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available at www.sciencedirect.com
journal homepage: euoncology.europeanurology.com

Rapid Review – Prostate Cancer

Prostate Magnetic Resonance Imaging for Local Recurrence

Reporting (PI-RR): International Consensus -based Guidelines on
Multiparametric Magnetic Resonance Imaging for Prostate Cancer
Recurrence after Radiation Therapy and Radical Prostatectomy

Valeria Panebianco a,*, Geert Villeirs b, Jeffrey C. Weinreb c, Baris I. Turkbey d, Daniel J. Margolis e,
Jonathan Richenberg f, Ivo G. Schoots g,h, Caroline M. Moore i, Jurgen Futterer j,
Katarzyna J. Macura k, Aytekin Oto l, Leonardo K. Bittencourt m, Masoom A. Haider n,
Georg Salomon o, Clare M. Tempany p, Anwar R. Padhani q, Jelle O. Barentsz j
a
Department of Radiological Sciences, Oncology and Pathology, Sapienza University/Policlinico Umberto I, Rome, Italy; b Department of Radiology and Nuclear Medicine,
Ghent University Hospital, Ghent, Belgium; c Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA; d National Cancer Institute,
Center for Cancer Research, Bethesda, MD, USA; e Weill Cornell Imaging, Cornell University, New York, NY, USA; f Department of Imaging, Brighton and Sussex University
Hospitals NHS Trust and Brighton and Sussex Medical School, Brighton, UK; g Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center
Rotterdam, Rotterdam, The Netherlands; h Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; i Department of Urology, University
College London, London, UK; j Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands; k Department of Radiology and Radiological
Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA; l Department of Radiology, University of Chicago, Chicago, IL, USA; m Department of Radiology,
University Hospitals Cleveland Medical Center, Cleveland, Ohio; n Department of Medical Imaging, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Sinai
Health System, Toronto, Canada; o Martini-Clinic Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; p Department of Radiology,
Brigham &Women’s Hospital, Boston, MA, USA; q Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK

Article info Abstract

Article history: Background: Imaging techniques are used to identify local recurrence of prostate
Received 3 January 2021Re- cancer (PCa) for salvage therapy and to exclude metastases that should be
ceived in revised form addressed with systemic therapy. For magnetic resonance imaging (MRI), a reduc-
16 January 2021Accepted Janu- tion in the variability of acquisition, interpretation, and reporting is required to
ary 22, 2021 detect local PCa recurrence in men with biochemical relapse after local treatment
with curative intent.
Associate Editor: Objective: To propose a standardised method for image acquisition and assessment
Gianluca Giannarini of PCa local recurrence using MRI after radiation therapy (RP) and radical prosta-
tectomy (RT).
Keywords: Evidence acquisition: Prostate Imaging for Recurrence Reporting (PI-RR) was
Prostate cancer recurrence formulated using the existing literature. An international panel of experts con-
Prostate Magnetic Resonance ducted a nonsystematic review of the literature. The PI-RR system was created via
Imaging for Recurrence consensus through a combination of face-to-face and online discussions.
Reporting (PI-RR) Evidence synthesis: Similar to with PI-RADS, based on the best available evidence
Magnetic resonance imaging and expert opinion, the minimum acceptable MRI parameters for detection of

* Corresponding author. Department of Radiological Sciences, Oncology and Pathology, Sapienza/Policlinico

Umberto I, Viale Regina Elena 324, 00161 Rome, Italy. Tel. +39 06 49975463; Fax: +39 06 49978509.
E-mail address: valeria.panebianco@uniroma1.it (V. Panebianco).

https://doi.org/10.1016/j.euo.2021.01.003
2588-9311/© 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
EUO-416; No. of Pages 9

2 E U R O P E A N U R O L O GY O N C O L O GY X X X ( 2 019 ) X X X – X X X

recurrence after radiation therapy and radical prostatectomy are set. Also, a
simplified and standardised terminology and content of the reports that use five
assessment categories to summarise the suspicion of local recurrence (PI-RR) are
designed. PI-RR scores of 1 and 2 are assigned to lesions with a very low and low
likelihood of recurrence, respectively. PI-RR 3 is assigned if the presence of
recurrence is uncertain. PI-RR 4 and 5 are assigned for a high and very high
likelihood of recurrence, respectively. PI-RR is intended to be used in routine
clinical practice and to facilitate data collection and outcome monitoring for
research.
Conclusions: This paper provides a structured reporting system (PI-RR) for MRI
evaluation of local recurrence of PCa after RT and RP.
Patient summary: A new method called PI-RR was developed to promote stan-
dardisation and reduce variations in the acquisition, interpretation, and reporting
of magnetic resonance imaging for evaluating local recurrence of prostate cancer
and guiding therapy.
© 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

