Focus on the Quality of Prostate Multiparametric Magnetic Resonance Imaging: Synopsis of the ESUR/ESUI Recommendations on Quality Assessment and Interpretation of Images and Radiologists’ Training

Abstract

Objectives This study aims to define consensus-based criteria for acquiring and reporting prostate MRI and establishing prerequisites for image quality. Methods A total of 44 leading urologists and urogenital radiologists who are experts in prostate cancer imaging from the European Society of Urogenital Radiology (ESUR) and EAU Section of Urologic Imaging (ESUI) participated in a Delphi consensus process. Panellists completed two rounds of questionnaires with 55 items under three headings: image quality assessment, interpretation and reporting, and radiologists' experience plus training centres. Of 55 questions, 31 were rated for agreement on a 9-point scale, and 24 were multiple-choice or open. For agreement items, there was consensus agreement with an agreement ≥ 70% (score 7-9) and disagreement of ≤ 15% of the panellists. For the other questions, a consensus was considered with ≥ 50% of votes. Results Twenty-four out of 31 of agreement items and 11/16 of other questions reached consensus. Agreement statements were (1) reporting of image quality should be performed and implemented into clinical practice; (2) for interpretation performance, radiologists should use self-performance tests with histopathology feedback, compare their interpretation with expert-reading and use external performance assessments; and (3) radiologists must attend theoretical and hands-on courses before interpreting prostate MRI. Limitations are that the results are expert opinions and not based on systematic reviews or meta-analyses. There was no consensus on outcomes statements of prostate MRI assessment as quality marker. Conclusions An ESUR and ESUI expert panel showed high agreement (74%) on issues improving prostate MRI quality. Checking and reporting of image quality are mandatory. Prostate radiologists should attend theoretical and hands-on courses, followed by supervised education, and must perform regular performance assessments. Key Points • Multi-parametric MRI in the diagnostic pathway of prostate cancer has a well-established upfront role in the recently updated European Association of Urology guideline and American Urological Association recommendations. • Suboptimal image acquisition and reporting at an individual level will result in clinicians losing confidence in the technique and returning to the (non-MRI) systematic biopsy pathway. Therefore, it is crucial to establish quality criteria for the acquisition and reporting of mpMRI. • To ensure high-quality prostate MRI, experts consider checking and reporting of image quality mandatory. Prostate radiologists must attend theoretical and hands-on courses, followed by supervised education, and must perform regular self-and external performance assessments. Maarten de Rooij and Bas Israël contributed equally to this work.

Can the Use of Serial Multiparametric Magnetic Resonance Imaging During Active Surveillance of Prostate Cancer Avoid the Need for Prostate Biopsies?—A Systematic Diagnostic Test Accuracy Review

“…A number of studies have reported significant variation in mp-MRI reporting amongst radiologists, uninfluenced by experience measured either in years or in the number of mp-MRI examinations reported, suggesting that experience does not necessarily reflect expertise [16][17][18][19][20][21]25]. Additionally, variation in MRI acquisition and quality of images will further influence diagnostic accuracy at an institutional level [29]. In a recent statement, the European Society of Urogenital Radiology and European Association of Urology Section of Urologic Imaging recommended that MRI image quality be checked and reported [30].…”

The future direction of imaging in prostate cancer: MRI with or without contrast injection

“…Indeed, mpMRI shows a pooled NPV of 91% (86%–94%), 32,33 the variation is mostly related to non‐comparable PCa prevalence among countries and to different definitions of csPCa. Also, it is thought to be due to different centers’ expertise and lack of general quality standards 34,35 . The clinical benefit of prostate MRI comes from its NPV to rule‐out csPCa that allows biopsy avoidance and reduces the detection of ciPCa.…”

“…PI‐QUAL might offer clinicians a scoring system for evaluating and reporting the quality of their prostate MRI scans. De Rooij et al 34,35 released a list of consensus statements on MRI images quality. Recommendations included checking and reporting on image quality, to visually assess images adequacy for determining diagnostic acceptability, to control image quality at 6 months intervals or in 5% of studies, and to standardize ADC measurements on phantom.…”

A multifaceted approach to quality in the MRI-directed biopsy pathway for prostate cancer diagnosis

“…The latter being image quality, image read-outs, and data processing. Because radiologists have direct control of MRI, they can point to multiple advances including technologies that improve the speed and consistencies of MRI acquisitions, uniform image interpretation criteria [16], certification efforts [17], quality checks scores [18], and recent advances in automated gland contouring and suspicion lesion heat-maps using deep learning techniques [19].…”

“…Secondly, measurements, control, and assurance of the sources of variability should be undertaken, such as compliance with technical standards [30], image quality assessment scores [18], inter-and intra-reader/center variability [31], and cancer detection rates (including underdiagnosis cancer rates). Third, we need to develop performance measures for the main individuals participating in the MRI biopsy pathway including radiologists, urologists, and pathologists (and others), ultimately laying down the foundations for the certification of the main players, once tolerances are known [17]. Finally, key performance indices for diagnostic units on their ability to effectively deliver a high-quality service need to be developed, as part of accreditation processes focusing on team working outputs.…”