Prostate MRI Report (PI-RADS)

Patient: [patient name and identifiers per local policy]

Exam: MRI Prostate (PI-RADS v2.1)

Date/Time: [exam date and time]

Accession: [accession number]

Referring Clinician: [referring clinician name]

Interpreting Radiologist: [radiologist name]

Indication

Reason for exam: [clinical question]

PSA: [value, date / not provided]

Prior biopsy: [type, date, key results / none / not provided]

Prior prostate therapy: [therapy details] (Include only if applicable; if prior therapy present, note that PI-RADS categories may not apply.)

Technique

[PI-RADS-compliant multiparametric MRI / biparametric protocol / limited protocol] (Specify any protocol limitations.)

Magnet strength and coils: [magnet strength; coil configuration]

Sequences obtained: [T2-weighted multiplanar; DWI with ADC and high b-value; DCE status]

Contrast: [agent, dose, route / not administered]

(If any sequence was technically compromised, document the specific limitation here.)

Comparison

[prior prostate MRI with date / None available]

Findings

Study quality: [diagnostic / limited / nondiagnostic] — [limitation details if applicable]

Prostate measurements: [AP] × [transverse] × [longitudinal] cm; volume [calculated volume] cc

PSA density: [value] (Include only if PSA provided; otherwise omit.)

Gland background: [peripheral zone and transition zone characterization] (Be concise; do not elaborate on normal findings.)

Hemorrhage: [presence and impact on assessment] (Omit if absent.)

Lesions: (Report up to 4 suspicious lesions PI-RADS 3–5 in rank order by PI-RADS category, then size. If no suspicious lesions, state "No PI-RADS 3–5 lesions identified" and omit lesion blocks.)

Lesion 1 [Index]

• Location: [sector label, side, zone, level; series/image reference]
• Size: [largest axial dimension in mm; measurement sequence]
• T2: [1–5 / X] — [brief descriptor]
• DWI/ADC: [1–5 / X] — [brief descriptor]
• DCE: [positive / negative / X]
• PI-RADS: [1–5]
• EPE: [none / indeterminate / definite]
• SVI: [not involved / indeterminate / involved] (Include only if relevant.)
• NVB: [not involved / indeterminate / involved] (Include only if relevant.)

Lesion 2 (Include only if present; use same format as Lesion 1.)

• Location: [sector label, side, zone, level; series/image reference]
• Size: [largest axial dimension in mm]
• T2: [1–5 / X] — [brief descriptor]
• DWI/ADC: [1–5 / X] — [brief descriptor]
• DCE: [positive / negative / X]
• PI-RADS: [1–5]
• EPE: [none / indeterminate / definite]

Lesion 3 (Include only if present; use same format as Lesion 1.)

• Location: [sector label, side, zone, level; series/image reference]
• Size: [largest axial dimension in mm]
• T2: [1–5 / X] — [brief descriptor]
• DWI/ADC: [1–5 / X] — [brief descriptor]
• DCE: [positive / negative / X]
• PI-RADS: [1–5]
• EPE: [none / indeterminate / definite]

Lesion 4 (Include only if present; use same format as Lesion 1.)

• Location: [sector label, side, zone, level; series/image reference]
• Size: [largest axial dimension in mm]
• T2: [1–5 / X] — [brief descriptor]
• DWI/ADC: [1–5 / X] — [brief descriptor]
• DCE: [positive / negative / X]
• PI-RADS: [1–5]
• EPE: [none / indeterminate / definite]

Lymph Nodes: [no suspicious pelvic lymphadenopathy / suspicious node location and short-axis size]

Bones: [no suspicious osseous lesions / suspicious lesion location]

Other Findings: [clinically significant abnormalities] (Omit if none.)

Impression

1. [Index lesion: PI-RADS category, location, size, EPE/SVI status]
2. [Additional lesions: PI-RADS category, location, size] (One line per lesion; omit if none.)
3. [Staging summary] (e.g., "No MRI evidence of EPE or SVI" or "Findings concerning for EPE"; omit if not applicable.)
4. [Significant limitations affecting diagnostic confidence] (Omit if none.)

(PI-RADS category reflects MRI findings only. Use "X" for any inadequate or missing sequence. If prostate has been treated, state that PI-RADS categories are not applicable.)