Prostate Cancer: Role of Pretreatment Multiparametric 3-T MRI in Predicting Biochemical Recurrence After Radical Prostatectomy

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1 Genitourinary Imaging Original Research Park et al. MRI to Predict Biochemical Recurrence After Radical Prostatectomy Genitourinary Imaging Original Research Jung Jae Park 1,2 Chan Kyo Kim 1 Sung Yoon Park 1 Byung Kwan Park 1 Hyun Moo Lee 3 Seong Whi Cho 2 Park JJ, Kim CK, Park SY, Park BK, Lee HM, Cho SW Keywords: multiparametric MRI, prediction, prostatectomy, prostate neoplasm, recurrence DOI: /AJR Received June 14, 2013; accepted after revision August 28, Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul , Republic of Korea. Address correspondence to C. K. Kim (chankyokim@skku.edu). 2 Department of Radiology, Kangwon National University Hospital, Chuncheon, Republic of Korea. 3 Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. WEB This is a web exclusive article. AJR 2014; 202:W459 W X/14/2025 W459 American Roentgen Ray Society Prostate Cancer: Role of Pretreatment Multiparametric 3-T MRI in Predicting Biochemical Recurrence After Radical Prostatectomy OBJECTIVE. The purpose of this study is to retrospectively investigate whether pretreatment multiparametric MRI findings can predict biochemical recurrence in patients who underwent radical prostatectomy (RP) for localized prostate cancer. MATERIALS AND METHODS. In this study, 282 patients with biopsy-proven prostate cancer who received RP underwent pretreatment MRI using a phased-array coil at 3 T, including T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced MRI (DCE-MRI). MRI variables included apparent tumor presence on combined imaging sequences, extracapsular extension, and tumor size on DWI or DCE-MRI. Clinical variables included baseline prostate-specific antigen (PSA) level, clinical stage, and Gleason score at biopsy. The relationship between clinical and imaging variables and biochemical recurrence was evaluated using Cox regression analysis. RESULTS. After a median follow-up of 26 months, biochemical recurrence developed in 61 patients (22%). Univariate analysis revealed that all the imaging and clinical variables were significantly associated with biochemical recurrence (p < 0.01). On multivariate analysis, however, baseline PSA level (p = 0.002), Gleason score at biopsy (p = 0.024), and apparent tumor presence on combined T2WI, DWI, and DCE-MRI (p = 0.047) were the only significant independent predictors of biochemical recurrence. Of the independent predictors, apparent tumor presence on combined T2WI, DWI, and DCE-MRI showed the highest hazard ratio (2.38) compared with baseline PSA level (hazard ratio, 1.05) and Gleason score at biopsy (hazard ratio, 1.34). CONCLUSION. The apparent tumor presence on combined T2WI, DWI, and DCE-MRI of pretreatment MRI is an independent predictor of biochemical recurrence after RP. This finding may be used to construct a predictive model for biochemical recurrence after surgery. R adical prostatectomy (RP) is an established treatment modality that reduces disease-specific mortality for patients with localized prostate cancer [1, 2], although biochemical recurrence occurs in quite a few patients after surgery. According to a postoperative nomogram predicting long-term outcomes, the 10-year actuarial rate of biochemical recurrence free survival was approximately 79%, but biochemical recurrence may occur beyond 10 years after RP [3, 4]. Because biochemical recurrence is associated with progression to distant metastases and cancer-specific mortality [5, 6], a prediction of biochemical recurrence before surgery is clinically important in determining primary treatment options, adjuvant therapies, and patient counseling. To date, several preoperative and postoperative clinical variables have been used to predict biochemical recurrence after RP, but the accuracies of each are limited [7]. The inclusion of novel biomarkers or imaging tools may potentially improve the predictive accuracy. As MRI evolves into a valuable diagnostic method in prostate imaging, pretreatment MRI findings also have been investigated to improve predictive accuracy for biochemical recurrence after primary local treatment. The T stage and the presence of extracapsular extension (ECE) and seminal vesicle invasion (SVI), as determined by MRI, are significant prognostic parameters for predicting biochemical recurrence after primary local treatment, such as RP [8, 9]. More recently, it was found that emerging multiparametric prostate MRI can provide W459

