Magnetic resonance imaging (MRI) is recommended for local prostate cancer tumor (T) staging. While MRI offers superior anatomical resolution compared to digital rectal examination, its accuracy in distinguishing organ-confined (T2) from locally advanced (T3a) tumors remains low. This narrative review critically examines the current MRI-based T-staging performance, its limitations, and the clinical implications of image scoring systems to assess local tumor extent. We highlight the evolution from qualitative assessments toward semi-quantitative and quantitative systems, each integrating features like tumor capsular contact length, bulging, capsular irregularity, neurovascular bundle asymmetry, and capsular enhancement. Emerging data suggest that tumor volume and curvilinear capsular contact length exhibit high specificity, however, most features lack sufficient sensitivity and inter-reader agreement to independently guide treatment management. We argue for favoring specificity over sensitivity in MRI-based T-staging, considering that false positive MRI readings carry negative side effects for patients following overtreatment. Finally, we propose the development of a universal MRI-based scoring system tailored to clinical relevance, prioritizing reproducible guidance for treatment decisions over traditional staging accuracy. Such a scoring system better aligns with contemporary therapeutic goals, reduces overtreatment with its negative side effects, and facilitates standardized reporting in clinical trials and practice.
European journal of radiology. 2025 Aug 14 [Epub ahead of print]
Georgios Agrotis, Sungmin Woo, Fredrik Jäderling, Stephan Ursprung, Sam J Withey, Andrei S Purysko, Tristan Barrett, Geert Villeirs, Ivo G Schoots
Department of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands. Electronic address: ., Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA., Department of Molecular Medicine and Surgery (Solna), Karolinska Institutet, Stockholm, Sweden; Department of Radiology, Capio St Görans Hospital, Stockholm, Sweden., Department of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiology, University Hospital Tübingen, Tübingen, Germany., Department of Radiology, Royal Marsden Hospital, Sutton, the United Kingdom of Great Britain and Northern Ireland., Section of Abdominal Imaging and Nuclear Radiology Department, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA., Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, the United Kingdom of Great Britain and Northern Ireland., Department of Medical Imaging, Ghent University Hospital, Ghent, Belgium., Department of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiology & Nuclear Medicine, Erasmus University Medical Center Rotterdam, the Netherlands.