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\begin{document}

\title{Prospective evaluation of the correlation between Prostate Imaging
--Reporting and Data System (PI-RADS) version 2.1 and International
Society of Urological Pathology (ISUP) score, and inter-observer
Reproducibility of the New Version}



\author[1]{GÜLŞEN YÜCEL OĞUZDOĞAN}%
\author[1]{Zehra Hilal Adıbelli}%
\author[1]{Ertugrul Sefik}%
\author[1]{Hulya Mollamehmetoğlu}%
\author[2]{Ibrahim Halil Bozkurt}%
\author[3]{Enver Vardar}%
\author[4]{Bulent GUNLUSOY}%
\author[1]{Hulya Cetin Tuncez}%
\affil[1]{University of Health Sciences Izmir Bozyaka Education and Research Hospital}%
\affil[2]{Affiliation not available}%
\affil[3]{Izmir Bozyaka Training and Research Hospital}%
\affil[4]{Bozyaka Teaching and Research Hospital}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Purpose: To evaluate the correlation between PI-RADSv2.1 and
International Society of Urologic Pathologists (ISUP) score for patients
who underwent multiparametric-MRI(MpMRI) prior to transrectal ultrasound
(TRUS) guided cognitive fusion biopsy (CF-Bx). And to investigate
inter-observer agreement of PI-RADSv2.1. Methods: Patients who underwent
MpMRI of prostate prior to first TRUS-guided CF-Bx, were included in
this prospective study. MpMRI examinations were evaluated by two
radiologists before biopsy according to the PI-RADSv2.1. Interobserver
agreement was recorded and the final PI-RADS categorization was
performed by consensus. Correlation of histopathological results with
PI-RADSv2.1 score was evaluated. Lesions with Gleason Score(GS)[?]6 were
considered as prostate cancer (PCa). Results: A total of 84 patients
with 106 lesions were included in the study. The ratio of PCa in the
PI-RADS groups 1,2,3,4,5 was 0\%, 0\%, 22.2\%, 56\%, 94.45\%,
respectively. There was a positive correlation with a value of 0.814
between the PI-RADSv2.1 and the ISUP score. When PI-RADS[?]3 is accepted
as the cut-off value in peripheral zone(PZ) and the whole gland, the NPV
for malignancy was 100.00\%. For PI-RADS [?]4, it was 76.47\% for PZ, and
80.65\% for the whole gland. For the whole gland; sensitivity,
specificity, and PPV of the PI-RADS[?]3 were 100\%, 12.9\%, and 44.33\%,
respectively; for PI-RADS[?]4, these values were 72.09\%, 80.65\%, and
72.09\% respectively. Without applying cut-off values, the interobserver
agreement for PI-RADS score was \selectlanguage{greek}κ\selectlanguage{english}appa:0.562. Conclusions: PI-RADSv2.1
was created in the framework of v2 to facilitate to evaluate MpMRI and
to increase interobserver agreement. We believe that further studies
will be necessary.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Prostate cancer(PCa) is the most commonly observed cancer in men in the
world and the 3\textsuperscript{rd} most common cause of cancer-related
deaths\textsuperscript{1}. An autopsy study of 1056 men, who died from
causes other than prostate cancer, found 68-77\% of men aged 60-79 years
had not received a diagnosis but had asymptomatic PCa identified. This
result shows the prevalence of this silent disease\textsuperscript{2,3}.
However, the mortality and morbidity of advanced stage PCa are very
high. Recent studies have focused on distinguishing lesions expressed as
``silent disease'' with almost no fatality potential, such as tumors
with a Gleason score(GS) of 6, and high-grade
cancers\textsuperscript{4}. Due to limited sensitivity and specificity
of serum PSA screening, digital prostate examination, and TRUS-bx,
advanced imaging methods are required to reduce biopsy numbers and to
perform target-specific biopsies\textsuperscript{5}. With advanced
imaging methods, diagnosis and treatment of prostate cancer can be
chosen specifically to the person or active surveillance may be
performed. To ensure standardization and reduce differences emerging in
the selection of parameters and interpretation of images on prostate
MRI, the ESUR published a guideline in 2012\textsuperscript{5,6}. Rapid
developments in this field and limitations encountered during the use of
the PI-RADSv1 led to an update of the PI-RADS system and PI-RADSv2 was
published in 2015 by a committee\textsuperscript{7}. In 2019,
PI-RADSv2.1 was published including changes ensuring more accurate and
reproducible interpretations can be made\textsuperscript{8,9}.

The aim of this prospective study is; to investigate the correlation of
the PIRADSv2.1 score with the histopathological result and the ISUP
score in patients with suspected prostate cancer in MpMRI examinations
guided PI-RADSv2.1 and diagnosed with TRUS-guided cognitive fusion
biopsy(TRUS-guided CF-Bx) and to assess the compatibility between
different experience levels of the radiologists.

\textbf{MATERIAL AND METHODS}

In this prospective single-center study, 166 consecutive patients who
underwent MpMRI for prostate cancer diagnosis between April'19 and
December'19 were evaluated. Ethical approval was obtained from a local
committee. Oral and written consents were obtained from all patients.
Twelve patients with unsuitable image quality for evaluation, 26
patients with bx performed previously, without cognitive fusion biopsy
in our hospital and with prostate cancer treatment before testing, and
44 patients with no tissue diagnosis due to PI-RADS-1 or refusing biopsy
were excluded from the study. A total of 106 lesions of 84 patients
diagnosed with TRUS-guided CF-Bx in our hospital were included in the
final study group. Patient age, serum PSA value, PSAd, and prostate
volume were recorded.~The prostate MpMRI examined in the study was
performed with a 1.5T Siemens Magnetom Aera MRI device with 18 channels
pelvic coil according to the protocols shown in below\emph{Table-1}
.~All sequences were assessed on a SYNGO.VIA-workstation.

