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General Surgery · Additional Topics

Prostate cancer

Carcinoma prostatae

Prostate cancer requires high-precision diagnostic imaging to decide on the need for biopsy and select treatment management. Today, multiparametric magnetic resonance imaging (mpMRI) plays a key role in this process, steadily replacing traditional staging methods.

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PI-RADS systemA 1-to-5 scale for the objective assessment of the probability of clinically significant prostate cancer.
PROMIS trialProved that mpMRI allows 27% of patients to safely avoid a primary biopsy.
Bone metastasesOccur in 85% of patients with advanced prostate cancer.
StagingMRI outperforms TRUS in accuracy for detecting extracapsular tumor extension.
3 min readFor medical studentsUpdated 10.10.2026
Material prepared by WhiteCoat Pro editorial team based on platform study guidesPending instructor review

Multiparametric MRI: The New Gold Standard

In modern prostate cancer diagnostics, multiparametric MRI holds a leading position. The examination invariably includes diffusion-weighted imaging (DWI or DWI) and dynamic contrast-enhanced sequences.

The landmark PROMIS clinical trial (Prostate MR Imaging Study) convincingly confirmed the value of this method. Performing mpMRI at the triage stage for patients with suspected malignancy not only significantly improves the detection of clinically significant tumors but also spares 27% of men from the need for an invasive primary biopsy.

Standardization Using the PI-RADS System

To ensure physicians of various specialties "speak the same language," the international PI-RADS system (Prostate Imaging-Reporting and Data System) is used.

Its main objectives:

  • Rigorous standardization of imaging report protocols.
  • Objective assessment of the risk of malignancy.
  • Creation of an accurate navigation "map" for subsequent targeted biopsy.

The PI-RADS risk scale assesses the probability of cancer on a 5-point scale:

  1. Very low.
  2. Low.
  3. Intermediate.
  4. High.
  5. Very high.
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Assessment of Local Extension (T-Staging)

Accurate staging is critical for choosing between radical and conservative treatment. It has been proven that MRI and transrectal ultrasound (TRUS) significantly outperform standard clinical digital rectal examination. Furthermore, MRI has markedly greater sensitivity and specificity compared to TRUS, especially when detecting tumor extension beyond the prostate capsule (extracapsular extension).

Typical MRI presentation of a primary tumor (illustrated by T2 stage):

  • On T2-weighted images (in coronal and axial planes), a tumor located in the peripheral zone is visualized as an area of low signal intensity.
  • If the tumor nodule reaches the edge of the capsule but there are no definitive signs of capsular invasion, T2 stage is assigned.
  • On DWI, restricted water molecule diffusion is noted in the affected area. On special ADC maps (ADC map), this appears as a zone of low signal intensity.

Distant Metastasis

Prostate cancer is prone to distant metastasis, predominantly to the skeletal bones (spine, pelvic bones). According to statistics, up to 85% of patients have bone metastases at the time of death from the disease.

Computed tomography (CT) remains the primary method for detecting distant metastases. The presence of metastases is not always an absolute contraindication to surgical treatment of the primary focus—sometimes local control is required to alleviate severe symptoms.

For palliative management of intractable pain from bone metastases refractory to external beam radiation therapy (EBRT) and opioid analgesics, thermal ablation is actively used. Pain in metastases is caused by:

  • stretching of the periosteum by the growing tumor nodule;
  • active osteolysis and cytokine release;
  • micro-motion of bone fragments under load;
  • infiltration of nerve trunks.

Class and exam questions

What is PI-RADS and why is it used?

This is an international standardized system for reporting prostate MRI. It allows for an objective risk assessment of cancer on a 5-point scale and helps the physician precisely plan a targeted biopsy.

Which is better for prostate cancer staging: MRI or TRUS?

MRI outperforms TRUS (transrectal ultrasound) in accuracy, sensitivity, and specificity, particularly when assessing extracapsular extension (tumor growth beyond the prostatic capsule).

Why is the PROMIS study considered important?

It proved that the use of multiparametric MRI at the primary triage stage allows 27% of patients to avoid unnecessary biopsy while increasing the detection rate of clinically significant cancer forms.

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What else to study on this topic

  • Technique of MRI-guided targeted biopsy
  • Principles of thermal ablation for bone metastases in prostate cancer
  • The role of PET/CT in detecting distant metastases
  • Percutaneous osteosynthesis and augmentative osteoplasty for pathological fractures
  • Evaluation of treatment response using imaging modalities

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