Prostate imaging: what have we learnt so far?
Over the past two decades, prostate imaging has evolved from a poorly standardised research technique into a key component of the prostate cancer pathway. Multiparametric MRI now acts as a gatekeeper to biopsy, supported by PI-RADS, which standardises acquisition and reporting for the detection of clinically significant cancer. As MRI use has increased, additional scoring systems have been developed to support radiologists and urologists in specific clinical contexts. The PI-QUAL scoring system assesses technical image quality, PRECISE longitudinally evaluates disease on active surveillance, PI-FAB and TARGET guide assessment after focal therapy and prostatectomy, and PI-RR is used to evaluate suspected recurrence following radiotherapy. PSMA PET has also become an important complementary tool to prostate MRI, used for staging intermediate risk and high risk disease and may improve evaluation when MRI findings are indeterminate.
Population-based screening is another key focus of current research initiatives. The UK TRANSFORM trial is evaluating PSA testing, genetic risk assessment and rapid-MRI to determine whether screening can identify prostate cancer early while limiting overdiagnosis and overtreatment, with particular attention on black men who form a higher risk group. AI is another major frontier, likely to support future prostate imaging through triage, quality control and decision support. Early studies suggest performance approaching that of expert radiologists in controlled settings, but robust validation and reliable reference standards
are essential.
Overall, the role of prostate imaging remains an exciting area of clinical development, with standardisation, validation and a focus on image quality underpinning advances that span the patient pathway.
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