\textbf{Assessment of images and histopathological correlation}

MpMRI images were evaluated before biopsy according to the PI-RADSv2.1
guidelines by two radiologists with 25-years of experience(reader-1) and
2-year of experience(reader-2) in abdominal MRI. The appearance,
localization, and dimensions of lesions were first independently
assessed by the two radiologists. Lesion localization was defined
according to the sector map in the PI-RADSv2.1 guidelines. Lesions
exceeding zonal anatomy (both PZ and transitional zone(TZ) spread) or
lesions with extraprostatic extension were defined as diffuse cancer.
Lesions were scored according to PI-RADSv2.1 criteria on T2 weighted
images(T2W) and diffusion weighted imaging(DWI). DCE-MRI was defined as
`negative' or `positive' and each lesion was given a
PI-RADSv2.1(category 1-5) score. These scores were recorded to evaluate
the interobserver agreement. Due to the different PI-RADS scores in
between the readers, the final PI-RADS categorization was performed by
consensus for 28 lesions\emph{(Table-2).}

Interobserver agreement of these variables and histopathological
correlation with PI-RADSv2.1 score were evaluated. Negative MpMRI
findings were assigned to PI-RADS-1.

Based on MpMRI findings and clinical suspicion of prostate cancer, a
biopsy was performed on the patients. While MpMRI cognitive fusion
TRUS-bx was applying with the 18G automatic tru-cut biopsy needle, the
hypoechogenic-hyperechogenic foci were considered, 2 samples were taken
from each lesion by correlating them with the foci defined in MpMRI and
marked on the sector map\textsuperscript{7}. In addition to cognitive
fusion, 12-core systematic bx was performed. The TRUS-bx procedure was
performed by one of 3 experienced urologists. A total of 84 patients
diagnosed with using TRUS-guided CF-Bx had 106 lesions identified.
Biopsy specimens were evaluated by a urogenital pathologist. Malignant
lesions were grouped according to the ISUP scoring (ISUP1, GS3+3; ISUP2,
GS3+4; ISUP3, GS4+3; ISUP4, GS4+4; ISUP5, GS[?]9)\textsuperscript{10}. On
MpMRI, lesions that have PI-RADSv2.1 score [?]3 were recorded as positive,
while lesions have \textless{}3 score were recorded as negative lesions.

\textbf{Statistical Method}

In descriptive analyzes, continuous variables are presented as
mean\selectlanguage{ngerman}±standard deviation or median (25th-75th percentile) and categorical
variables as a percentage(\%). The compliance of the data to normal
distribution was evaluated using the Shapiro-Wilk test. If the data has
a normal distribution, a t-test was used to compare two groups; under
non-parametric conditions, the Mann-Whitney U test was used. Comparison
of continuous variables between three and more categories was used the
one-way ANOVA or the non-parametric equivalent of the Kruskal-Wallis
test. The power of the correlation between two continuous variables was
assessed with the Spearman correlation analysis. Accordingly, the
correlation coefficient(r) values \textless{}0.2 show very weak or no
correlation, values from 0.2-0.4 show weak correlation, from 0.4-0.6
show moderate correlation, 0.6-0.8 show a high correlation, and
values\textgreater{}0.8 are interpreted as very high correlation.
Interobserver agreement was evaluated by using kappa coefficients(\selectlanguage{greek}κ\selectlanguage{english}),
were computed and assessed as follows: 0.01--0.20, slight agreement;
0.21--0.40, fair agreement; 0.41--0.60, moderate agreement; 0.61--0.80,
substantial agreement; and 0.81--0.99, almost perfect agreement. To
evaluate the success of the obtained variables, to diagnose prostate
cancer and to determine cut-off points, ROC analysis was used with the
area under the curve(AUC) used to calculate sensitivity, specificity,
positive predictive value(PPV), and negative predictive value(NPV). SPSS
22.0 and MEDCALC programs were used for statistical analyses.
p\textless{}0.05 was accepted as statistically significant.

\textbf{RESULTS}

The mean age, PSA, prostate volume and mean PSAd values for the 84 cases
included in the study were 63.5\selectlanguage{ngerman}±7.5 years, 11.68±17.34ng/ml,
62.4±38.08cm\textsuperscript{3}, and 0.23±0.39ng/ml\textsuperscript{2},
respectively. There were no statistically significant differences
between malignant and benign diseases for age and PSA values. Prostate
volume in the malignant group was found to be significantly lower and
PSAd higher than the benign group
(p\textless{}0.001,p\textless{}0.001)(\emph{Table-3} ).

Of the 106 lesions examined in this study from the 84 patients,
26(24.5\%) were benign prostatic tissue, 36(33.96\%) were prostatitis,
43(40.46\%) were malignant lesions and 1(0.94\%) was high-grade
prostatic intraepithelial neoplasia. Among malignant lesions, 65.1\%
were localized in the PZ, 14\% in the TZ, and 20.9\% were diffuse
cancers.

In the PI-RADS groups 1, 2, 3, 4, and 5, there were 5, 4, 54, 25, and 18
lesions identified respectively. No malignancy was detected in any of
the 9 lesions who had PI-RADS-1 and 2. Systematic biopsy was performed
to these patients with the decision of the clinician due to the increase
in PSA, rectal examination findings and the age of the patient. Of the
PI-RADS-3, 4, and 5 lesions, the PCa ratios were 22.2\%, 56\% and
94.45\%, respectively.

\emph{Table-4} shows the statistical parameters in PZ and TZ when the
cut-off value PI-RADS\selectlanguage{english}[?]3 and PI-RADS\selectlanguage{english}[?]4 taken as positive for cancer
detection when T2W and DWI are independently evaluated. In TZ, there was
no patient with a PI-RADS\textless{}3, so the diagnostic parameters for
this variable could not be calculated.

The success of the PI-RADS score to predict cancer was found to have an
AUC value of 0.764 (0.646-0.882) for PZ and 0.629 (0.347-0.910) for TZ
when PI-RADS\selectlanguage{english}[?]3 positive is considered. Evaluation by excluding the zonal
anatomy and taking the PI-RADS score as \selectlanguage{english}[?]3 positive found the cancer
prediction success had AUC values of 0.773 (0.683-0.864), 0.722
(0.621-0.824), 0.740 (0.641-0.838), 0.619 (0.514-0.724), and 0.764
(0.646-0.882) for T2W, DWI, DCE, T2W and DWI combinations
(biparametric), and the T2W, DWI and DCE combination (MpMRI),
respectively.

