This multicenter study evaluated PI-RADS and automated RSI restriction score (RSIrs) for detecting unfavorable-histology prostate cancer (uhPC — Grade Group ≥3, or GG 2 with cribriform/intraductal features) at the patient level (n=1022, biopsy reference) and lesion level (n=103, whole-mount histopathology from radical prostatectomy).
Patient-level AUC did not differ significantly between PI-RADS and RSIrs (p=0.13). For the index tumor, combined sensitivity was 93% (95% CI 86–98%) vs. 87% for PI-RADS alone and 85% for RSIrs alone. For all uhPC tumors, combined sensitivity reached 90% (95% CI 82–97%) vs. 81% and 86% individually.
Lesion-level analysis included only surgical patients (selection bias toward higher-risk disease); multicenter design may introduce variability in MRI acquisition and PI-RADS scoring; RSIrs is an automated tool not yet universally available.
MRI (PI-RADS and RSIrs) shows high sensitivity for biologically aggressive prostate cancer — combining both tools pushes index-tumor detection to 93%. Clinicians can use this combined approach to guide targeted biopsy and focal therapy planning (e.g., dose escalation to aggressive intraprostatic lesions).
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