The role of MRI in prostate cancer management: pushing the diagnostic frontier

The role of Magnetic Resonance Imaging (MRI) in prostate cancer (PCa) diagnostic work-up has drastically changed over the last 40 years. Years of innovations have produced outstanding advances in diagnostic imaging and MR-guided interventional procedures. In early 2019, the updated version of the PI-RADS score system was released. The same year a real breakthrough occurred when the updated version of the European Association of Urology (EAU) guidelines was released: MRI is currently recommended as the first line imaging modality for biopsy-naive patients. Among all the published studies supporting the use of MRI in the diagnostics of PCa, robust trials have played a pivotal role: The PROMIS study, the MRI-FIRST study, the PRECISION study and the 4M trial. The success of MRI is heavily dependent on high-quality image acquisition and interpretation to minimise the number of equivocal cases, standardise negative MRIs, reduce overdiagnosis and overtreatment and promote biopsy improvement and focal therapeutic approaches. Future perspectives include the spread of non-contrast MRI as the most efficient way to face the expected upcoming large number of MRI requests for PCa diagnosis and the application of artificial intelligence-based tools that might profoundly shape modern imaging, with major implications for medical practice. The goal is to review PCa natural history and management, with an insight on MRI applications and future perspectives.