The sensitivity, specificity, NPV, and PPV values for prostate cancer
detection according to PI-RADSv2.1 and regardless of the zone, for T2W
and DWI independently, for biparametric and MpMRI assessment when
PI-RADS\selectlanguage{english}[?]3 and \selectlanguage{english}[?]4 taken as positive are summarized in\emph{Table-5} .
When the results for cut-off value of \selectlanguage{english}[?]3 are compared with the results
for cut-off value \selectlanguage{english}[?]4 in\emph{Table-4} and\emph{Table-5} , the
differences between the two cut-off values were statistically
significantly different(p\textless{}0.001). Accordingly, when the
PI-RADS score cut-off value of \selectlanguage{english}[?]4 was taken as positive, the sensitivity
and NPV moderately fall, while specificity and PPV increase.

All lesions in the ISUP\textgreater{}1 group (n=27) were evaluated as
PI-RADS-4 or 5. While 25.47\% of all lesions had ISUP\textgreater{}1
observed, 40.56\% of the lesions (n=43) were identified to have
PI-RADS-4 and 5. When PI-RADS-3 lesions are evaluated, 22.2\% of these
lesions received PCa. In this group, there were no lesions with
ISUP\textgreater{}1 diagnosis. There was a positive correlation between
PI-RADSv2.1 score with ISUP score and the correlation value was
0.814(p\textless{}0.001) \emph{(Table-6)}

In PZ, for the ISUP grades 1, 2, 3, 4, and 5, there were 4(57.1\%),
2(28.6\%), 0(0\%), 0(0\%), and 1(14.3\%) lesions which upgraded to
PI-RADS group 4 with DWI score 3 and DCE positivity, identified
respectively\emph{(Table-7)} . For lesions with DWI score 4 and PIRADS
4, 0(\%0), 2(33.3\%), 2(33.3\%), 2(33.3\%), and 0 lesions identified
respectively for the ISUP grades 1, 2, 3, 4, and 5. Lesions that are
primary PI-RADS4, were observed to have higher ISUP grades. When grouped
according to ISUP grade 1 and \textgreater{}1, there were significant
differences in terms of the DWI score 3 and 4 percentages
(p:0.03)(\emph{Figure-1} ,\emph{Figure-2} ).

The interobserver agreement kappa value(\selectlanguage{greek}κ\selectlanguage{english}) for the PI-RADS score,
without applying the cut-off value, was 0.562 which represents moderate
agreement. When PI-RADS cut-off value of [?]3 positive is considered,
kappa was 0.320, which represents fair agreement but when the cut-off
value was determined as [?]4, the kappa is 0.770 which corresponds to a
substantial agreement. Interobserver agreement for T2W was moderate with
kappa:0.575 when PI-RADS[?]3 positive taken as the cut-off and reached the
substantial agreement with kappa: 0.814 when PI-RADS[?]4 is taken.
Interobserver agreement for DWI was fair with kappa:0.321, when
PI-RADS[?]3 is taken as the cut-off value but reached the substantial
level when PI-RADS[?]4 is taken as the cut-off(\selectlanguage{greek}κ\selectlanguage{english}=0.757). For DCE
investigation with positive and negative scores evaluation,
interobserver agreement was at substantial levels with \selectlanguage{greek}κ\selectlanguage{english}=0.721.

\textbf{DISCUSSION}

In this study, the correlation of prostate gland diseases with patient
age, gland volume, serum PSA value and, PSA density, the effectiveness
of the MpMRI and PI-RADSv2.1 scoring system in detecting prostate gland
diseases, PI-RADSv2.1 and ISUP score correlation, and interobserver
agreement were assessed. In our study, serum PSA did not show a
significant difference for malignant or benign disease. PSAd was
observed significantly high in the malignant group. Joshua Stephen Jueve
et al. reported a sensitivity of 90-95\% for PSAd and considering the
0.15 ng/ml\textsuperscript{2} threshold value, they supported that the
high NPV may prevent unnecessary biopsy in patients with proportional
PSA increase compared to prostate volume\textsuperscript{11}. There was
a negative correlation found between prostate volume and malignancy
diagnosis. This result is similar to the results of studies by Shadi
Al-Khalil et al.\textsuperscript{12} and Tang et
al.\textsuperscript{13}. The causes for the increase of prostate volume
may be interpreted as due to benign causes like hyperplasia and
prostatitis.~The study of Haas et al. presented that patients with
prostate cancer were of advanced ages\textsuperscript{14}. Droz et al.
showed high mean age in the cancer group\textsuperscript{15}. In our
study, the mean age in the cancer group was consistent with the
literature and was higher compared to benign diseases of the prostate
gland; however, the difference was not statistically
significant(p:0.053).~PI-RADSv2 is a scoring system widely used for the
detection of PCa and its reliability has been demonstrated by numerous
studies. When we examine these studies in the literature, the cut-off
value for detection of clinically significant prostate cancer on MpMRI
of PI-RADS 3 or 4 had ranges of 85.7-94.5\% for sensitivity, 23-71\% for
specificity, and 34-97\% and 50-92\% for PPV and NPV,
respectively\textsuperscript{16--21}. Venderink et
al.\textsuperscript{22} determined the clinically significant PCa rates
(GS[?]3+4) for PI-RADS-3, 4, and 5 lesions were 17\%, 34\%, and 67\%,
respectively. A study by Mathur et al. found the detection rates for
clinically significant PCa were 6.1\%, 33.3\%, and 64.4\% for PI-RADS 3,
4, and 5 respectively, and increased in proportion to the
score\textsuperscript{23}. A study assessing 737 lesions with
MpMRI-targeted TRUS-bx found the PCa rates for PI-RADS 1, 2, 3, 4 and 5
lesions were 0\%, 10\%, 12\%, 22\% and 72\%
respectively\textsuperscript{24}. In our study, 22.2\%, 56\%, and
94.45\% cancers were detected in PI-RADS 3, 4, and 5 groups
respectively. None of the malignant lesions in the PI-RADS3 group had
ISUP\textgreater{}1 pathology results. As in all PI-RADS versions,
disease management after scoring is not specified for patients in v2.1.
In PI-RADS v2.1, ''Category 3 lesions are of intermediate status with an
equivocal risk of presenting clinically significant prostate cancer
(csPCa)'' risk is stated and there are limited studies in the literature
regarding the selection of follow-up-biopsy and it has not been
clarified yet\textsuperscript{9,25}. Therefore, all PI-RADS-3 lesions
were biopsied with the clinician's preference.

