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Objectives To evaluate the value of multiparametric MRI (mpMRI) for the prediction of prostate cancer (PCA) aggressiveness. Methods In this single center cohort study, consecutive patients with histologically confirmed PCA were retrospectively enrolled. Four different ISUP grade groups (1, 2, 3, 4–5) were defined and fifty patients per group were included. Several clinical (age, PSA, PSAD, percentage of PCA infiltration) and mpMRI parameters (ADC value, signal increase on high b-value images, diameter, extraprostatic extension [EPE], cross-zonal growth) were evaluated and correlated within the four groups. Based on combined descriptors, MRI grading groups (mG1–mG3) were defined to predict PCA aggressiveness. Results In total, 200 patients (mean age 68 years, median PSA value 8.1 ng/ml) were analyzed. Between the four groups, statistically significant differences could be shown for age, PSA, PSAD, and for MRI parameters cross-zonal growth, high b-value signal increase, EPE, and ADC ( p  &lt; 0.01). All examined parameters revealed a significant correlation with the histopathologic biopsy ISUP grade groups ( p  &lt; 0.01), except PCA diameter ( p  = 0.09). A mixed linear model demonstrated the strongest prediction of the respective ISUP grade group for the MRI grading system ( p  &lt; 0.01) compared to single parameters. Conclusions MpMRI yields relevant pre-biopsy information about PCA aggressiveness. A combination of quantitative and qualitative parameters (MRI grading groups) provided the best prediction of the biopsy ISUP grade group and may improve clinical pathway and treatment planning, adding useful information beyond PI-RADS assessment category. Due to the high prevalence of higher grade PCA in patients within mG3, an early re-biopsy seems indicated in cases of negative or post-biopsy low-grade PCA. Key Points •  MpMRI yields relevant pre-biopsy information about prostate cancer aggressiveness.  •  MRI grading in addition to PI-RADS classification seems to be helpful for a size independent early prediction of clinically significant PCA.  •  MRI grading groups may help urologists in clinical pathway and treatment planning, especially when to consider an early re-biopsy.

MRI grading for the prediction of prostate cancer aggressiveness