New Prostate MRI Scoring Systems (PI-QUAL, PRECISE, PI-RR, and PI-FAB): AJR Expert Panel Narrative Review

Multiparametric MRI (mpMRI), interpreted using PI-RADS, improves the initial detection of clinically significant prostate cancer. Prostate MR image quality has increasingly recognized relevance to the use of mpMRI for prostate cancer diagnosis. Additionally, mpMRI is increasingly used in scenarios beyond initial detection, including active surveillance and assessment for local recurrence after prostatectomy, radiation therapy, or focal therapy. In acknowledgment of these evolving demands, specialized prostate MRI scoring systems beyond PI-RADS have emerged to address distinct scenarios and unmet needs. Examples include Prostate Imaging Quality (PIQUAL) for assessment of image quality of mpMRI, Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) recommendations for evaluation of serial mpMRI examinations during active surveillance, Prostate Imaging for Recurrence Reporting (PI-RR) system for assessment for local recurrence after prostatectomy or radiation therapy, and Prostate Imaging after Focal Ablation (PI-FAB) for assessment for local recurrence after focal therapy. These systems' development and early uptake signal a compelling shift toward prostate MRI standardization in different scenarios, and ongoing research will help refine their roles in practice. This AJR Expert Panel Narrative Review critically examines these new prostate MRI scoring systems (PI-QUAL, PRECISE, PI-RR, and PI-FAB), analyzing the available evidence, delineating current limitations, and proposing solutions for improvement.