There was a positive correlation found between the PI-RADSv2.1 score
with the ISUP score\emph{(Table-6)} (p\textless{}0.001). A study by
Walker et al.\textsuperscript{26} found a positive correlation between
PI-RADSv2.1 categories and ISUP groups with a correlation value of 0.5
and with the increase of the PI-RADS category, clinically significant
cancer rates were shown to increase. Additionally, as shown in the study
by Walker et al., also in our study, in PZ when lesions with DWI score 3
upgraded to PI-RADS4 group with DCE positivity and PI-RADS4 lesions with
DWI score 4 are compared, the PI-RADS4 lesions with DWI score 4 were
observed to have higher ISUP grades\textsuperscript{26}. These results
clearly show that as the PI-RADSv2.1 score increases, the
clinically-significant cancer detection rate increases, and can be
interpreted as the tumors have more aggressive histopathology. However,
in our study, the histopathological evaluation of lesions observed
25.47\% had ISUP\textgreater{}1, while 40.56\% of lesions had PI-RADS
scores of 4 or 5. It is clear that PI-RADSv2.1 also needs improvements
and more objective recommendations, and further research may contribute
to achieving this aim. In our study, when cut-off values for PZ and
whole gland are accepted as PI-RADS[?]3, the NPV for malignancy was
100.00\%. For cut-off value PI-RADS[?]4 lesions, this value was 76.47\%
for PZ, 83.33\% for TZ, and 80.65\% for the whole gland, compatible with
the literature\textsuperscript{27--29}. The high NPV is very important
in terms of excluding cancer for patients without performing bx. The
sensitivity, specificity, PPV, and NPV analysis in terms of PI-RADSv2.1
sequences and zones are summarized in\emph{Table-4} and\emph{Table-5} .
However, no study in the literature separately evaluated the sequences
in PI-RADSv2.1. When we compare with meta-analyses performed for
PI-RADSv2, the sensitivity, specificity, PPV, and NPV values for the
sequences are compatible with the previous
studies\textsuperscript{30}.~A study comparing PI-RADSv2 and 2.1
calculated the diagnostic sensitivity, specificity, PPV, and NPV for
PI-RADSv2.1 according to PI-RADS[?]3 are taken as positive for the
detection of GS[?]7 tumors according to zones as 94.3\%, 24.2\%, 46.1\%,
and 86.1\% for PZ and 93.8\%, 42.1\%, 45\% and 93\% for TZ,
respectively\textsuperscript{31}. In our study, taking the PI-RADS score
cut-off value as [?]3 positive for PZ, the sensitivity for PCa was 100\%,
specificity was 11.11\%, PPV was 46.67\% and NPV was 100.00\%, similar
to levels to the literature for PZ was observed. Although the PI-RADSv2
system is well standardized and expanded for MpMRI use, studies have
reported interobserver agreement is highly variable from low to
high\textsuperscript{32--34}. A study with 3 observers by Popita et
al.\textsuperscript{35} found the interobserver agreement kappa
coefficient(\selectlanguage{greek}κ\selectlanguage{english}) was 0.643, 0.664, and 0.568. A study which two
radiologists examined 170 patients, determined the interobserver
agreement for PI-RADS[?]3 was substantial (all zones \selectlanguage{greek}κ\selectlanguage{english}=0.63 PZ \selectlanguage{greek}κ\selectlanguage{english}=0.62, TZ
\selectlanguage{greek}κ\selectlanguage{english}=0.53) and for PI-RADS[?]4 was almost perfect (all zones \selectlanguage{greek}κ\selectlanguage{english}=0.91, PZ
\selectlanguage{greek}κ\selectlanguage{english}=0.91, TZ \selectlanguage{greek}κ\selectlanguage{english}=0.87)\textsuperscript{36}. Smith et
al.\textsuperscript{37}found the interobserver agreement was fair with
\selectlanguage{greek}κ\selectlanguage{english}=0.24. The compatibility degree between experienced observers was
higher for the whole gland and PZ lesions compared to the observers with
moderate levels of experience. When the sequence-specific interobserver
agreement is assessed, values were \selectlanguage{greek}κ\selectlanguage{english}=0.24, 0.24, and 0.23 for T2W, DWI,
and DCE respectively. Between two radiologists with different levels of
experience, we observed moderate compatibility for the use of
PI-RADSv2.1 without the cut-off value(all zones \selectlanguage{greek}κ\selectlanguage{english}=0.562) and the cut-off
value of PI-RADS[?]4(all zones \selectlanguage{greek}κ\selectlanguage{english}=0.77). Our data show that the use of the
new update to PI-RADSv2.1 increases interobserver agreement with more
specific definitions. Increasing observers' experience and future
PI-RADS updates will increase the agreement power between inexperienced
observers or observers with similar experience.

\textbf{Limitation}

\begin{itemize}
\tightlist
\item
  The small sample group, and lack of equal numbers of lesions according
  to pathologic diagnosis and zones. Increasing the number of patients
  in the study may provide better results and beneficial statistical
  data for the literature.
\item
  As the study was prospectively designed, there were 9/106 lesions in
  PI-RADS\textless{}3 group, so we could not evaluate the sensitivity
  and specificity of PI-RADS-3, especially in TZ.
\item
  The main disadvantage of TRUS-guided CF-Bx is that the success of the
  procedure is depending on the operator's experience and lack of
  standardization.\textsuperscript{38}
\item
  Measuring interobserver agreement between radiologists before and
  after PI-RADS training may reveal the difference between experience
  and training in terms of MpMRI.
\end{itemize}

PI-RADSv2.1 was observed to be very effective for detecting lesions, for
determining patient selection for biopsy, identifying risk level for
patients with prostate cancer suspicion, and follow-up strategies
according to risk level. When the PI-RADS[?]3 cut-off value is increased
to PI-RADS[?]4, the significant increase in the specificity, PPV and
interobserver agreement suggests that the PI-RADS3 criteria will be
revised in new versions of the PI-RADS.

