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RadioGraphics Update:
PI-RADS Version 2.1—A Pictorial Update
Andrei S. Purysko, MD
Andrew B. Rosenkrantz, MD
Ismail Baris Turkbey, MD
Katarzyna J. Macura, MD, PhD
Abbreviations: ADC = apparent diffusion co-
efficient, BPH = benign prostatic hyperplasia,
DCE = dynamic contrast material–enhanced,
DWI = diffusion-weighted imaging, PI-RADS =
Prostate Imaging Reporting and Data System
RadioGraphics 2020; 40:E33–E37
https://doi.org/10.1148/rg.2020190207
Content Codes:
From the Section of Abdominal Imaging and
Nuclear Radiology Department, Cleveland
Clinic, Imaging Institute, 9500 Euclid Ave, JB3,
Cleveland, OH 44195 (A.S.P.); Department of
Radiology, NYU Langone Medical Center, New
York, NY (A.B.R.); Molecular Imaging Pro-
gram, National Cancer Institute, Bethesda, Md
(I.B.T.); and Department of Radiology and Ra-
diological Sciences, Johns Hopkins University,
Baltimore, Md (K.J.M.). Received November
14, 2019; revision requested December 10 and
received January 7, 2020; accepted January 24.
All authors have provided disclosures (see end of
article). Address correspondence to A.S.P. (e-
mail: puryska@ccf.org).
©
RSNA, 2020
E33
GENITOURINARY IMAGING |
Editor’s Note.—Articles in the RadioGraphics Update section provide current knowl-
edge to supplement or update information found in full-length articles previously
published in RadioGraphics. Authors of the previously published article provide a
brief synopsis that emphasizes important new information such as technological
advances, revised imaging protocols, new clinical guidelines involving imaging, or
RADIOGRAPHICS UPDATE
updated classification schemes. Articles in this section are published solely online
and are linked to the original article.
Introduction
In 2019, the Prostate Imaging Reporting and Data System (PI-
RADS) steering committee published a document clarifying and up-
dating the assessment categories and technical parameters described
in PI-RADS version 2 (1,2). The update was considered necessary to
address limitations and inconsistencies of the system that had been
observed since its release in 2015. Because the overall framework of
the system was maintained, the updated version was termed PI-
RADS version 2.1 rather than version 3 (3). This article describes
the changes in PI-RADS since our earlier review.
Updates in Technical Parameters
T2-weighted Imaging
The update states that T2-weighted imaging should always be
performed in the axial plane and in at least one orthogonal plane,
sagittal or coronal, to facilitate morphologic assessment of lesions.
Assessing lesions on axial images is challenging because of volume
averaging (eg, encapsulation of transition zone nodules). Axial im-
ages—acquired as straight axial images or as oblique axial images
perpendicular to the long axis of the prostate—are used to measure
the transverse diameter of the prostate. Sagittal images can be used
to measure the maximum anteroposterior and longitudinal diam-
eters. Those three diameters are multiplied by 0.52 to obtain the
prostate volume.
E34 November-December 2020 radiographics.rsna.org

Table 1: Updated Transition Zone Assessment

T2-weighted PI-RADS Assessment

Imaging DWI Category (likelihood
Appearance at T2-weighted Imaging* Score Score† of csPCa)
Normal-appearing transition zone (rare) or a 1 NA 1 (highly unlikely)
round completely encapsulated nodule (typical
nodule)
Mostly encapsulated nodule or homogeneous cir- 2 <4 2 (unlikely)
cumscribed nodule without encapsulation (atypi- ≥4 3 (equivocal)
cal nodule) or homogeneous mildly hypointense
area between nodules
Heterogeneous signal intensity with obscured 3 <5 3 (equivocal)
margins; includes other lesions that do not 5 4 (likely)
qualify as 2, 4, or 5
Lenticular or noncircumscribed, homogeneous, 4 NA 4 (likely)
moderately hypointense lesion that is <1.5 cm
in greatest dimension
Same as 4 but ≥1.5 cm in greatest dimension or 5 NA 5 (highly likely)
definite extraprostatic extension or invasive
behavior
Note.—csPCa = clinically significant prostate cancer, NA = not applicable.
*Dominant parameter.
†Ancillary parameter.