1. Introduction set of guidelines for mpMRI to assess local pelvic recurrence

In men with biochemical recurrence (BCR) and prostate-
specific antigen (PSA) persistence following local treatment
with curative intent for prostate cancer (PCa), it is important
to identify those who will likely benefit from local salvage
therapy. Imaging should provide a step-by-step multimodal
approach that facilitates both local and systemic staging,
depending on clinical priorities and primary therapy.
Clinical guidelines recommend the use of both nuclear
medicine imaging (positron emission tomography [PET]/
computed tomography [CT] scans) and magnetic resonance
imaging (MRI) to assess local recurrence and distant
metastases [1,2].
Salvage radiation therapy (RT) after radical prostatec-
tomy (RP) is often indicated on the basis of BCR alone,
independently from imaging. This is because of the known
poor sensitivity of imaging techniques at very low PSA
levels, especially taking into account that the relevant PSA
threshold for metastasis prediction is 0.4 ng/ml [1]. In
patients with BCR and PSA persistence after RP, the clinical
priority is to rule out systemic recurrence as opposed to rule
in local recurrence. Conversely, for patients with BCR after
RT, detection of local recurrence via biopsy performed 18–
24 mo after treatment is the major predictor of long-term
outcome [1,3]. In view of the morbidity related to local
salvage therapy after RT, it is essential to provide histologi-
cal evidence of local relapse before initiating retreatments.
Therefore, the clinical priority after RT is to both rule in local
recurrence and rule out systemic recurrence.
Although it has been proved that multiparametric MRI
(mpMRI) is accurate in early detection of PCa local
recurrence after RT and RP [4], no optimal acquisition
and reporting protocols are available and standardisation is
needed. Considering the current lack of standardisation, it is
not advisable to wait for evidence from large-scale studies.
Experts from the European Society of Urogenital Radiology,
the European Society of Urologic Imaging, and individual
members of the Prostate Imaging-Reporting and Data
System (PI-RADS) Steering Committee have established a
of PCa. The aim was to standardise image acquisition,
interpretation, and reporting of MRI in local PCa recurrence
after RT and RP by creating a Prostate Imaging for
Recurrence Reporting (PI-RR) system. Like PI-RADS, PI-RR
was designed to combine criteria for multiple MRI
techniques to assess the likelihood of relapse.
2. Evidence acquisition
PI-RR was formulated via consensus using existing litera-
ture and clinical expertise. An international panel of experts
from the European Society of Urogenital Radiology, the
European Society of Urologic Imaging, and individual
members of the PI-RADS Steering Committee conducted a
nonsystematic review of the literature using Medline,
PubMed, and Web of Science databases. The PI-RR system
was then created via consensus through a combination of
face-to-face and online discussions.
3. Evidence synthesis
3.1. Overview of the anatomy
PI-RR evaluates the likelihood of PCa local recurrence using
pelvic mpMRI and applies exclusively to the postoperative
prostatic bed after RP and to the prostate after RT. The
anatomy of the postoperative bed differs depending on
the surgical technique used [5]. The normal anatomy
generally comprises the conical-shaped bladder neck anas-
tomosed to the extraprostatic distal urethra. Fat stranding
and scarring often surround the bladder base and the
vesicourethral anastomosis, respectively. The vas deferens
and seminal vesicles are resected in most cases, but in 20% of
cases they are retained in their normal locations and appear as
tubular structures [6]. Metallic clips can be found and might
act as susceptibility artefacts. Lymphoceles are common in
patients who undergo lymph node dissection [6–8]. Images
should include the anastomotic site, the prostatic bed, the

Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
EUO-416; No. of Pages 9
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bladder base, the periurethral tissue, the levator ani, the
rectum, and the residual seminal vesicles (if present) [8]. The
anatomy of the irradiated prostate consists of a smaller and
diffuse hypointense gland on T2-weighted imaging (T2WI)
due to glandular atrophy and fibrosis [7]. The seminal vesicles
also decrease in size [9]. The bladder and rectal walls, the
perirectal fascia, and the pelvic muscles show greater signal
intensity (SI) on T2WI [10]. Bone-marrow fat replacement is
often found [11]. After RT, the caudal and cranial boundaries
of the field of view should include the genitourinary
diaphragm-prostate interface at the apex, and the bladder-
prostate interface at the base [12].
3.2. MRI acquisition
PI-RR recommends the same patient preparation, MRI
equipment, and imaging protocols as described in PI-RADS
version 2.1 [13]. Following RP, however, T2WI should be
acquired at three orthogonal levels (axial, coronal, and
sagittal) including the vesicourethral anastomosis, the
residual seminal vesicles, when present, and the complete
posterior wall of the bladder, as these are the primary sites
of relapse. Acquisition of at least one pulse sequence with a
large field of view (either T1-weighted or diffusion-
weighted imaging [DWI], with b values of 50/100 and
900/1000) is also advised to assess for the presence of large
lymph nodes and bone marrow abnormalities.
3.3. Scoring and reporting of mpMRI in suspected PCa
recurrence
PI-RR for recurrence uses a 5-point scoring system that
indicates the level of suspicion for PCa recurrence on
mpMRI. Scores of 1 and 2 are assigned to lesions with a very
low and low likelihood of recurrence, respectively. A score
of 3 is assigned if the presence of recurrence is uncertain.
Scores 4 and 5 are assigned when there is a high and very
high likelihood of recurrence, respectively.
The reporting criteria are based on anatomical and
functional imaging findings. Anatomical criteria are size,
location, and shape of the lesion. Local recurrence after RT is
most common in the gland at the site of the original primary
tumour, with disease developing elsewhere in only 4–9% of
cases [14–16]. Functional criteria are based on DWI and
dynamic contrast enhancement (DCE), which represent the
cellularity and vascularity of the tissue, respectively.
3.3.1. Recurrence following RT
3.3.1.1. T2WI. A variety of RT techniques exist, including
external beam RT (EBRT), intensity-modulated RT (IMRT),
and brachytherapy, as well as the recent MRI-guided linear
accelerator modality. Owing to RT-induced changes in SI
and morphology of the prostate, it can be challenging to
identify a local recurrence. The anatomy of a treated
prostate comprises a smaller and diffusely hypointense
gland on T2WI. Owing to reactive inflammation, glandular
atrophy, and fibrosis, there is lower zonal differentiation
and a less evident distinction between benign and
malignant tissue [12,17–19].
Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
3
A local recurrence after EBRT appears as a mass-like
abnormality that can cause capsular bulging and may be
slightly hypointense compared to treated prostatic tissue.
This is because of growth of the tumour relative to atrophic
tissue [20]. However, a focal SI change on T2WI does not
always represent recurrence [21]. The recurrence occurs
most frequently at the site of the previous tumour [14], so a
comparison with previous studies is essential.
After low-dose-rate (LDR) brachytherapy, the radioactive
seeds appear as small ellipsoid signal voids scattered
throughout the gland. Changes to the tissue are similar to
those following EBRT. The prostate becomes increasingly
atrophic and shrinks in size, often with caudal seed
migration [11], which can lead to a significant degradation
in dose coverage of the prostate and inadequate spacing of
areas that should be examined more carefully for local
failure [22]. To summarise, T2WI provides detailed ana-
tomical information, but is of limited value in the
assessment of local recurrence [23].
3.3.1.2. DWI. After RT, the SI of a local recurrence is similar to
that of the primary tumour. Thus, local recurrence can be
seen as a focal hyperintensity on high b value correspond-
ing to a dark area on the apparent diffusion coefficient
(ADC) map, which may or may not correspond to a nodular
area visualised on T2WI. Owing to seed implants, which
cause susceptibility artefacts, DWI may be less useful in
detecting a local recurrence after LDR [10]. In these
circumstances, DCE MRI is of particular importance
[3]. Susceptibility artefacts do not occur after high-dose-
rate (HDR) brachytherapy, since no permanent seeds are
implanted. The early inflammatory effect of RT resembles
the high ADC values of benign tissue. Therefore, DWI
should not be performed during and shortly after RT
(within 6 wk) [24,25].
3.3.1.3. DCE imaging. Post-RT glandular fibrosis is charac-
terised by lower cellularity and vascularity compared to
normal glandular tissue before treatment. Conversely,
recurrent tumours have high vascularity and vascular
permeability [26,27]. A local recurrence, therefore, can be
seen as an enhancing focal lesion that “shines” against the
background of non-enhancing or only minimally and slowly
enhancing surrounding tissue [28]. The disadvantage of DCE
is that it should be performed at 3 mo after RT at the earliest,
since the inflammatory reaction induced by RT in benign
prostate tissue can also lead to increased blood flow and
blood volume, which can lead to false-positive interpreta-
tions [10,29].
3.3.1.4. Overall risk assessments. The PI-RR assessment after
RT is mainly derived from the DWI and DCE sequences
(Figs. 1 and 2). T2WI is only helpful in identifying benign
prostatic hyperplasia nodules, in locating suspicious
lesions, and in comparing them to pre-RT imaging, when
available. Please note that T2WI findings are not part of the
overall score. The risk assessment after RT is determined
by both DWI and DCE findings [4,29–37]. The likelihood of
recurrence increases when DCE demonstrates a highly
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Fig. 1 – Overall Prostate Imaging-Recurrence Reporting (PI-RR) assessment score for local recurrence after radiation therapy. The definitive category is
determined by the sequence with the highest score. Use (A) when the highest score is obtained by diffusion-weighted imaging (DWI), and (B) when
obtained by dynamic contrast enhancement (DCE).

