PI-RADS v2.1 for prostate MRI: current applications, ongoing debates, and synergies with advanced technologies-a narrative review
Abstract
Background and objective: Prostate Imaging Reporting and Data System (PI-RADS) version 2.1 is the current standard for prostate multiparametric magnetic resonance imaging (mpMRI) reporting, aimed at improving diagnostic consistency for clinically significant prostate cancer (csPCa). This review aims to summarize the current applications of PI-RADS v2.1, analyze its diagnostic performance and limitations, and explore emerging synergies with biomarkers, biparametric MRI (bpMRI), artificial intelligence (AI), and advanced quantitative MRI techniques.
Methods: A comprehensive literature search was conducted in PubMed and Web of Science databases up to December 2025, covering English-language articles on PI-RADS v2.1, prostate MRI, and related diagnostic innovations. Both original research and systematic reviews were considered to provide a balanced overview.
Key content and findings: Compared with version 2.0, PI-RADS v2.1 refines technical specifications and interpretive criteria, but persistent challenges remain, including inter-reader variability and ambiguous guidance on patient preparation. Integration with prostate-specific antigen (PSA) density helps optimize risk stratification for PI-RADS 3 lesions. The bpMRI pathway offers a contrast-free, time-efficient alternative with comparable diagnostic accuracy. AI, particularly deep learning and radiomics, augments lesion detection, classification, and workflow efficiency, narrowing the experience gap among radiologists.…
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