MR image quality in local staging of prostate cancer: Role of PI-QUAL in the detection of extraprostatic extension

Purpose: To assess the impact of prostate MRI image quality by means of the Prostate Imaging Quality (PI-QUAL) score, on the identification of extraprostatic extension of disease (EPE), predicted using the EPE Grade Score, Likert Scale Score (LSS) and a clinical nomogram (MSKCCn). Methods: We retrospectively included 105 patients with multiparametric prostate MRI prior to prostatectomy. Two radiologists evaluated image quality using PI-QUAL (≥4 was considered high quality) in consensus. All cases were also scored using the EPE Grade, the LSS, and the MSKCCn (dichotomized). Inter-rater reproducibility for each score was also assessed. Accuracy was calculated for the entire population and by image quality, considering two thresholds for EPE Grade (≥2 and = 3) and LSS (≥3 and ≥ 4) and using McNemar's test for comparison. Results: Overall, 66 scans achieved high quality. The accuracy of EPE Grade ranged from 0.695 to 0.743, while LSS achieved values between 0.705 and 0.733. Overall sensitivity for the radiological scores (range = 0.235-0.529) was low irrespective of the PI-QUAL score, while specificity was higher (0.775-0.986). The MSKCCn achieved an AUC of 0.76, outperforming EPE Grade (=3 threshold) in studies with suboptimal image quality (0.821 vs 0.564, p = 0.016). EPE Grade (=3 threshold) accuracy was also better in high image quality studies (0.849 vs 0.564, p = 0.001). Reproducibility was good to excellent overall (95 % Confidence Interval range = 0.782-0.924). Conclusion: Assessing image quality by means of PI-QUAL is helpful in the evaluation of EPE, as a scan of low quality makes its performance drop compared to clinical staging tools.