Fig. 2 – Schematic diagram of Prostate Imaging-Recurrence Reporting (PI-RR) assessment categories for prostate cancer recurrence after radiation
therapy. Dashed lines denote the location of the primary tumour; filled circles show the location of the recurrence.

vascularised focal lesion (early enhancement) and DWI
demonstrates highly cellular tissue (bright on high b-value
images and dark on ADC maps).
The final assessment is determined by the sequence with
the highest score for any of the DWI and DCE images, as
shown in Fig. 1. Fig. 1A shows the final assessment score
when the highest score is for DWI, and Fig. 1B when the
highest score is for DCE. Upgrading from PI-RR 4 to PI-RR 5 is
appropriate if the locations for diffusion restriction and
enhancement match. Whenever there is discordance
regarding the lesion localisation between DWI and DCE
sequences, morphological T2WI can be helpful.
3.3.2. Recurrence following RP
3.3.2.1. T2WI. In most cases, a local recurrence differs from
normal postoperative inflammation and fibrosis. Fibrotic
tissue has a lower SI than recurrent tissue [10]. Recurrent
tissue can have various forms, including curly, semi-circular,
nodular, and plaque-like masses. In the case of asymmetric
perianastomotic soft-tissue thickening with an SI in
between the SIs for pelvic muscle and the surrounding
adipose tissue, a local recurrence is likely to be present
[38]. In approximately 20% of cases, remnants of seminal
vesicles are seen, which must be recognised as such to avoid
misinterpretation as local recurrence [6].

Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
EUO-416; No. of Pages 9
E U R O P E A N U RO L O GY O N C O L O GY X X X ( 2 019 ) X X X – X X X
Fig. 3 – Overall assessment score for local recurrence after radical
prostatectomy.
DCE = dynamic contrast enhancement; DWI = diffusion-weighted
imaging.
Whenever available, interpretation of mpMRI must be
performed with a full review of the whole-mount RP
specimen. This may provide information on the possible
location of the recurrence, as well as positive surgical
margins and their location. Local recurrence after RP can be
found anywhere within the surgical bed. The most frequent
sites are the perianastomotic areas around the bladder neck
or membranous urethra, the vesicorectal space, and the
seminal vesicle remnants [39]. Other common recurrence
sites are the anterior and lateral edges of the prostate (eg,
abutting the levator ani muscles) [6,40]. The localisation of a
local recurrence should be described in terms of the clock
position, with the vesicourethral anastomosis at the centre
of the clock.
3.3.2.2. DWI. DWI has good diagnostic accuracy in detecting
local recurrence after RP when combined with other
sequences [38]. Quite often, there is geometric distortion
caused by susceptibility artefacts due to surgical clips. Local
recurrence after RP, like primary tumours, shows high SI on
high b-value DWI and low ADC values. This is mostly seen in
focal or mass-like areas exceeding 1 cm in size. Conversely,
postoperative inflammation and granulation tissue show no
notable abnormality on DWI. DWI can help in clarifying
recurrence from slowly enhancing benign tissue on DCE
MRI [41].
3.3.2.3. DCE imaging. DCE imaging plays a dominant role in
the detection of RP recurrence. This technique has high
sensitivity [42–44]; even tiny recurrence “foci” that may not
be visible on T2WI tend to show significant enhancement in
the early arterial phase, often with contrast wash-out [4]. In
addition, post-RP recurrences enhance sooner and faster
than normal postoperative changes [45]. The kinetics of a
recurrence are generally similar to those of primary cancers,
with rapid enhancement in the early phase and variable
Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
5
wash-out patterns, while postoperative changes either do
not enhance or enhance slowly, as expected for fibrotic or
granulation tissue.
In the post-RP setting, mpMRI should be performed at
least 3 mo after surgery.
3.3.2.4. Overall risk assessments. The final PI-RR assessment
score after RP is generated using the individual DWI and
DCE sequences (Fig. 3). The dominant sequence is DCE
. Upgrading from PI-RR 2 to PI-RR 3 and from PI-RR 3 to PI-
RR 4 is appropriate when the DWI score is superior or equal
to 4. T2WI is useful for locating suspicious lesions and
comparing them to preoperative imaging and provides
valuable anatomical information, but it is not part of the
final assessment. A post-RP recurrence can be initially seen
on DCE MRI. If there are discrepancies between DCE and
DWI sequences, morphological T2WI findings for recur-
rence localisation can be used.
Tables 1 and 2 and Supplementary Figures 1–6 show how
MRI scoring should be performed for T2WI, DWI, and DCE
sequences for overall risk assessment of local recurrence
after RT and RP.
3.4. Clinical implications of the PI-RR scoring system
PI-RR is a 5-point assessment scale for mpMRI prediction of
the likelihood of local recurrence after RT and RP, with
specific management implications. Nonetheless, PI-RR
categories should be interpreted critically according to
the individual risk of recurrence based on existing
conventional clinicopathological risk factors. After both
RT and RP, PI-RR scores of 1 and 2 indicate a very low and
low likelihood of local recurrence, respectively, and these
patients should be screened for regional or distant
metastases using nuclear medicine imaging modalities
(PSMA, fluciclovine, or choline PET/CT imaging) in cases
with both BCR and PSA persistence (post-RP). However,
when appropriate according to clinical guidelines, patients
with BCR in the post-RP setting should be treated with
salvage RT, even in the absence of imaging findings
suspicious for local recurrence. After RT, PI-RR assessment
scores of 3–5 would be an indication to perform biopsy
before focal salvage therapy. After RP, no histological
evidence of a suspected local recurrence is usually required
[1]. Thus, for patients with BCR and PSA persistence in the
post-RP setting, in the case of a PI-RR score of 3 the next step
should be nuclear imaging or biopsy of the prostatectomy
bed/vesicourethral anastomosis, especially if PSA exceeds
1 ng/ml [3]. For PI-RR 4–5 findings, salvage therapy without
biopsy could be indicated if disease recurrence is likely,
whereas targeted biopsy could be performed to confirm
recurrence in clinically low-risk cases. In all cases for which
salvage therapy is considered, staging for nodal or distant
metastases should be performed according to clinical
guidelines to exclude metastases [1,46]. The diagnostic
imaging pathway for PCa recurrence is currently defined in
clinical guidelines. To rule out metastatic disease, the
European Association of Urology (EAU) guidelines recom-
mend a PSMA PET/CT scan in men with total serum
EUO-416; No. of Pages 9

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Table 1 – Assessment categories by magnetic resonance imaging sequence after radiation therapy

