Role of the Prostate Imaging Quality PI-QUAL Score for Prostate Magnetic Resonance Image Quality in Pathological Upstaging After Radical Prostatectomy: A Multicentre European Study

BACKGROUND: Increasing use of multiparametric magnetic resonance imaging (mpMRI) has come with heterogeneity in image quality. The Prostate Imaging Quality (PI-QUAL) score is under scrutiny to assess its usefulness in predicting clinical outcomes. OBJECTIVE: To compare upstaging of localized disease on mpMRI (mrT2) to locally invasive disease in radical prostatectomy (RP) specimens (≥pT3a) in relation to PI-QUAL. DESIGN, SETTING, AND PARTICIPANTS: Patients treated with RP between 2015 and 2020 who underwent 1.5–3-T mpMRI within 6 mo before surgery and had systematic and mpMRI-US targeted biopsies were included. mpMRI scans were retrospectively assigned a PI-QUAL score, and prospectively acquired Prostate Imaging-Recording and Data System (PI-RADS) scores (version 2.0 or 2.1) were used. PI-QUAL scores were categorized as nondiagnostic (PI-QUAL <3), sufficient (PI-QUAL 3), or optimal (PI-QUAL >3). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed the relationship between the PI-QUAL score and upstaging using multivariate logistic regression. mpMRI, clinical, and pathological findings were compared using χ(2) tests and analysis of variance. RESULTS AND LIMITATIONS: We identified 351 patients, of whom 40 (11.4%) had PI-QUAL <3, 57 (16.3%) had PI-QUAL 3, and 254 (72.3%) had PI-QUAL >3 scores. The distribution of PI-QUAL <3 (0–33.6%; p < 0.001) and PI-QUAL >3 (37.3–100%; p < 0.001) scores varied widely among centers. PI-QUAL ≥3 in comparison to PI-QUAL <3 was associated with a lower rate of upstaging (19% vs 35%; p = 0.02), greater detection of mrT3a and mrT3b prostate cancer (17.0% vs 2.5%; p = 0.016), a higher rate of PI-RADS 5 lesions (47% vs 27.5%; p = 0.002), a higher number of suspicious lesion (PI-RADS ≥3: 34.7% vs 15%; p = 0.012), and higher detection rates for aggregated (50.7% vs 22.5%; p = 0.001) and late (21.2% vs 0%; p < 0.001) extraprostatic extension. On multivariate analysis, PI-QUAL<3 was associated with more frequent upstaging in the RP specimen (odds ratio 3.4; p = 0.01). CONCLUSIONS: In comparison to PI-QUAL ≥3, PI-QUAL <3 was significantly associated with a higher rate of upstaging from organ-confined disease on mpMRI to locally advanced disease on pathology, lower detection rates for PI-RADS 5 lesions and extraprostatic extension, and a lower number of suspicious lesions. PATIENT SUMMARY: Poor image quality for magnetic resonance imaging (MRI) scans of the prostate is associated with underestimation of the stage of prostate cancer.