Diffusion-weighted Imaging Updates in Imaging

The update clarified that diffusion-weighted
imaging (DWI) should be performed with at
least two b values, including one low b value set
at 0–100 sec/mm2 (although 50–100 sec/mm2
is preferred) and one intermediate b value set
at 800–1000 sec/mm2. The data acquired with
these b values are used to generate the appar-
ent diffusion coefficient (ADC) map. In some
systems, these data can also be used to gener-
ate images with high b value (≥1400 sec/mm2),
which are needed for qualitative assessment
of abnormalities seen at DWI. If high-b-value
images cannot be generated from the images
obtained with low and intermediate b values,
these images should be acquired separately to
avoid the kurtosis effect that manifests at DWI
with b values greater than 1000 sec/mm2. This
kurtosis effect can corrupt the calculation of
ADC values.
Dynamic Contrast–enhanced Imaging
For dynamic contrast-enhanced (DCE) imag-
ing, preference is given to three-dimensional
acquisitions over two-dimensional acquisitions
because of the better signal-to-noise ratio. In
addition, a temporal resolution of no more than
15 seconds instead of 10 seconds or less is now
considered acceptable to mitigate the poten-
tial trade-off in image quality (eg, lower spatial
resolution) associated with very high temporal
resolutions.
Interpretation Criteria
Transition Zone Assessment
The criteria for T2-weighted imaging scores of 1
and 2 for transition zone lesions have been modi-
fied (Table 1). Because of the extremely com-
mon occurrence of benign prostatic hyperplasia
(BPH), nodules with typical BPH features (ie,
complete T2-weighted hypointense capsule) now
receive a score of 1. The update also clarifies that
nodules differing from the predominant imaging
appearance of the background transition zone
should be scored. Nodules with an incomplete
or absent capsule and areas with homogeneous
low signal intensity between the nodules now
receive a T2-weighted imaging score of 2 (Fig 1).
In addition, in recognition of the role of DWI in
the transition zone, transition zone lesions that
receive a score of 2 at T2-weighted imaging are
to be upgraded to an assessment category of 3 if
they have a DWI score greater than or equal to
4. As in PI-RADS version 2, lesions that re-
ceive a T2-weighted imaging score of 3 are only
upgraded to an assessment category of 4 if they
have a DWI score of 5. Representative examples
of lesions in the transition zone according to the
revised criteria are shown in Figure 2.
DWI Criteria
As in PI-RADS version 2, the same set of DWI
criteria applies to peripheral zone and transi-
RG  •  Volume 40  Number 7 Purysko et al  E35

Figure 1.  Diagram illustrates transition zone findings seen on axial high-b-value DWI and ADC images. A = lenticular or noncircum-
scribed, homogeneous, moderately hypointense lesion; B = heterogeneous signal intensity with obscured margins, includes other
lesions that do not qualify as scores 2, 4, or 5; C = mostly encapsulated nodule; D = homogeneous mildly hypointense area between
nodules; E = homogeneous circumscribed nodule without encapsulation; F = completely encapsulated nodule; G = completely en-
capsulated nodule with cystic change. EPE = extraprostatic extension.

tion zone lesions (Table 2). Changes were made
in the criteria for DWI scores of 2 and 3. For a
score of 2, the previous morphologic descriptor
of indistinct was recognized to be unclear and
has been replaced with linear or wedge-shaped.
For a DWI score of 3, the update indicates that
the abnormality needs to be discrete and dif-
ferent from the background. In addition, the
abnormality may have markedly hypointense
signal on ADC maps or markedly hyperintense
signal at DWI , but not both. The term marked,
which is used in scores 3 to 5, is also defined
in PI-RADS version 2.1 as a more pronounced
signal intensity change than any other focus in
the same zone (2).
DCE MRI Interpretation
The binary (ie, positive or negative) DCE
criteria have been clarified. DCE is considered
positive if it is focal and occurs earlier than or
contemporaneously with enhancement of adja-
cent normal prostatic tissues and corresponds
to suspicious findings at T2-weighted imaging
or DWI. DCE is considered negative if no early
or contemporaneous enhancement is noted. In
addition, diffuse multifocal enhancement not
corresponding to a focal finding at T2-weighted
imaging or DWI and focal enhancement that
corresponds to BPH at T2-weighted imaging
(including ectopic BPH in the peripheral zone)
are also considered negative.
Central Zone and Anterior Fibromuscular
Stroma Assessment
Clarifications have been made regarding assess-
ment of the central zone and anterior fibromus-
cular stroma. If no abnormalities are identified in
these two normal anatomic regions, they do not
need to be reported separately. For the central
zone, focal early enhancement plus asymmetries
at T2-weighted imaging, at DWI, or on the ADC
map that cannot be explained by BPH may help
differentiate tumors from benign anatomy. For
the anterior fibromuscular stroma, the assess-
ment criteria should be those of the zone from
which the lesion appears to arise (eg, if the focal
abnormality arises from the transition zone, the
transition zone criteria should be used).
Considerations regarding
Biparametric MRI
The PI-RADs update acknowledges the growing
interest in using biparametric MRI (T2-weighted
imaging and DWI without DCE imaging) to
reduce examination time and cost and elimi-
nate the risks associated with gadolinium-based
contrast agents. However, a number of concerns
regarding biparametric MRI are raised in the
update and further research is encouraged. The
update states that biparametric MRI should be
currently reserved for select clinical indications
and describes a number of situations in which
multiparametric MRI is still preferred, including
E36 November-December 2020 radiographics.rsna.org