2 Park et al. functional information along with anatomic information; thus, it has contributed to tumor detection, localization, local staging, and determination of aggressiveness [10 14]. This promising technique may offer incremental value to a prognostic model using clinical variables to predict biochemical recurrence in prostate cancer after RP, with improved accuracy. However, few studies have reported the prognostic value of pretreatment multiparametric MRI findings in predicting biochemical recurrence after RP [8, 15]. The purpose of our study was to retrospectively investigate whether pretreatment multiparametric MRI findings at 3 T, including T2-weighted imaging (T2WI), diffusion-weighted (DWI), and dynamic contrastenhanced MRI (DCE-MRI), can predict biochemical recurrence in patients who undergo RP for localized prostate cancer. Materials and Methods Patients This retrospective study was approved by our institutional review board, with a waiver of the requirement for informed consent. Between May 2007 and April 2009, 435 consecutive men with biopsy-proven clinically localized prostate cancer were treated with RP. Of these, 372 patients underwent preoperative prostate MRI at 3 T, including T2WI, DWI, and DCE-MRI, in our institution. Of the 372 patients, 85 were excluded for the following reasons: hormone or radiation treatment before surgery (n = 29); imaging artifact or missing sequence (n = 18); missing data, such as Gleason score at biopsy or baseline prostate-specific antigen (PSA) level (n = 16); and Biochemical recurrence absent n = 221 Patients who underwent radical prostatectomy n = 435 Preoperative MRI n = 372 Final inclusion n = 282 insufficient follow-up to determine biochemical recurrence (n = 22). Five patients were also excluded because of a 3-month or longer interval between pretreatment MRI and surgery. Finally, 282 men (mean [± SD] age, 64 ± 7.2 years; range, years) were enrolled in this study (Fig. 1). The mean interval between biopsy and MRI was 28.2 ± 4.9 days (range, days), and surgery was performed 3 35 days after MRI (mean, 16 ± 6.2 days). The clinical stage was evaluated with digital rectal examination. Before surgery (mean, 2 ± 2.4 days; range, 1 28 days), baseline PSA level was identified in all patients. After surgery, the patients were followed-up with digital rectal examination and serum PSA level within 1 month, then every 3 months for the first 2 years, and every 6 months from the third year. Biochemical recurrence after RP was defined as an initial serum PSA level greater than or equal to 0.2 ng/ml, with a second confirmatory level of PSA of greater than 0.2 ng/ml [16]. Imaging Technique All patients underwent prostate MRI at 3 T (Intera Achieva 3 T or 3TX, Philips Healthcare System) using a phased-array coil. To reduce bowel peristalsis, 20 mg of butyl scopolamine (Buscopan, Boehringer Ingelheim) was administered intramuscularly before imaging. The MRI protocol was composed of routine T1-weighted imaging, T2WI, DWI, and DCE-MRI. After obtaining three plane localizer images, T2-weighted turbo spin-echo images were obtained in the axial, sagittal, and coronal planes. The imaging parameters were as follows: TR/TE, /80 100; slice thickness, 3 mm; interslice gap, 1 mm; matrix, or ; FOV, cm; Excluded patients n = 90 Biochemical recurrence present n = 61 Fig. 1 Flowchart of study design. number of signals acquired, 3; sensitivity encoding factor, 2; number of slices, 21; and acquisition time of each plane, 3 minutes 48 seconds. Axial T1-weighted turbo spin-echo images (4-mm slice thickness) were acquired to assess the lymph nodes and the pelvic bone. Axial DWI was acquired using the single-shot echo-planar imaging technique with the following parameters: TR/TE, /63 75; slice thickness, 3 mm; interslice gap, 1 mm; matrix, ; FOV, 20 cm; sensitivity encoding factor, 2; number of signals acquired, 4; number of slices, 20; acquisition time, within 1 minute 40 seconds. Diffusion-encoding gradients were applied at b values of 0 and 1000 s/mm 2, along the three orthogonal directions of the motion-probing gradients. The direction of the phase-encoding gradient was from left to right to minimize motion artifacts. Apparent diffusion coefficient (ADC) maps were automatically constructed using the manufacturer s software. Axial DCE-MRI was obtained using a 3D fastfield echo sequence (TR/TE, 7.4/3.9; flip angle, 25 ; matrix, ; slice thickness, 4 mm; interslice gap, no; number of signals acquired, 1; FOV, 20 cm; and 11 partitions on a 3D slab). DCE- MRI was performed from the apex to the base of the prostate. The 3D volume with 11 partitions was acquired every 5 seconds with 58 repetitions, or every 3 seconds with 60 repetitions. A contrastenhanced series was performed immediately after a bolus injection of gadopentetate dimeglumine (Magnevist, Schering) or gadolinium diethylenetriamine