When lesions with DCE positivity and DWI score 3 upgrading PI-RADS 3 to
4 and PI-RADS 4 lesions with DWI score 4 are compared, we identified
significant differences between ISUP grades. For this reason, we suggest
there should be differences in the scoring of these groups.

PI-RADSv2.1 is created to increase interobserver agreement within the
framework of v2 and also provides additional explanations for certain
criteria. We believe that, as more data to be obtained with further
studies, PI-RADS guidelines will be more accurate.

\textbf{Conflict of Interest:}

The authors declare no conflicts of interest.

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5. Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR
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6. Mottet N, Bergh RCN Van Den, Vice-chair PC, et al.
EAU-ESUR-ESTRO-SIOG Guidelines on Prostate Cancer/ Guias
Europeas.\emph{Eur Assoc Urol 2018} . 2018:1-145.
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7. ACR. Prostate Imaging Reporting and Data System (PI-RADS). \emph{Am
Coll Radiol} . 2015.
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8. Richenberg JL. PI-RADS: Past, present and future. \emph{Clin Radiol}
. 2016;71(1):23-24. doi:10.1016/j.crad.2015.10.019

9. PI-RADS. PI-RADS v2.1 - ACR. 2019.

10. Epstein JI, Zelefsky MJ, Sjoberg DD, et al. A Contemporary Prostate
Cancer Grading System: A Validated Alternative to the Gleason
Score.\emph{Eur Urol} . 2016. doi:10.1016/j.eururo.2015.06.046

11. Jue JS, Barboza MP, Prakash NS, et al. Re-examining
Prostate-specific Antigen (PSA) Density: Defining the Optimal PSA Range
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12. Al-Khalil S, Ibilibor C, Cammack JT, de Riese W. Association of
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13. Tang P, Jin XL, Uhlman M, et al. Prostate volume as an independent
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-1.\emph{Asian J Androl} . 2013. doi:10.1038/aja.2013.11

14. Haas GP, Delongchamps N, Brawley OW, Wang CY, de la Roza G. The
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15. Droz JP, Balducci L, Bolla M, et al. Management of prostate cancer
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16. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy
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17. Grey ADR, Chana MS, Popert R, Wolfe K, Liyanage SH, Acher PL.
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18. Abd-Alazeez M, Kirkham A, Ahmed HU, et al. Performance of
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. 2014. doi:10.1038/pcan.2013.43

19. Thompson JE, Moses D, Shnier R, et al. Multiparametric magnetic
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20. Zhang L, Tang M, Chen S, Lei X, Zhang X, Huan Y. A meta-analysis of
use of Prostate Imaging Reporting and Data System Version 2 (PI-RADS V2)
with multiparametric MR imaging for the detection of prostate
cancer.\emph{Eur Radiol} . 2017. doi:10.1007/s00330-017-4843-7

21. Woo S, Suh CH, Kim SY, Cho JY, Kim SH. Diagnostic Performance of
Prostate Imaging Reporting and Data System Version 2 for Detection of
Prostate Cancer: A Systematic Review and Diagnostic
Meta-analysis.\emph{Eur Urol} . 2017. doi:10.1016/j.eururo.2017.01.042

22. Venderink W, van Luijtelaar A, Bomers JGR, et al. Results of
Targeted Biopsy in Men with Magnetic Resonance Imaging Lesions
Classified Equivocal, Likely or Highly Likely to Be Clinically
Significant Prostate Cancer. \emph{Eur Urol} . 2018.
doi:10.1016/j.eururo.2017.02.021

23. Mathur S, O'Malley ME, Ghai S, et al. Correlation of 3T
multiparametric prostate MRI using prostate imaging reporting and data
system (PIRADS) version 2 with biopsy as reference standard. \emph{Abdom
Radiol} . 2019;44(1):252-258. doi:10.1007/s00261-018-1696-8

24. Mehralivand S, Bednarova S, Shih JH, et al. Prospective Evaluation
of PI-RADS\textsuperscript{TM} Version 2 Using the International Society
of Urological Pathology Prostate Cancer Grade Group System. \emph{J
Urol} . 2017;198(3):583-590. doi:10.1016/j.juro.2017.03.131

25. Yang S, Zhao W, Tan S, et al. Combining clinical and MRI data to
manage PI-RADS 3 lesions and reduce excessive biopsy. \emph{Transl
Androl Urol} . 2020;9(3):1252-1261. doi:10.21037/tau-19-755

26. Walker SM, Mehralivand S, Harmon SA, et al. Prospective Evaluation
of PI-RADS Version 2.1 for Prostate Cancer Detection. \emph{Am J
Roentgenol} . 2020;215(5):1098-1103. doi:10.2214/ajr.19.22679

27. Wysock JS, Mendhiratta N, Zattoni F, et al. Predictive value of
negative 3T multiparametric magnetic resonance imaging of the prostate
on 12-core biopsy results. \emph{BJU Int} . 2016. doi:10.1111/bju.13427

28. Pokorny MR, De Rooij M, Duncan E, et al. Prospective study of
diagnostic accuracy comparing prostate cancer detection by transrectal
ultrasound-guided biopsy versus magnetic resonance (MR) imaging with
subsequent mr-guided biopsy in men without previous prostate
biopsies.\emph{Eur Urol} . 2014. doi:10.1016/j.eururo.2014.03.002

29. Itatani R, Namimoto T, Atsuji S, et al. Negative predictive value of
multiparametric MRI for prostate cancer detection: outcome of 5-year
follow-up in men with negative findings on initial MRI studies.\emph{Eur
J Radiol} . 2014. doi:10.1016/j.ejrad.2014.06.026

30. Chen Z, Zheng Y, Ji G, et al. Accuracy of dynamic contrast-enhanced
magnetic resonance imaging in the diagnosis of prostate cancer:
Systematic review and meta-analysis. \emph{Oncotarget} . 2017.
doi:10.18632/oncotarget.20316

31. Rudolph MM, Baur ADJ, Cash H, et al. Diagnostic performance of
PI-RADS version 2.1 compared to version 2.0 for detection of peripheral
and transition zone prostate cancer. \emph{Sci Rep} . 2020;10(1):1-10.
doi:10.1038/s41598-020-72544-z

