EURURO Vol. 72 No. 2

190 320

men vs men with previous negative biopsy/biopsies or men
on active surveillance), decreasing inter-observer variability,
update the system according to new technical develop-
ments, use for surveillance, and incorporation of PI-RADS
with other relevant information (such as PSA and family
history) into nomograms to improve diagnosis and manage-
ment. Efforts are already underway to incorporate these and
other improvements into PI-RADS v3.
2. Experience and training
Despite the heterogeneous level of experience of the
radiologists (4–22 yr) who participated in the 21 studies
included in the review and meta-analysis, Woo et al did not
perform a meta-regression analysis or subgroup analysis of
the quality of the reader/reading. This is an important issue,
and it may be a major contributor to differences in results
from the studies analyzed. The inappropriate and unreliable
use of PI-RADSv2 by users who have not had sufficient
training or experience may not only result in suboptimal and
variable results for research but may also be compromising
clinical care
Puech et al proposed three levels of competence in
reading prostate MRI:
(1) Level I: the reader can select the appropriate modality
and is able to review images and use the results. At this
level, the technique is not performed.
(2) Level II: the reader follows an initial training course
with practical experience on interpreting prostate MRI,
but with a cover of double reading.
(3) Level III: the reader can independently report prostate
MRI under all circumstances without double reading.
Of course, several factors influence the learning curve:
the dedication and quality of the individual radiologist, the
quality of the initial course, the availability of histopatho-
logic and urologic feedback during multidisciplinary
meetings, and the learning process during consensus or
double readings. Many radiologists may achieve the
equivalent of level III competence by completing a recent
accredited training program. However, for others who
received their training where prostate mpMRI is not
routinely performed or who completed their training
before prostate mpMRI was a substantial component of a
training program, level III competence will be more
challenging.
3. Certification and quality criteria
Several authors have advocated for additional training and
certification (credentialing) for radiologists who supervise
and interpret prostate mpMRI .
To improve the current diagnostic pathway for PCa,
many lessons can be learned from mammography screen-
ing, for which dedicated courses and certification
(credentialing) of individual readers are used. Several
measures that could be considered to secure high quality
for individual reporting of prostate mpMRI include:
Make initial continuing medical education courses and
yearly hands-on courses mandatory for prostate MRI
readers.
Perform a minimum number of procedures per year.
Define an upper limit for equivocal diagnoses (PI-RADS 3),
depending on the indications and patient population.
Define a lower limit for PI-RADS 4 and 5 cases that should
yield clinically significant PCa.
Required participation in multidisciplinary meetings to
compare PI-RADS findings with histopathology.
Transparency of institutional clinical outcome data.
Expert panels of the ESUR and ACR should take the lead
to further define these criteria to secure high-quality
(reading of) prostate MRI and allow further implementation
by the urology community.
4. Prostate expertise network
A prerequisite for further development and evolution of high-
quality (reading of) prostate MRI is concentration of specific
knowledge on this topic. Bymeans of a worldwide network of
prostate MRI expert centers—which are sharing their
knowledge—the technique can be constantly updated and
improved. Internet connectivity of centers with expertise
may allow ‘‘double reading’’ of difficult cases, with subse-
quent better outcomes and diagnoses. Of course, this could be
beneficial not only for men with (a suspicion of) PCa but also
for fast implementation of newly validated techniques and
the development of a large scientific database.
5. Conclusions
It has been shown that PI-RADSv2 is an adequate
‘‘language’’ for assessing the risk of the presence of clinically
significant PCa. The sensitivity is significantly better than
that of PI-RADSv1. Nonetheless, there is large heterogeneity
that could be reduced by an improved PI-RADSv3 and by
training and certification of radiologists. Equally important,
however, is the training of urologists and other involved
physicians in being able to communicate in the same
‘‘language’’.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
[2]
E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 1 8 9 – 1 9 1 190