pentaacetic acid (Gadovist, Schering) at a dose of 0.1 mmol/kg body weight and a rate of 2 3 ml/s using a power injector, followed by a 20-mL saline flush. All dynamic datasets were transferred to an independent workstation (View- Forum, Philips Healthcare). After time signal intensity curves were first fit to a general exponential signal-enhancement model, dynamic images were converted to a five-parameter model: washin rate, washout rate, maximal enhancement, maximal relative enhancement, and time to peak [17]. The dynamic images of the five-parameter model on DCE-MRI were superimposed onto enhanced fast-field echo or T2-weighted images, resulting in color-coded parametric images. Image Analysis All MR images were retrospectively reviewed in consensus by two radiologists (with 6 and 8 years of experience in prostate MRI, respectively) using our PACS (Centricity, GE Healthcare). Patients clinical, pathologic, and outcome results were blinded to minimize bias, although readers were aware that all patients had undergone RP for biopsy-proven prostate cancer. W460

3 MRI to Predict Biochemical Recurrence After Radical Prostatectomy By using established morphologic and functional findings of multiparametric prostate MRI [11, 18 22], the readers assigned a radiologically determined tumor stage that was based on the American Joint Committee on Cancer staging system [23]. T1 tumors were not apparent on MRI, and T2 tumors were visible on MRI but were organ confined. T3a and T3b tumors extended outside the prostate capsule and into the seminal vesicles, respectively, and T4 tumors invaded the adjacent structures. The apparent tumor presence was assessed by the readers at three separate sessions, as follows: combined T2WI and DWI, combined T2WI and DCE-MRI, and combined T2WI, DWI, and DCE-MRI in sequence. Each session was separated by 1 month to avoid learning bias. An apparent tumor on combined T2WI, DWI, and DCE-MRI was regarded as present if it was visible on both DWI and DCE-MRI. To determine the probability for the presence of apparent tumor, a 5-point grading scale was adopted, as follows: 1, definitely invisible; 2, probably invisible; 3, possibly visible; 4, probably visible; and 5, definitely visible. Any lesions marked grade 3 5 on the MR images of each combination were regarded as apparent tumors. Tumor size was defined as the longest axial diameter measured on the ADC map image on the combined T2WI and DWI session and also on the acquired image of DCE-MRI on the combined T2WI and DCE-MRI session using the electronic caliper function of our PACS workstation. If there was not an apparent tumor, the size was recorded as zero. A prostate cancer was defined on each MRI as follows [11, 18 22]: a masslike lesion with abnormally low signal intensity compared with that of normal prostate tissue on T2WI, except for an area of high signal intensity on T1-weighted imaging suggestive of postbiopsy hemorrhage; a focal lesion with high signal intensity and a b value of 1000 s/mm 2 on DWI, with a low ADC value on the ADC map; or a focal lesion with the presence of an asymmetric wash-in rate, washout rate, maximal enhancement, maximal relative enhancement or time-to-peak on color-coded parametric image, or early arterial enhancement with or without early washout on DCE-MRI. The presence of ECE and SVI was also determined on combined T2WI and DWI and DCE-MRI, using the same grading scale. The ECE was considered present if a tumor revealed asymmetric neurovascular bundle thickening, an irregular bulge in the prostate contour, measurable extracapsular disease, or obliteration of the rectoprostatic angle on T2WI or high wash-in rate or maximal enhancement with or without washout rate at DCE-MRI. The SVI was considered present if a tumor showed contiguous low-signal-intensity extension from the base TABLE 1: Demographic Characteristics and Postoperative Findings for 282 Patients Who Underwent Radical Prostatectomy Variable of the gland into the seminal vesicles or asymmetric decrease in the signal intensity of the seminal vesicles with mass effect on T2WI, or revealed high wash-in rate or maximal enhancement with or without washout rate in the seminal vesicles on DCE-MRI or had low ADC value in the seminal vesicles on DWI. Statistical Analysis Statistical analysis was performed using PASW statistical software (version 18.0, SPSS). Univariate and multivariate Cox regression analyses were performed for all clinical and imaging variables to determine their relationship with biochemical recurrence. The clinical variables included clinical stage, baseline PSA level, and Gleason score at biopsy. The imaging variables were apparent tumor presence at each combination of MRI