32. Benndorf M, Hahn F, Kr\selectlanguage{ngerman}önig M, et al. Diagnostic performance and
reproducibility of T2w based and diffusion weighted imaging (DWI) based
PI-RADSv2 lexicon descriptors for prostate MRI. \emph{Eur J Radiol} .
2017. doi:10.1016/j.ejrad.2017.05.015

33. Greer MD, Shih JH, Barrett T, et al. All over the map: An
interobserver agreement study of tumor location based on the PI-RADSv2
sector map. \emph{J Magn Reson Imaging} . 2018. doi:10.1002/jmri.25948

34. Sonn G, Fan R, Ghanouni P, et al. Prostate Magnetic Resonance
Imaging Interpretation Varies Substantially Across
Radiologists.\emph{Eur Urol Focus} . 2017;5.
doi:10.1016/j.euf.2017.11.010

35. Popita C, Popita AR, Andrei A, et al. Interobserver agreement in
prostate cancer detection using multiparametric MRI. \emph{J BUON} .
2018;23(4):1061-1069.

36. Purysko AS, Bittencourt LK, Bullen JA, Mostardeiro TR, Herts BR,
Klein EA. Accuracy and interobserver agreement for prostate imaging
reporting and data system, version 2, for the characterization of
lesions identified on multiparametric MRI of the prostate. \emph{Am J
Roentgenol} . 2017;209(2):339-345. doi:10.2214/AJR.16.17289

37. Smith CP, Harmon SA, Barrett T, et al. Intra- and interreader
reproducibility of PI-RADSv2: A multireader study. \emph{J Magn Reson
Imaging} . 2019. doi:10.1002/jmri.26555

38. Brown AM, Elbuluk O, Mertan F, et al. Recent advances in
image-guided targeted prostate biopsy. \emph{Abdom Imaging} .
2015;40(6):1788-1799. doi:10.1007/s00261-015-0353-8

\textbf{TABLES:}

\textbf{Table-1:} MpMRI Protocols (1.5T Siemens MagnetomAera)

\textbf{MpMRI Protocols (1.5T Siemens Magnetom Aera)}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllllll@{}}
\toprule
& sequence & slice thickness (mm) & number of slice & voxel size
(mm\textsuperscript{3}) & field of view(mm) & TE (ms) & TR (ms) & gap
(mm) & b value* & Flip Angle\tabularnewline
T2W Coronal & haste & 5 mm & 30 & 1.4x1.4x5 & 360x360 & 92 & 1400 & 1 mm
& & 180\tabularnewline
T2W axial & haste & 6 mm & 30 & 1.5x1.5x6 & 380x380 & 91 & 1400 & 1.2mm
& & 180\tabularnewline
T2W sagittal & haste & 5 mm & 30 & 1.2x1.2x5 & 300x300 & 92 & 1400 & 0
mm & & 180\tabularnewline
T2W Coronal & TSE & 3 mm & 20 & 0.7x0.7x3 & 224x224 & 96 & 5490 & 0 mm &
& 160\tabularnewline
T2W axial & TSE & 3 mm & 24 & 0.6x0.6x3 & 200x200 & 101 & 6620 & 0 mm &
& 160\tabularnewline
DWI & & 3 mm & 20 & 0.8x0.8x3 & 200x200 & 80 & 5000 & 0 mm & 50 800 1200
1800 2000** & -\tabularnewline
T1W axial Lymph node & TSE & 4 mm & 26 & 0.9x0.9x4 & 300x300 & 20 & 552
& 0.8mm & & 167\tabularnewline
T1Map axial & vibe tra & 3,5 mm & 20 & 1.4x1.4x3.5 & 260x260 & 1,9 &
4,11 & 0 mm & & 2 15\tabularnewline
T1W DCE-MRI*** & vibe tra & 3,5 mm & 20 & 1.4x1.4x3.5 & 260x260 & 1,58 &
4,46 & 0 mm & & 12\tabularnewline
postcontrast T1W axial & TSE & 4 mm & 34 & 0.6x0.6x4 & 360x360 & 11 &
606 & 0.8mm & & 180\tabularnewline
\textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B value}
& \textbf{HASTE:Half-fourier acquisition single shot turbo spin echo
TSE:Turbo Spin Echo TE:Time of Echo TR:Time of Repetition} \textbf{VIBE
TRA:Volumetric interpolated breath-hold examination T1W: T1-Weighted
T2W: T2-Weighted DWI: Diffusion-Weighted Imaging **:Calculated B
value}\tabularnewline
\bottomrule
\end{longtable}

*There is no currently widely accepted optimal ``high b-value'' beyond
the requirement for a DW image set with a b-value [?]1,400
sec/mm\textsuperscript{2}.\textsuperscript{9}

***In dynamic contrast enhancement imaging (DCE-MRI), a gadolinium-based
contrast agent with an automatic injector at 0.1-0.2 mmol/kg
concentration and 2-4 mL/s injection rate via IV were used and T1 axial
sections were obtained over 240-300 sc. duration with one every 7 sc.
before, during, and after administration including the entire prostate.

\textbf{Table-2:} Distribution of PI-RADS scores given to lesions by two
readers.\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Variables}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS Score of 1\textsuperscript{st} Reader}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS Score of 1\textsuperscript{st} Reader}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS Score of 1\textsuperscript{st} Reader}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS Score of 1\textsuperscript{st} Reader}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS Score of 1\textsuperscript{st} Reader}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Total}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{PI-RADS Score of} \textbf{2\textsuperscript{nd} Reader}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{1}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{2}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{3}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{4}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{5}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{1}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{5}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{2}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{2}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
17\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{3}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{37}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
45\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{4}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{17}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{5}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{15}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Final PI-RADS Score}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
54\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
25\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
106\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table-3:} Descriptive statistics of patients included in the
study.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Characteristics of patient}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Histopathological diagnosis}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Histopathological diagnosis}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Malignant(n:43)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Benign (n:63)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Average±Standard Deviation} \textbf{Median (25p-75p)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{Average±Standard Deviation} \textbf{Median (25p-75p)}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Age}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
65.24\selectlanguage{ngerman}±7.90 65.0(59.75-70.0)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
62.07\selectlanguage{ngerman}±6.90 62.50(57.0-66.0)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.053\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{PSA}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
15.24\selectlanguage{ngerman}±24.12 7.56(5.28-11.19)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
8.75\selectlanguage{ngerman}±7.52 6.94(4.00-9.71)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.259\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Prostate Volume}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
46.11\selectlanguage{ngerman}±29.21 39.37(30.74-50.53)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
75.94\selectlanguage{ngerman}±39.51 72.50(44.87-100.75)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{PSAd}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.37\selectlanguage{ngerman}±0.55 0.20(0.11-0.33)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.13\selectlanguage{ngerman}±0.121 0.11(0.07-0.147)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Prostate Volume and PSAd values are statistically significant for malign
and benign lesion differentation.