Figure 2. Representative examples of lesions in the transition zone according to the revised PI-RADS version 2.1 criteria. T2WI = T2-
weighted image, TZ = transition zone.
RG  •  Volume 40  Number 7 Purysko et al  E37

Table 2: Updated Peripheral Zone Assessment

DWI PI-RADS Assessment Category

Appearance at DWI* Score DCE† (Likelihood of csPCa)
No abnormality (ie, normal) on ADC map and at high-b- 1 NA PI-RADS 1 (highly unlikely)
value DWI
Linear or wedge-shaped hypointensity on ADC map or lin- 2 NA PI-RADS 2 (unlikely)
ear or wedge-shaped hyperintensity at high-b-value DWI
Focal (discrete and different from the background) hypoin- 3 Negative‡ PI-RADS 3 (equivocal)
tensity on ADC map or focal hyperintensity at high-b-val- Positive§ PI-RADS 4 (likely)
ue DWI, may be markedly hypointense on ADC map or
markedly hyperintense at high-b-value DWI, but not both
Focal markedly hypointense on ADC map and markedly 4 NA PI-RADS 4 (likely)
hyperintense at high-b-value DWI, <1.5 cm in greatest
dimension
Same as 4 but ≥1.5 cm in greatest dimension or definite 5 NA PI-RADS 5 (highly likely)
extraprostatic extension or invasive behavior
Note.—csPCa = clinically significant prostate cancer, NA = not applicable.
*Dominant parameter. DWI criteria used for the peripheral zone also apply for the transition zone.
†
Ancillary parameter.
‡
Negative DCE: no early or contemporaneous enhancement or diffuse multifocal enhancement not correspond-
ing to a focal finding at T2-weighted imaging or DWI or focal enhancement corresponding to a lesion demon-
strating features of BPH at T2-weighted imaging (including features of extruded BPH in the peripheral zone).
§
Positive DCE: enhancement that is focal and occurs earlier than or contemporaneously with enhancement of
adjacent normal prostatic tissues and corresponds to a suspicious finding at T2-weighted imaging or DWI.

when clinical parameters indicate a high likeli-
hood of clinically significant prostate cancer and
when adequate DWI cannot be performed.
Conclusion
Adjustments in the technical parameters and
refinements in the interpretation criteria intro-
duced in PI-RADS version 2.1 address important
limitations of the system’s predecessor. Further
changes are expected to be made as more data
become available.
Disclosures of Conflicts of Interest.—A.S.P. Activi-
ties related to the present article: support from Profound
Medical. Activities not related to the present article: grants
from the RSNA R&E Foundation; payment from the
American College of Radiology for development of edu-
cational presentations; support from Profound Medical;
research support provided to Invivo. Other activities: dis-
closed no relevant relationships. A.B.R. Activities related
to the present article: disclosed no relevant relationships.
Activities not related to the present article: institution re-
ceived royalties from Thieme Medical Publishers. Other
activities: disclosed no relevant relationships. I.B.T. Ac-
tivities related to the present article: disclosed no relevant
relationships. Activities not related to the present article:
cooperative research and development agreements with
Philips and NVIDIA; royalties from Invivo. Other ac-
tivities: disclosed no relevant relationships. K.J.M. Ac-
tivities related to the present article: disclosed no relevant
relationships. Activities not related to the present article:
grants from Siemens Healthineers and Profound Medi-
cal; royalties from Elsevier. Other activities: disclosed no
relevant relationships.
References
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