sequences, ECE, and tumor size on DWI or DCE-MRI. We did not include SVI as a predictive MRI variable because we observed very few cases (n = 9) on MRI. Two-tailed tests were used to calculate all p values; p < 0.05 was considered statistically significant. Results After a median follow-up of 26 ± 8.5 months (range, months), 61 (22%) of 282 patients had biochemical recurrence after RP. The median interval between biochemical recurrence and RP was 14 ± 4.6 months (range, 3 32 months). The patients clinical characteristics and postoperative surgical findings are summarized in Table 1. Value Age (y), median ± SD (range) 64 ± 7.2 (38 88) Baseline PSA level (ng/ml), median ± SD (range) 6.59 ± 6.84 ( ) Gleason score at biopsy, median (range) 7 (6 9) Clinical stage (no. of patients) T1c 187 T2a 70 T2b 16 T2c 2 T3a 7 Postoperative findings Gleason score at surgical specimen, median (range) 7 (6 9) Extracapsular extension, no. (%) of patients 68 (24) Seminal vesicle invasion, no. (%) of patients 22 (8) Lymph node metastasis, no. (%) of patients 2 (0.7) Distant metastasis, no. of patients 0 Note PSA = prostate-specific antigen. The number of patients who exhibited apparent prostate cancer at each combined interpretation session was as follows: 187 patients (66%) on combined T2WI and DWI session, 185 (65%) on combined T2WI and DCE-MRI session, and 145 (51%) on combined T2WI, DWI, and DCE-MRI sessions. The mean tumor size was 10.3 ± 6.7 mm (range, 0 44 mm) on DWI and 11.3 ± 7.2 mm (range, 0 51 mm) on DCE-MRI. The ECE and SVI were shown on MRI for 96 (34%) and 9 (3%) patients, respectively. Table 2 presents the results of univariate and multivariate Cox regression analyses of clinical and imaging variables for predicting biochemical recurrence after RP. On univariate Cox regression analysis, all of the clinical and imaging variables were significantly related to biochemical recurrence (p < 0.01) (Figs. 2 and 3). Multivariate Cox regression analysis revealed that the only significant predictors of biochemical recurrence after RP were baseline PSA level (p = 0.002), Gleason score at biopsy (p = 0.024), and apparent tumor presence on combined T2WI, DWI, and DCE-MRI (p = 0.047). Of the independent predictors, the hazard ratio (HR) of apparent tumor presence on combined T2WI, DWI, and DCE-MRI (HR = 2.38) was higher compared with that of the other predictors (HR = 1.05 and 1.34 for baseline PSA level and Gleason score at biopsy, respectively). ECE at MRI showed a statisti- W461

4 Park et al. TABLE 2: Results of Univariate and Multivariate Analyses for MRI and Clinical Variables in Predicting Biochemical Recurrence in 282 Patients Who Underwent Radical Prostatectomy Variable Univariate Analysis cally borderline significance for predicting biochemical recurrence on multivariate Cox analysis (p = 0.081). Discussion Our results show that all MRI variables (apparent tumor presence on combined imaging sequences, ECE, and tumor size on DCE-MRI or DWI) and all clinical variables (baseline PSA level, clinical stage, and Gleason score at biopsy) were significantly associated with biochemical recurrence after RP in univariate Multivariate Analysis HR (95% CI) p HR (95% CI) p Apparent tumor on T2WI 4.23 ( ) < ( ) and DWI Apparent tumor on T2WI 1.57 ( ) ( ) and DCE-MRI Apparent tumor on T2WI 4.90 ( ) < ( ) and DWI and DCE-MRI Tumor size on DWI 1.05 ( ) < ( ) Tumor size on DCE-MRI 1.04 ( ) < ( ) Extracapsular extension 4.00 ( ) < ( ) at MRI Clinical stage 1.71 ( ) < ( ) Pretreatment PSA level 1.07 ( ) < ( ) Gleason score at biopsy 1.69 ( ) < ( ) Note HR = hazard ratio, T2WI = T2-weighted imaging, DWI= diffusion-weighted imaging, DCE-MRI = dynamic contrast-enhanced MRI, PSA= prostate-specific antigen. A analysis. Of the MRI variables, apparent tumor presence on combined T2WI, DWI, and DCE-MRI of pretreatment MRI was the only independent indicator in predicting biochemical recurrence in the multivariate analysis. In addition, clinical variables of baseline PSA level and Gleason score at biopsy were also independent indicators of biochemical recurrence in the multivariate analysis. These findings suggest that pretreatment multiparametric MRI findings at 3 T, as a promising indicator, might have the potential to predict biochemical recurrence after RP in patients with localized prostate cancer. Considering the promising role of multiparametric MRI findings in assessing the detection, localization, staging, or aggressiveness of prostate cancer, we hypothesized that the presence or absence of apparent tumor at each combination of multiparametric MRI sequences might be a significant predictor of patient outcome, because radiologically invisible cancers may represent low tumor burden or tumor with