The future direction of imaging in prostate cancer: MRI with or without contrast injection

Background Multiparametric MRI (mpMRI) is the state of the art management tool for patients with suspicion of prostate cancer (PCa). The role of non-contrast MRI is investigated to move toward a more personalized, less invasive, and highly cost-effective PCa diagnostic workup. Objective To perform a non-systematic review of the existing literature to highlight strength and flaws of performing non-contrast MRI, and to provide a critical overview of the international scientific production on the topic. Materials and Methods Online databases (Medline, PubMed, and Web of Science) were searched for original articles, systematic review and meta-analysis, and expert opinion papers. Results Several investigations have shown comparable diagnostic accuracy of biparametric (bpMRI) and mpMRI for the detection of PCa. The advantage of abandoning contrast-enhanced sequences improves operational logistics, lowering costs, acquisition time, and side effects. The main limitations of bpMRI are that most studies comparing non-contrast with contrast MRI come from centers with high expertise that might not be reproducible in the general community setting; besides, reduced protocols might be insufficient for estimation of the intra- and extra-prostatic extension and regional disease. The mentioned observations suggest that low-quality mpMRI for the general population might represent the main shortage to overcome. Discussion Non-contrast MRI future trends are likely represented by PCa screening and the application of artificial intelligence (AI) tools. PCa screening is still a controversial topic; bpMRI has become one of the most promising diagnostic applications, as it is a more sensitive test for PCa early detection, compared to serum PSA level test. Also, AI applications and radiomic have been the object of several studies investigating PCa detection using bpMRI, showing encouraging results. Conclusion Today, the accessibility to MRI for early detection of PCa is a priority. Results from prospective, multicenter, multireader, and paired validation studies are needed to provide evidence supporting its role in the clinical practice.

Automated summary

Multiparametric MRI is the current state of the art management tool for patients with suspected prostate cancer. Non-contrast MRI is being investigated as a more personalized, less invasive, and cost-effective diagnostic approach for PCa. Studies have shown that biparametric and multiparametric MRI have comparable diagnostic accuracy for PCa detection, with the advantage of cost and time savings. However, the main limitation lies in the reproducibility of high-expertise center results in a general community setting, suggesting a need for improvements in MRI quality for the general population. Future trends in non-contrast MRI may focus on PCa screening and the application of AI tools, with promising results in early PCa detection and radiomic studies.