The role of magnetic resonance imaging in the active surveillance of prostate cancer: state of the art

POURPOSE: To provide an update on the role of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) of prostate cancer, with particular focus on standardizing image acquisition and reporting through PI-RADS v2.1, PI-QUAL v2, and PRECISE v2, as well as their clinical implications in risk stratification and follow-up. MATERIALS AND METHODS: Narrative review of the literature and the most recent international guidelines on the use of mpMRI in patients undergoing AS. Selection criteria, follow-up protocols (12-24 months), imaging quality parameters (PI-QUAL v2), the longitudinal assessment system PRECISE v2, and the main radiological triggers for re-biopsy and multidisciplinary discussion were analyzed. RESULTS: Baseline mpMRI improves candidate selection and reduces the risk of underestimating clinically significant disease. During follow-up, radiological progression shows a sensitivity of approximately 59% and specificity of approximately 75%, with a high negative predictive value (81-88%) but moderate positive predictive value. PRECISE v2 introduces updated categories, mandatory integration of image quality assessment, and systematic comparison with prior examinations, thereby improving reproducibility and comparability. CONCLUSIONS: The standardized integration of mpMRI, PI-QUAL v2, and PRECISE v2 enables more structured patient monitoring and supports multidisciplinary decision-making. However, mpMRI does not replace scheduled biopsies. The implementation of radiomics and artificial intelligence may further enhance the objectivity and effectiveness of active surveillance.