low Gleason score and, thus, a cancer with a lower T stage and better prognosis. Similarly, a previous study [24] found that sparse prostate cancer shows relatively similar signal intensity on T2WI and ADC values similar to those of normal peripheral zone tissue compared with dense tumors. Accordingly, this result suggests that there is a relationship between the histologic features of prostate cancer and visibility on MRI [24]. In the present study, on univariate analysis, apparent tumor presence on combined T2WI and DWI, combined T2WI and DCE-MRI, and combined T2WI, DWI, and DCE-MRI showed a statistical significance in predicting biochemical recurrence after RP. However, on multivariate analysis, apparent tumor presence on combined T2WI, DWI, and DCE-MRI was the only marker predictive of biochemical recurrence after RP. These findings suggest that the combination of T2WI, DWI, and DCE-MRI might improve the accuracy for assessing tumor extent. Although statistical significance was not found, the HR Fig year-old man with pathologic stage T3b prostate cancer, Gleason score of 9 at surgical specimen, and baseline prostate-specific antigen (PSA) level of ng/ml. A, Axial T2-weighted turbo spin-echo image shows focal low-signal-intensity lesion that is suspicious for tumor in right peripheral zone. Lesion is associated with irregular contour bulge (arrowhead) and obliteration of rectoprostatic angle at right peripheral zone, representing possible extracapsular extension. B, Axial apparent diffusion coefficient (ADC) map image also shows focal mass (arrows) with decreased ADC value, which is highly suspicious for prostate cancer in right peripheral zone, associated with focal contour bulge (arrowhead) in same location as in (A) representing possibility of extracapsular extension. C, Parametric image of wash-in rate shows asymmetric color-coded lesion (arrows) in site corresponding with site of lesion in (A), associated with focal contour bulge (arrowhead) representing possibility of extracapsular extension. At 5 months after surgery, serum PSA level was elevated to 0.51 ng/ml, which confirmed biochemical recurrence. B C W462

5 MRI to Predict Biochemical Recurrence After Radical Prostatectomy of the apparent tumor presence on combined T2WI and DWI was higher than the HR on combined T2WI and DCE-MRI. According to a recent study [25], combined T2WI and DWI showed a better diagnostic performance than did combined T2WI and DCE- MRI for the detection of prostate cancer. Furthermore, the ADC value of prostate cancer also showed better performance to identify peripheral zone tumors compared with the quantitative parameters derived from DCE-MRI, such as volume transfer constant and extravascular extracellular volume fraction [10]. These findings suggest that DWI has superior diagnostic value for the detection of prostate cancer, compared with DCE- MRI, which was consistent with our study. A recent study [26] found that a tumor s being inapparent at 1.5-T endorectal MRI and MR spectroscopic imaging was not a favorable predictive factor in patients with prostate cancer who select active surveillance, suggesting that the distinction between stage T1 and stage T2 prostate cancer is of questionable prognostic value. Although prostate MRI using an endorectal coil may provide higher resolution and signal-to-noise ratio than the use of phased-array body coil, that study [26] did not include DWI and DCE- MRI in the assessment of prostate cancer. The present study performed T2WI, DWI, and DCE-MRI at 3 T, which is a minimal requirement for the multiparametric MRI protocol [21] to detect and localize prostate cancer. Furthermore, another study with a larger population and longer follow-up period showed the relationship between the presence of suspicious prostate lesions on MRI A Fig year-old man with pathologic stage T2a prostate cancer who had 1.6-cm lesion on left peripheral zone with Gleason score of 7 at surgical specimen and baseline prostate-specific antigen level of 4.18 ng/ml. A and B, On axial T2-weighted turbo spin-echo (A) and axial apparent diffusion coefficient map image (B), there is no focal lesion in prostate. C, Parametric image of wash-in rate shows no asymmetric color-coded lesions (arrows) in left peripheral zone. Patient had no biochemical recurrence for 4 years after surgery. B and increased risk for subsequent upgrade of Gleason score during active surveillance [27]. According to our results, both univariate and multivariate analyses found that apparent tumor presence at each combination of multiparametric MRI sequences was an independent predictor for biochemical recurrence after RP. A recent study [15] reported that tumor apparent presence on DWI before RP