PSA: prostate spesific anjigen PSAd: PSA density

\textbf{Table-4:} Statistical parameters for the cancer detection in
Peripheral Zone(PZ) and Transitional Zone(TZ).\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\textbf{Zone} & \textbf{Sequence} & \textbf{Cut-off Value} &
\textbf{Sensitivity} & \textbf{Specificity} & \textbf{PPV} &
\textbf{NPV} & \textbf{Accuracy}\tabularnewline
\midrule
\endhead
\textbf{PZ} & \textbf{T2W} & PI-RADS [?]3 positive & 100\% & 27.78\% &
51,85\% & 100\% & 59.38\%\tabularnewline
& & PI-RADS[?]4 positive & 32.14\% & 97.22\% & 90\% & 64.81\% &
68.75\%\tabularnewline
& \textbf{DWI} & PI-RADS [?]3 positive & 92.86\% & 13.89\% & 45.61\% &
71.43\% & 48.44\%\tabularnewline
& & PI-RADS[?] 4 positive & 46.43\% & 91.67\% & 81.25\% & 68.75\% &
71.88\%\tabularnewline
& \textbf{MpMRI (T2W, DWI and DCE)} & PI-RADS [?]3 positive & 100\% &
11.11\% & 46.67\% & 100\% & 52.98\%\tabularnewline
& & PI-RADS [?]4 positive & 71.43\% & 72.22\% & 66.67\% & 76.47\% &
71.87\%\tabularnewline
\textbf{TZ} & \textbf{T2W} & PI-RADS[?]4 positive & 33.33\% & 90.91\% &
50\% & 83.33\% & 78.57\%\tabularnewline
& \textbf{DWI} & PI-RADS[?]4 positive & 33.33\% & 59.09\% & 18.18\% &
76.47\% & 53.57\%\tabularnewline
& \textbf{MpMRI (T2W, DWI and DCE)} & PI-RADS[?]4 positive & 33.33\% &
90.91\% & 50\% & 83.33\% & 78.57\%\tabularnewline
\bottomrule
\end{longtable}

Statistical parameters when the threshold value for cancer detection
PI-RADS[?]3 and PI-RADS[?]4 taken as positive in PZ and TZ when T2W and DWI
are independently evaluated. In TZ, there was no patient with a PI-RADS
score \textless{}3, so the diagnostic parameters for this variable could
not be calculated.

PZ: peripheral zone TZ: transitional zone PPV: positive predictive value
NPV: negative predictive value MpMRI:multiparametric magnetic resonance
imaging T2W: T2Weighted imaging DWI: diffusion-weighted imaging DCE:
dynamic contrast enhancement imaging

\textbf{Table-5:} Statistical parameters for the cancer detection in the
whole gland\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Cut off value}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Sensitivity}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Specificity}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{PPV}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{NPV}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Accuracy}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{T2W}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS [?]3 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22.58\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
47.25\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
53.77\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS[?]4 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
46.51\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
93.75\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
45.26\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
94.04\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
71.43\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{DWI}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS [?]3 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
95.35\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14.52\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
43.62\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
81.82\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
47.62\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS[?]4 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
54.55\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
80.65\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
23.84\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
94.10\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
69.81\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{DCE}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS[?]3 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
79.07\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
68.85\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
64.15\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
82.35\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
80.21\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{T2W and DWI (biparametric)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS[?]3 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
23.81\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
47.25\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
54.85\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{MpMRG} \textbf{(T2W, DWI and DCE)}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PI-RADS [?]3 positive\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12.90\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
44.33\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
100\%\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
49.06\%\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PI-RADS[?]4 positive\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
72.09\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
80.65\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
72.09\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
80.65\%\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
77.36\%\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Sensitivity, specificity, negative predictive value, and positive
predictive values for prostate cancer detection are shown for T2W, DWI
independently and T2W-DWI (biparametric) and MpMRI, when PI-RADS [?]3 and
[?]4 scores taken as positive accordingly PI-RADS v2.1.

PPV: positive predictive value NPV: negative predictive value
MpMRI:multiparametric magnetic resonance imaging T2W: T2Weighted imaging
DWI: diffusion-weighted imaging DCE: dynamic contrast enhancement
imaging

\par\null

\textbf{Table-6:} Assesments of lesions' ISUP grades according to their
PI-RADS category.\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{BENIGN}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{ISUP 1} \textbf{(37.2\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{ISUP 2} \textbf{(13.9\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{ISUP 3} \textbf{(13.9\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{ISUP 4} \textbf{(13.9\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{ISUP 5} \textbf{(20.9\%)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
n\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS 1}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS 2}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS 3}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
42\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS 4}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{PI-RADS 5}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{TOTAL}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{63}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{16}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{6}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{6}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{6}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{9}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

There was a positive correlation between the PI-RADSv2.1 score and the
ISUP score.

