score 3 Moderately low ADC, focal, iso-intense or of

intermediate signal or in hypersignal in
Diffusion
Score 4 ADC low, focal, marked hypersignal in
High diffusion, <1.5cm major axis

Score 5 ADC base, focal, marked hypersignal in Diffusion

to b high, ≥1.5cm of major axis
Or mass not limited to the prostate (extra extension
prostatic)
Sequence with dynamic injection of
contrast agent (DCE)
It is a series of T1 axial sequences in Echo of
gradient
Injection of a gadolinium bolus intravenously (2-4 mL/s)
The DCE is evaluated in 3 ways:
a. Qualitative
[Link]-quantitative
c. Quantitative.

Prostate cancer: increased vascularization

compared to normal prostatic tissue
Intense early elevation
Rapid washout
 Score in DCE: For the area
peripheral and transitional

Score (-) Absence of early elevation

Or diffuse enhancement without focal correspondence
in T2 and/or DWI
Or focal enhancement corresponding in T2 to a
lesion of BPH
Score (+) Early focal enhancement compared to
normal adjacent prostatic parenchyma
With corresponding suspected anomaly in T2 and/or
DWI
 ROLES OF THE DIFFERENT
SEQUENCES
In the PZ, diffusion is the determining sequence thus
If the T2 score is 2 and the diffusion is 4, the lesion will be
classified PI-RADS 4

For theTZ, T2 is the determining sequence so if the score

in T2 is 4 and in diffusion is 2, the lesion will be classified as PI-
RADS 4

It is preferable to measure the lesion on the sequence

determinant by taking the largest axis

If the lesion is poorly defined on the dominant sequence, prefer

the sequence that allows for the best analysis of the lesion

Since the classification of the lesion depends on its location, a

sector mapping system has been developed
 Source: Case courtesy of Dr. Alexandra Stanislavsky,
[Link], rID: 43046

For the PZ: For the TZ:

theDWIest is the determining sequence T2 is the determining sequence
if the score in DWI is 3 the DCE If the score in T2 is 3 the DWI
trancheentre tranche between
•the PI-RADS4 if the score in DCE is •the PI-RADS4 if the score in DWI is
(-) from =5
•the PI-RADS 3 if the score in DCE •PI-RADS 3 if the score in DWI <
is (+) 5 (1 to 4)
 SECTORIAL CARTOGRAPHY
It is a segmentation of the prostate into 39 sectors/regions:
36 sectors for the prostate
2 sectors for the seminal vesicles
1 sectors for the external urethral sphincter

The prostate is divided:

In the axial plane in right and left sectors by
a vertical plane passing through the center of the urethra
prostatic
In the frontal plane in anterior sectors and
posterior by a horizontal line passing through the
center of the gland
 PZ: divided into 3 parts
at the base level,
medium part and apex
anterior (a)
medial posterior (mp)
and posterior lateral
(lp)
divided into 2 parts
at the level of the base,
middle part and apex
=>
anterior and posterior
(p)
LaCZest located at the
base of the prostate
around the channels
ejaculators

The last is divided

in right parties and
gauges at the level of
the base, part
average and apex
 LIMITATIONS OF THE PI-RADS SYSTEM
The PI-RADS system is not used for:

Post-therapeutic relapse search during the

monitoring of treated cancers
Research on progression during cancer monitoring
Evaluation of other parts of the body such as the
skeleton
 TYPE REPORT
MULTI-DETECTION PROSTATE MRI
PARAMETRIC
INDICATION Target number Score Score ESUR Remarks
Assessment of: TR : sequence
PSAlevel: ng/ml T2:
Biopsies : DWI:
DCE:
TECHNIQUE
Séquence T2 TSE axiale/sagittale/coronale
focused on the prostate.
Diffusion sequence (b) centered on the prostate.
Infusion sequence after injection of 10 cc of
Gadolinium chelate.
RESULTS
Estimated prostate volume in cc
Identified intra-prostatic target(s):
->Lésion cible n° :siège+ (tableau)
MRI signs of capsular breach:
Seminal vesicles of morphology and signal
normal
Pelvic adenomegalies:
CONCLUSION
X target(s) of seat..., ranked PI-RADS...
 TAKE HOME MESSAGES
The PI-RADS is an assessment score used to
standardize the interpretation of the prostate MRI

It is designed to improve detection, localization,

characterization and stratification of risk in patients with
a suspicion of prostate cancer

Thanks to a 5-point scale based on the probability of

Cancer calculates a score by adding the scores of each one.
The 3 techniques (T2, diffusion, and DCE) for each lesion.
total serum correlated with the presence of clinically evident cancer
significant.
Prostatic biopsies will be considered for PI lesions.
RADS 4 or 5 and avoided for PI-RADS 1 and 2 lesions for
each lesion
 QUIZZ number 1
In the PZ, the determining sequence is
The DCE sequence
B. The T2 sequence
C. The DWI sequence
If the score in T2 is 3 and in diffusion is 3, the lesion
will be classified as PI-RADS 3

If the score in T2 is 3 and in diffusion is 3, the lesion

will be classified according to the DCE in PI-RADS 3 or 4
(according to DCE- or +)

(Réponses :CE)
 QUIZ n°2
In the TZ, the determining sequence is
A. The DCE sequence
B. The T2 sequence
C. The DWI sequence
If the score in T2 is 4 and in diffusion is 2, the lesion
will be classified as PI-RADS 4

If the score in T2 is 3, the lesion will be classified as

function of DWI in PI-RADS 3 or 4

(Responses: BDE)
 QUIZ n°3
In the TZ, is
A. Score 4 corresponds in T2 to an area of hyposignal.
moderate, homogeneous, well-defined, limited to the prostate
B. The score of 4 corresponds to a signal attenuation area
homogeneous poorly bounded
C. A lesion that exceeds 1.5cm in major axis is scored 5.
The T2 sequence is the determining sequence.
The DWI sequence is the determining sequence.

(Réponses :BCD)