was an important factor to predict biochemical recurrence. Park et al. [28] also suggested that a low ADC value of prostate cancer was a significant predictor of biochemical recurrence after RP. This result can be explained by a possible relationship between tumor ADC and aggressiveness. Therefore, aggressive prostate cancer, which has the potential for biochemical recurrence after RP, may be easily distinguished from normal prostate tissue on DWI, possibly explaining our results. Furthermore, another recent study [29] found that MR spectroscopic findings, such as index lesion volume and high-grade voxels, were correlated with biochemical recurrence after RP. These findings suggest that multiparametric MRI findings have the potential to predict biochemical recurrence in patients who undergo RP. Further research is needed to predict patient outcome after treatment of localized prostate cancer using multiparametric MRI. Several previous studies have assessed the utility of MRI and MR spectroscopic imaging to predict biochemical recurrence of prostate cancer after RP [8, 30, 31]. These results suggest that MRI and MR spectroscopic imaging findings of ECE are independent significant predictors of biochemical recurrence. More recently, a study reported that the ECE findings of combined T2WI and DWI were a significant predictor of biochemical recurrence after RP [15]. However, our study did not have the statistical power to reveal the prognostic significance of ECE at multiparametric MRI on multivariate analysis (p = 0.081). In our study, an endorectal coil was not used for 3-T MRI, which might have affected the accuracy of ECE prediction. A further study should be performed using endorectal multiparametric MRI at 3 T. To date, several preoperative factors have been identified as predictors of biochemical recurrence after RP in patients with prostate cancer [7]. In our study, the clinical variables of baseline PSA level and Gleason score at biopsy revealed a statistical significance to predict biochemical recurrence after RP in univariate and multivariate analyses, and these clinical variables were independently predictive markers for biochemical recurrence after RP. These results are consistent with those of previous studies [6, 32, 33]. Furthermore, compared with those well-known predictors, the presence of visible tumors on combined multiparametric MRI showed an even higher HR in multivariate analysis. These results suggest that preoperative multiparametric MRI findings may have a significant role in the prediction of patient prognosis. Moreover, it may be incorporated into a prognostic model for prostate cancer to stratify the patients for individualized treatment plans (i.e., selection of active surveillance or watchful waiting, nonsurgical treatment, or RP). In C W463

6 Park et al. addition, our findings are remarkable because even a negative finding for biopsyproven prostate cancer on preoperative MRI has clinical significance regarding a favorable outcome after RP. Our study has several limitations. First, this study was performed retrospectively at a single institution with a relatively small population (n = 282). It is likely that there was selection bias in our study design. Further investigation with a larger number of subjects may reveal more statistically significant pretreatment multiparametric MRI variables for predicting biochemical recurrence after RP. Second, the follow-up period was relatively short (median, 26 months). However, predicting early biochemical recurrence is clinically meaningful, because approximately 60% of biochemical recurrences happen within 2 years after RP [34] and early recurrence may represent an unfavorable prognosis in the natural history of prostate cancer after treatment [5, 35]. Nonetheless, further studies should be conducted with a longer follow-up period to evaluate prostate cancer specific mortality and recurrence-free survival rates in association with findings of pretreatment multiparametric MRI. Third, a completely blinded study was impossible because it was known which patients underwent RP for biopsy-proven prostate cancer. To minimize bias, other medical information was withheld and image analysis was done in random order with a sufficient time interval. Fourth, our study is limited by the lack of pathologic correlation with MRI findings related to apparent tumor presence, although the purpose of this study was to evaluate an apparent tumor presence determined by the radiologist on multiparametric MRI as an imaging predictor for biochemical recurrence. Fifth, we did not include quantitative imaging parameters derived from DWI or DCE-MRI in our analysis. 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