Radiomics-Based Characterization of Aggressive Prostate Cancer Variants: Diagnostic Challenges and Opportunities

Background/Objectives: Aggressive variants of prostate cancer pose significant diagnostic and prognostic challenges due to atypical imaging appearances, variable prostate-specific antigen behavior, and distinct molecular features. Conventional imaging may underestimate their biological aggressiveness. This review aimed to synthesize current evidence on imaging characteristics, biomarker dynamics, tumor localization, histology, and radiomic features of aggressive prostate cancer variants, and to evaluate the potential role of radiomics in early recognition and risk stratification. Methods: A structured narrative review was performed of studies reporting imaging, clinical, and molecular features of aggressive prostate cancer variants. Imaging modalities included multiparametric magnetic resonance imaging, positron emission tomography with prostate-specific membrane antigen or fluorodeoxyglucose, bone scintigraphy, and transrectal ultrasound. Data on prostate-specific antigen levels and kinetics, intraprostatic tumor location, tumor size, metastatic patterns, and molecular alterations were extracted. Evidence for rare entities such as basaloid and primary squamous carcinomas was derived from published case reports and series, while selected variants were complemented by institutional imaging and histopathologic observations. Results: Neuroendocrine and small cell carcinomas frequently showed low prostate-specific antigen levels, high fluorodeoxyglucose uptake, low prostate-specific membrane antigen expression, and central or transitional zone involvement with large tumor size at diagnosis. Ductal adenocarcinoma demonstrated marked diffusion restriction and elevated prostate-specific antigen, whereas basal cell carcinoma often appeared inconspicuous on conventional imaging. Radiomic analysis consistently captured tumor heterogeneity and spatial complexity beyond standard qualitative metrics. Conclusions: Aggressive prostate cancer variants represent a diagnostic blind spot in routine imaging. Radiomics offers complementary quantitative information that may improve early detection, subtype differentiation, and risk stratification when integrated into multimodal imaging workflows. Further prospective and radiogenomic studies are warranted to validate these findings.