\textbf{Table-7:} The correlation between ISUP Grades and DWI scores of
PI-RADS 4 lesions in the Peripheral Zone\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\textbf{PI-RADS 4} & \textbf{PI-RADS 4} & \textbf{ISUP Grade} &
\textbf{ISUP Grade} & \textbf{ISUP Grade} & \textbf{ISUP Grade} &
\textbf{ISUP Grade} & \textbf{ISUP Grade}\tabularnewline
\midrule
\endhead
\textbf{DWI score} & \textbf{DCI Status} & \textbf{1} & \textbf{2} &
\textbf{3} & \textbf{4} & \textbf{5} & \textbf{Total}\tabularnewline
3 & Upgraded by +DCI & 4(57.1\%) & 2(28.6\%) & 0(0.0\%) & 0(0.0\%) &
1(14.3\%) & 7\tabularnewline
4 & NA & 0(0.0\%) & 2(33.3\%) & 2(33.3\%) & 2(33.3\%) & 0(0.0\%) &
6\tabularnewline
\textbf{Total} & & \textbf{4} & \textbf{4} & \textbf{2} & \textbf{2} &
\textbf{1} & \textbf{13}\tabularnewline
\bottomrule
\end{longtable}

\textbf{FIGURES:}

\textbf{Figure-1}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

\textbf{Figure.1} 56-year-old man with prostate-specific antigen level
of 5.6 ng/mL. Arrows present Prostate Imaging Reporting and Data and
System (PI-RADS) category 4 lesions visible in the peripheral
zone.\textbf{A} , Axial T2-weighted MR image shows lesion in the
left-mid peripheral zone. The dimension of the lesion is 1.0 cm which is
consistent with the PI-RADS score of 3 on T2-weighted image. \textbf{B}
,\textbf{C,} show that the lesion is hypointense on DWI(b=50
s/mm\textsuperscript{2}) and hyperintense, on DWI(b=1800
s/mm\textsuperscript{2}). \textbf{D} , Apparent Diffusion Coefficient
map, indicates that the lesion is mildly hypointense, making it PI-RADS
score of 3 on DWI. \textbf{E} (precontrast T1-Weighted) \textbf{and
F,}Dynamic contrast enhancement MR image shows early enhancement within
same location as lesion in \textbf{A--D} with early enhancement for
overall PI-RADSv2.1 score of 4. TRUS-guided cognitive MRI fusion biopsy
is detected prostate cancer with ISUP 1.

\textbf{Figure.2}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image8/image8}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image9/image9}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image10/image10}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image11/image11}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image12/image12}

\end{center}
\end{figure}

\textbf{Figure.2} 67-year-old man with prostate-specific antigen level
of 8.31 ng/mL. Arrows present Prostate Imaging Reporting and Data and
System (PI-RADS) category 5 lesions visible in the peripheral
zone.\textbf{A} , Axial T2-weighted MR image shows lesion in the
right-apex peripheral zone. The dimension of the lesion is 2.0 cm which
is consistent with the PI-RADS score of 5 on T2-weighted image.
\textbf{B} ,\textbf{C,} show that the lesion is hypointense on DWI(b=50
s/mm\textsuperscript{2}) and hyperintense, on DWI(b=1800
s/mm\textsuperscript{2}). \textbf{D} , Apparent Diffusion Coefficient
map, indicates that the lesion is significantly hypointense, making it
PI-RADS score of 5 on DWI. \textbf{E} (precontrast
T1-Weighted)\textbf{and F,} Dynamic contrast enhancement MR image shows
early enhancement within same location as lesion in \textbf{A--D} with
early enhancement for overall PI-RADSv2.1 score of 5. TRUS-guided
cognitive MRI fusion biopsy is detected prostate cancer with ISUP 5.

\textbf{TABLE and FIGURE LEGENDS:}

\textbf{Table-1:} MpMRI Protocols (1.5T Siemens MagnetomAera)

\textbf{Table-2:} Distribution of PI-RADS scores given to lesions by two
readers.

\textbf{Table-3:} Descriptive statistics of patients included in the
study.

\textbf{Table-4:} Statistical parameters for the cancer detection in
Peripheral Zone(PZ) and Transitional Zone(TZ).

\textbf{Table-5:} Statistical parameters for the cancer detection in the
whole gland

\textbf{Table-6:} Assesments of lesions' ISUP grades according to their
PI-RADS category.

\textbf{Table-7:} The correlation between ISUP Grades and DWI scores of
PI-RADS 4 lesions in the Peripheral Zone

\textbf{Figure.1} 56-year-old man with prostate-specific antigen level
of 5.6 ng/mL. Arrows present Prostate Imaging Reporting and Data and
System (PI-RADS) category 4 lesions visible in the peripheral
zone.\textbf{A} , Axial T2-weighted MR image shows lesion in the
left-mid peripheral zone. The dimension of the lesion is 1.0 cm which is
consistent with the PI-RADS score of 3 on T2-weighted image. \textbf{B}
,\textbf{C,} show that the lesion is hypointense on DWI(b=50
s/mm\textsuperscript{2}) and hyperintense, on DWI(b=1800
s/mm\textsuperscript{2}). \textbf{D} , Apparent Diffusion Coefficient
map, indicates that the lesion is mildly hypointense, making it PI-RADS
score of 3 on DWI. \textbf{E} (precontrast T1-Weighted) \textbf{and
F,}Dynamic contrast enhancement MR image shows early enhancement within
same location as lesion in \textbf{A--D} with early enhancement for
overall PI-RADSv2.1 score of 4. TRUS-guided cognitive MRI fusion biopsy
is detected prostate cancer with ISUP 1.

\textbf{Figure.2} 67-year-old man with prostate-specific antigen level
of 8.31 ng/mL. Arrows present Prostate Imaging Reporting and Data and
System (PI-RADS) category 5 lesions visible in the peripheral
zone.\textbf{A} , Axial T2-weighted MR image shows lesion in the
right-apex peripheral zone. The dimension of the lesion is 2.0 cm which
is consistent with the PI-RADS score of 5 on T2-weighted image.
\textbf{B} ,\textbf{C,} show that the lesion is hypointense on DWI(b=50
s/mm\textsuperscript{2}) and hyperintense, on DWI(b=1800
s/mm\textsuperscript{2}). \textbf{D} , Apparent Diffusion Coefficient
map, indicates that the lesion is significantly hypointense, making it
PI-RADS score of 5 on DWI. \textbf{E} (precontrast
T1-Weighted)\textbf{and F,} Dynamic contrast enhancement MR image shows
early enhancement within same location as lesion in \textbf{A--D} with
early enhancement for overall PI-RADSv2.1 score of 5. TRUS-guided
cognitive MRI fusion biopsy is detected prostate cancer with ISUP 5.\selectlanguage{english}
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