Sequence Score Pattern changes

T2WI 1 No abnormal signal intensity compared to the background

2 Linear, wedge-shaped, or diffuse moderate hypointensity or residual BPH nodules
3 Focal or mass-like mild hypointensity not at the primary tumour site; includes others that do not
qualify as 2, 4, or 5
4 Focal or mass-like moderate hypointensity not at the same site as the primary tumour, or location of
primary tumour not known
5 Focal or mass-like marked hypointensity at the same site as the primary tumour
DWI 1 No abnormality on high b-value DWI and ADC map
2 Diffuse moderate hyperintensity on high b-value DWI and/or diffuse moderate hypointensity on the
ADC map
3 Focal marked hyperintensity on high b-value DWI or focal marked hypointensity on the ADC map, but
not on both
4 Focal marked hyperintensity on high b-value DWI and marked hypointensity on the ADC map not at
the same site as the primary tumour, or site of the primary tumour not known
5 Focal marked hyperintensity on high b-value DWI and marked hypointensity on the ADC map at the
same site as the primary tumour
DCE 1 No enhancement
2 Diffuse or heterogeneous enhancement
3 Focal or mass-like late enhancement
4 Focal or mass-like early enhancement not at the same site as the primary tumour, or tumour site not
known
5 Focal or mass-like early enhancement at the same site as the primary tumour

ADC = apparent diffusion coefficient; BPH = benign prostatic hyperplasia; DCE = dynamic contrast enhancement; DWI = diffusion-weighted imaging; T2WI = T2-
weighted imaging.

Table 2 – Assessment categories by magnetic resonance imaging sequence after radical prostatectomy

Sequence Score Pattern changes

T2WI 1 Normal hypointense vesicourethral anastomosis and seminal vesicle bed remnants
2 Diffuse thickening of the vesicourethral anastomosis and/or thick-walled seminal vesicle remnants
and/or coarse scar tissue within the seminal vesicle beds
3 Symmetric focal or mass-like signal intensity in the perianastomotic area or seminal vesicle bed(s)
4 Asymmetric focal or mass-like iso/hyperintensity in the perianastomotic area or seminal vesicle bed(s)
not on the same side as the primary tumour, or tumour side not known
5 Asymmetric focal or mass-like iso/hyperintensity in the perianastomotic area or seminal vesicle bed(s)
on the same side as the primary tumour
DWI 1 No signal abnormality on high b-value DWI and ADC map
2 Diffuse moderate hyperintensity on high b-value DWI and diffuse moderate hypointensity on the ADC
map
3 Focal marked hyperintensity on high b-value DWI or focal marked hypointensity on the ADC map, but
not on both
4 Focal marked hyperintensity on high b-value DWI and marked hypointensity on the ADC map not on
the same side as the primary tumour, or side of the primary tumour not known
5 Focal marked hyperintensity on high b-value DWI and marked hypointensity on the ADC map on the
same side as the primary tumour
DCE 1 No enhancement
2 Diffuse or heterogeneous enhancement
3 Focal or mass-like late enhancement
4 Focal or mass-like early enhancement not on the same side as the primary tumour, or tumour side not
known
5 Focal or mass-like early enhancement on the same side as the primary tumour

ADC = apparent diffusion coefficient; DCE = dynamic contrast enhancement; DWI = diffusion-weighted imaging; T2WI = T2-weighted imaging.

PSA > 0.2 ng/ml after RP or alternatively fluciclovine/cho-
line PET/CT imaging at PSA > 1 ng/ml if PSMA PET/CT is not
available. Owing to a lack of randomised controlled trials,
there are no firm recommendations for PSA persistence,
even though it is acknowledged that patients may benefit
from early aggressive multimodal treatment. Therefore,
mpMRI and PI-RR should be used as an adjunct to PSMA
PET/CT, especially when PET is not conclusive (negative) in
patients with high clinical suspicion of local recurrence. In
addition, mpMRI should be performed before PSMA PET/CT
in patients with low-risk disease (according to EAU BCR risk
groups [47]) since it is a minimally invasive imaging
modality that can rule in or rule out local recurrence and can
guide targeted salvage IMRT and/or targeted biopsy. PSMA
PET/CT will be used more frequently for patients with BCR.
Some recent key studies have shown that PSMA PET/CT has

Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
EUO-416; No. of Pages 9
E U R O P E A N U RO L O GY O N C O L O GY X X X ( 2 019 ) X X X – X X X
good performance in detecting subtle lymph node and bone
metastases within and outside the pelvis when compared to
conventional imaging. However, the accuracy of PSMA PET/
CT in the prostatectomy bed can be limited by the presence
of urine in the bladder, which may obscure a local
recurrence. In these challenging locations, MRI was
reported to be of additional value to PSMA PET/CT [48–
50]. For men with BCR following RT with curative intent,
mpMRI is recommended for locating intraprostatic recur-
rence and guiding biopsy if patients are eligible for local
salvage therapy [1].
PI-RR was developed to provide radiologists with a
robust tool for acquiring and reading mpMRI for risk
assessment of local PCa recurrence following RT and RP.
Furthermore, PI-RR could improve communication between
clinicians (radiologists, urologists, radiation oncologists,
and nuclear medicine physicians) and introduce a new
paradigm in the management of BCR and PSA persistence,
pointing toward individualised therapeutic planning and
possibly lowering toxicity rates related to salvage RT, among
others.
3.5. Limitations
There are several limitations that need to be addressed. First,
the risk assessment is limited exclusively to the prostate
gland or prostatic bed in men who have undergone RT and RP.
For a comprehensive assessment of BCR, use of additional
imaging modalities for evaluation of nodal and distant organs
according to clinical risk groups is recommended. Second, the
PI-RR assessment categories are based on expert consensus,
and the actual recurrence rates in individual PI-RR categories
are currently unknown. Biopsy or correlation with other
imaging modalities and clinical validation is therefore
needed. Third, the assessment scores do not apply to
recurrence or new disease following focal therapy, as there
is no consensus or robust evidence on this topic yet. Fourth,
both inter- and intraobserver variability still need to be
investigated. Finally, the criteria identified for each technique
that define the different scores are not yet universally
accepted, and redefinition might be necessary after validation
in prospective studies and randomised trials, as has been
done with existing imaging reporting and data systems.
4. Conclusions
PI-RR is designed to assess the likelihood of local PCa
recurrence using mpMRI in post-RT or -RP patients. Like PI-
RADS, PI-RR offers a uniformly structured assessment score.
PI-RR recommendations are likely to meet the need for
standardisation and consistency in the acquisition, inter-
pretation, and reporting of mpMRI for PCa recurrence. The
system is designed as a clinical guide to improve the
management of men with recurrent PCa by achieving better
diagnostic performance and personalised treatment tai-
lored to individual patients. In addition, use of PI-RR is also
advised in clinical trials, where reproducibility of prospec-
tive assessments and comparisons of results from different
Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003
7
centres are required. Finally, it should be noted that PI-RR is
based on expert consensus and therefore still requires
validation, including evaluation of reproducibility among
readers and integration with biomarkers, such as PSA
kinetics after RT and RP.
Author contributions: Valeria Panebianco had full access to all the data
in the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Panebianco, Villeirs, Padhani, Barentsz.
Acquisition of data: Panebianco, Villeirs, Padhani, Barentsz, Shoots,
Futterer.
Analysis and interpretation of data: Panebianco, Villeirs, Padhani,
Barentsz, Richenberg, Salomon, Moore.
Drafting of the manuscript: Panebianco, Villeirs, Padhani, Barentsz,
Weinreb, Turkbey, Margolis, Macura, Oto, Bittencourt, Haider.
Critical revision of the manuscript for important intellectual content:
Panebianco, Villeirs, Weinreb, Tempany, Padhani, Barentsz.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Panebianco, Villeirs, Padhani, Barentsz.
Other: None.
Financial disclosures: Valeria Panebianco certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
Acknowledgments: The authors thank Martina Pecoraro and Riccardo
Campa from the Department of Radiological Sciences, Oncology and
Pathology, Sapienza University of Rome, Rome, Italy.
Data-sharing statement: Preparation of this paper did not involve
analysis of data.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at doi:https://doi.org/10.1016/j.
euo.2021.01.003.
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Please cite this article in press as: Panebianco V, et al. Prostate Magnetic Resonance Imaging for Local Recurrence Reporting (PI-
RR): International Consensus -based Guidelines on Multiparametric Magnetic Resonance Imaging for Prostate Cancer Recurrence
after Radiation Therapy and Radical Prostatectomy. Eur Urol Oncol (2021), https://doi.org/10.1016/j.euo.2021.01.003