Prostate MRI plays a central role in the detection, staging and follow-up of prostate cancer. Its use continues to grow due to its non-invasive nature and diagnostic reliability. With more patients undergoing MRI following PSA screening or as part of active surveillance programmes, imaging services are experiencing increased demand. Longer waiting times and higher costs reflect this pressure on radiology departments.
Strategies that allow optimisation of imaging workflows without compromising diagnostic performance have become a priority. One such strategy involves personalising the use of gadolinium-based contrast agents. Evidence now supports more selective use, particularly through on-table monitoring techniques that guide decisions during the scan. This approach offers an opportunity to reduce contrast use in many patients, streamline care and better match resources to individual clinical needs.
Adapting MRI Protocols Through On-Table Monitoring
On-table monitoring provides a flexible pathway to tailor MRI protocols during the scanning session. Initially, patients undergo non-contrast sequences such as T2-weighted and diffusion-weighted imaging. Based on those results, the radiologist decides in real-time whether to administer contrast for dynamic sequences. This method allows contrast use to be limited to cases where it is likely to enhance diagnostic confidence. Recent studies have shown that contrast can be safely omitted in nearly three-quarters of men undergoing prostate MRI. Despite this reduction, detection rates for clinically significant prostate cancer and biopsy decisions remained stable.
Must Read: PSMA-RADS 2.0 Improves Prostate Cancer Imaging
The benefits of contrast use were most evident in specific situations. These included scans affected by artefacts from rectal gas, metal implants or patient movement. In some cases, contrast sequences helped clarify indeterminate lesions, particularly those scored as PI-RADS 3. Upgrading these lesions to a higher risk category led to additional cancer detection, though this did not alter the overall detection rate between monitored and unmonitored groups. Contrast sequences also played a role in staging more advanced disease, including assessment of seminal vesicle or bladder neck invasion. However, the clinical impact of these findings still requires further exploration. Importantly, men with renal failure or contrast allergies were excluded from contrast use altogether.
Benefits of a Personalised Contrast Approach
Personalised contrast use offers multiple practical advantages. Direct cost savings are one of the most immediate benefits. Reducing the use of gadolinium agents lowers expenditure on contrast materials and decreases the need for intravenous cannulas. Avoiding unnecessary cannulation also reduces patient discomfort and procedural time. By minimising contrast exposure, risks associated with gadolinium, although rare, are also avoided. This approach supports a more sustainable use of resources within radiology departments.
Operational efficiency is another major gain. By limiting the number of full contrast-enhanced scans, departments can increase throughput and reduce scan duration. These improvements support faster patient turnover and help reduce waiting lists. On a broader scale, this approach contributes to environmental goals. Gadolinium has been found in wastewater systems, raising concerns about its environmental footprint. Reducing its use supports responsible practice in line with sustainability goals in healthcare.
Decisions tailored to patient-specific risk profiles allow a more thoughtful approach to imaging. Some patients may benefit more from a contrast-free pathway, particularly those with low-risk disease under surveillance. Others may need enhanced imaging to support surgical planning or clarify ambiguous findings. Incorporating such individualised decisions into standard practice can raise the overall quality of care. Furthermore, this strategy may support different clinical preferences, whether to avoid missing significant cancers or to reduce unnecessary biopsies.
Implementation Challenges and Future Directions
Despite its promise, several challenges must be addressed before routine implementation. On-table monitoring relies on the presence of skilled radiologists who can interpret images during the scan and decide promptly about contrast use. In many settings, radiologist shortages and heavy workloads limit the availability of staff for this real-time decision-making. These constraints are particularly significant outside regular working hours. Additionally, scheduling and workflow logistics must account for possible contrast administration, including consent procedures and intravenous line placement. This requires a degree of flexibility in planning that may not be feasible in all departments.
Inter-reader variability represents another concern. Findings such as PI-RADS 3 lesions are subject to interpretation differences between radiologists. Quality assurance is essential to ensure consistency and maintain confidence in imaging decisions. Multi-centre studies are needed to assess the practicality and safety of this approach in different clinical environments. These studies should explore how patient characteristics and disease profiles influence the benefit of contrast-enhanced imaging.
There is growing interest in technological solutions that may support decision-making. Artificial intelligence systems could assist by identifying patients who may need contrast, allowing radiologists to focus on interpretation rather than protocol decisions. These tools could also help address staffing gaps and support consistent, efficient workflows. AI-supported contrast selection may play a role in future imaging protocols, offering further gains in speed and accuracy. However, technology alone will not replace the need for well-defined imaging strategies built around clinical evidence and patient-centred care.
Prostate MRI services must adapt to rising demand without sacrificing quality. Tailoring the use of contrast agents through on-table monitoring offers a practical method to manage resources more efficiently. This approach reduces costs, lowers patient exposure to contrast and helps departments meet service demands. While certain cases still benefit from dynamic contrast sequences, most men undergoing MRI may not require them. A personalised strategy supports more thoughtful care and better alignment between clinical need and imaging intensity. Successful implementation will require operational adjustments, workforce planning and continued research. With further development, this method may become a standard element in efficient and sustainable prostate cancer imaging.
Source: European Radiology
Image Credit: iStock
