Is there a Prostate Imaging Reporting and Data System (PI‑RADS) version 2.2, and should it be used for prostate MRI interpretation?

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Last updated: February 17, 2026 • View editorial policy

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PI-RADS Version 2.1: Current Standard for Prostate MRI Interpretation

Yes, PI-RADS version 2.1 exists and should be used as the current standard for prostate MRI interpretation—it was released in 2019 specifically to address limitations in version 2.0, particularly reducing inter-reader variability in the transition zone while maintaining the same diagnostic accuracy. 1, 2

What Changed in Version 2.1

Core Modifications to Reduce Variability

  • Diffusion-weighted imaging (DWI) now has an explicitly stronger role in transition zone (TZ) assessment, addressing the primary source of disagreement between readers that plagued version 2.0. 2, 3

  • An ultra-high b-value of ≥1400 s/mm² is now mandatory for DWI sequences across all prostate zones, standardizing acquisition parameters. 2, 3

  • Clearer criteria distinguish DWI scores 3 versus 4/5 in both the transition zone and peripheral zone, reducing subjective interpretation that contributed to inconsistency. 1, 2

New Anatomic Guidance

  • Specific instructions address lesions arising solely from the central zone, a scenario completely absent from version 2.0 that left radiologists without clear direction. 1, 2

  • Separate criteria for anterior-superior tumors substantially involving the anterior fibromuscular stroma provide appropriate scoring guidance for these challenging lesions. 1, 2

  • Detailed recommendations on nodular benign prostatic hyperplasia lacking classic encapsulation improve lesion classification in the transition zone. 1, 2

DCE-MRI Clarifications

  • More precise guidance on dynamic contrast-enhanced (DCE) positivity for non-focal peripheral zone lesions eliminates prior ambiguity in applying DCE as an ancillary assessment tool. 2

Expected Performance: No Change in Accuracy

The amendments in version 2.1 are not anticipated to alter overall diagnostic accuracy—sensitivity and specificity remain comparable to version 2.0. 2 The primary goal is improving consistency among readers, not changing intrinsic test performance. 2

Current Diagnostic Benchmarks (Version 2.1)

  • At the patient level with PI-RADS ≥3 as positive: 96% sensitivity (95% CI: 95-98%) and 43% specificity (95% CI: 33-54%). 4

  • At the patient level with PI-RADS ≥4 as positive: 89% sensitivity (95% CI: 85-92%) and 66% specificity (95% CI: 58-74%). 4

  • Cancer detection rates by category: PI-RADS 1 (6%), PI-RADS 2 (5%), PI-RADS 3 (19%), PI-RADS 4 (54%), PI-RADS 5 (84%). 4

Critical Implementation Point: The 2+1 TZ Lesion Controversy

The upgraded transition zone 2+1 lesion pathway (atypical BPH nodules with marked diffusion restriction) may result in unnecessary biopsies. 5, 6

  • Prospective data shows only 6% of 2+1 TZ lesions harbor clinically significant cancer, not significantly different from conventional 3+0 lesions (11%), but both rates are low. 6

  • Consider avoiding routine biopsy of 2+1 TZ lesions unless other high-risk features are present (elevated PSA density, concerning clinical parameters), as the upgrade pathway may increase false positives. 5, 6

Why Version 2.1 Matters Clinically

Improved Standardization

  • Minor revisions to the sector map provide more consistent anatomical referencing across institutions and readers. 2

  • Stricter emphasis on PI-RADS compliance and standardized reporting templates promotes uniform interpretation. 2

Maintained Clinical Utility

  • Version 2.1 preserves the fundamental framework: DWI dominates peripheral zone assessment, T2-weighted imaging dominates transition zone assessment, and DCE serves an ancillary role. 3, 7

  • The system continues to improve detection of clinically significant cancers while reducing overdiagnosis of indolent disease, with fewer targeted biopsies needed per patient. 1, 8

Common Pitfalls to Avoid

  • Do not use version 2.0 criteria—version 2.1 is the current standard and addresses known ambiguities that increase variability. 1

  • Do not automatically biopsy all PI-RADS 3 lesions, particularly 2+1 TZ lesions—integrate PSA density and clinical risk factors into decision-making. 5, 6

  • Do not expect version 2.1 to detect all clinically significant cancers—mpMRI still misses some cases, and the negative predictive value varies with disease prevalence in your patient population. 1, 8

  • Do not apply PI-RADS to previously treated prostates—the system is designed for treatment-naïve glands only. 8

Future Evolution

The PI-RADS steering committee describes version 2.1 as an incremental update; the next major revision is anticipated to require several years and additional research on clinical outcomes and MRI-directed biopsy performance. 1, 2 Version 2.1 remains a "living document" that will continue evolving as clinical experience accumulates. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

PI‑RADS Version 2.1: Updates and Clinical Implications

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

PI-RADS 2.1 - Image Interpretation: The Most Important Updates and Their Clinical Implications.

RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 2021

7
Research

PI-RADS version 2: what you need to know.

Clinical radiology, 2015

8
Guideline

PI-RADS Guidelines for Prostate Cancer Detection

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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