Impact of central review and MRI image quality on prostate cancer diagnosis and biopsy decision-making in referred patients.

OBJECTIVES

To evaluate the impact of central review on prostate MRI interpretation, clinically significant prostate cancer (csPCa) detection, and biopsy decision-making in referred patients, and to investigate the influence of MRI image quality on diagnostic performance.

METHODS

This retrospective study included consecutive patients referred to a tertiary cancer center for biopsy after undergoing prostate MRI at external hospitals between December 2024 and November 2025. All MRI examinations underwent blinded expert central review with reassessment of Prostate Imaging Reporting and Data System (PI-RADS) v2.1 and Prostate Imaging Quality (PI-QUAL) v2 scores. Diagnostic performance and biopsy recommendations based on local assessments and central review were compared using area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity.

RESULTS

A total of 154 patients were included, of whom 76.0% (117/154) had csPCa. Compared with local assessments, central review significantly improved diagnostic performance for csPCa detection (AUC: 0.653 [0.558-0.747] vs 0.860 [0.785-0.936], P < 0.001). Using PI-RADS ≥ 3 as the threshold, central review improved diagnostic accuracy, sensitivity, and specificity (all P < 0.05). Biopsy decision accuracy also improved from 0.779 [0.705-0.842] to 0.857 [0.792-0.908] (P < 0.05), with the benefit primarily observed in examinations with acceptable image quality (PI-QUAL v2 > 1: 0.768 [0.651-0.861] vs 0.870 [0.767-0.939], P < 0.05), whereas no significant improvement was observed in PI-QUAL v2 = 1 examinations. In patients with prostate-specific antigen < 10 ng/mL, central review escalated 36.4% (4/11) of initially non-biopsy-recommended patients to biopsy, with 75.0% confirmed as csPCa, while avoiding 18.0% (11/61) of initially recommended biopsies; the only missed csPCa case (9.1% [1/11]) occurred in a PI-QUAL v2 = 1 examination.

CONCLUSION

Expert central review showed potential in improving prostate MRI interpretation and biopsy decision-making in referred patients. However, MRI image quality remains a critical determinant of diagnostic reliability, supporting routine implementation of image quality assessment and expert consultation in referral pathways.