Cribriform Pattern of The Prostate Adenocarcinoma: Sensitivity of Multiparametric MRI Mustafa Bilal Tuna1*, Aydan Arslan2, Yunus Baran Kök3, Tunkut Doganca4, Omer Burak Argun5, Ilter Tufek5, Betül Zehra Pirdal6, Yesim Saglican3, Can Obek5, Ercan Karaarslan7, Ali Riza Kural5 INTRODUCTION MpMRI improves the detection of clinically sig-nificant prostate cancers and helps to prevent unnecessary biopsies.(1-3) PI-RADS v2.1 scoring system precisely predicts the clinically significant prostate can- cer, with scores of 1 and 5 reflecting a very low and very high possibility of clinically significant cancer.(4) Four subtypes of Gleason pattern 4 are identified (cri- briform, fused, glomeruloid and poorly formed) in re- cent years. The cribriform pattern is accepted more aggressive and more fatal than non-cribriform Gleason pattern 4 and is associated with increased risk of lymph node and distant metastasis, biochemical recurrence, and cancer-specific death.(5-7) Recent studies have shown for active surveillance can- didates; a cribriform pattern in the biopsy specimen is an exclusion criterion.(8) Therefore; identification of the cribriform pattern is crucial in terms of oncologic out- comes and clinical decision-making. However, data to date have claimed that cribriform pattern-predominant lesions are less visible on mpMRI and there are limited data on the radiologic evaluation of cribriform architec- ture.(9,10) In this study, we investigate the diagnostic ef- fectiveness of mpMRI for detecting cribriform pattern prostate cancer. MATERIALS AND METHODS A total of 33 patients whose final pathologic speci- men contains the cribriform pattern of prostate cancer after robot-assisted laparoscopic radical prostatecto- my between September 2018 to February 2021 were included in this study. All patients had pre-operative biopsy-proven clinically significant prostate cancer. MpMRI was performed for all patients by the PI-RADS v2.1 guideline before the prostate biopsy and radical prostatectomy. All whole-mount step-section patholog- ical slices were available and collected for pathological review. Patients who received neoadjuvant treatment 1Department of Urology, Acibadem Maslak Hospital, Istanbul, Turkey. 2Department of Radiology, Umraniye Training and Research Hospital; Istanbul,Turkey. 3Department of Pathology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey. 4Department of Urology, Acibadem Taksim Hospital, Istanbul, Turkey. 5Department of Urology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey. 6Department of Public Health, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098 Istanbul, Turkey. 7Department of Radiology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey. *Correspondence: Department of Urology, Acibadem Maslak Hospital, Istanbul, 34457,Turkey. Tel:+905052532047, Fax: +9002122190987, E-mail: mustafabilaltuna@gmail.com. Received July 2022 & Accepted December 2022 Background: The aim of this study was to investigate the diagnostic performance of mpMRI for detecting cribri- form pattern prostate cancer. Materials and Methods: This study retrospectively enrolled 33 patients who were reported cribriform pattern prostate cancer at final pathology. The localization, grade and volumetric properties of the dominant tumors and areas with cribriform pattern at the final pathological specimens were recorded and the diagnostic value of mpMRI was evaluated on the basis of the cribriform morphology detection rate. It was analyzed using Wilcoxon test, the Chi-square test and Fisher's Exact test. The significance level (P-value) was set at .05 in all statistical analyses. Results: A total of 58 prostate cancer foci were (38 cribriform, 20 non-cribriform foci) identified on the final pa- thology. mpMRI identified 36 of the 38 cribriform morphology harboring tumor foci with a sensitivity of 94.7% (95% confidence interval 82.7–98.5%). In 17 of the 33 patients mpMRI detected single lesion and for these lesions; mpMRI identified cribriform morphology positive areas precisely in 15 patients with significantly low ADCmean and ADCmin values compared to the non-cribriform cancer areas within the primary index lesion (P < .001). For the remaining 16 patients with multiple lesions; all of the tumor foci that harboring cribriform morphology were identified by mpMRI but in none of them any ADCmean and ADCmin value divergence were detected between the cribriform and non-cribriform pattern tumor foci within the primary index lesion. Conclusion: Cribiform pattern should be considered in single lesions with an area of lower ADC value on mpMRI. Keywords: cribriform pattern, multiparametric MRI, prostate cancer UROLOGICAL ONCOLOGY Urology Journal/Vol 20 No. 1/ January-February 2023/ pp. 34-40. [DOI:10.22037/uj.v19i.7382] including androgen deprivation therapy or chemother- apy and underwent mpMRI after prostate biopsy were excluded from the study. This study was approved by the Acibadem Mehmet Ali Aydınlar University Institutional Review Board (İstanbul, Turkey), (decision number:2022-05/10), and signed informed consent were collected from all sub- jects before MR imaging. MRI Protocol and Image Analysis MpMRI was performed with a 3.0-T MR scanner (Sie- mens Healthineers, Magnetom Skyra, Erlangen, Ger- many, or Siemens Healthineers) using either Gadovist (0.1mL / kg) or Dotarem, (0.2 mL/kg) as a contrast agent before the prostate biopsy. Detailed prostate mp- MRI protocol is given in Table 1. All images were evaluated by two experienced radiol- ogists. The radiologists were blinded to the other radi- ologist's reports but after the evaluation of the dataset, consensus was achieved. The radiologists identified abnormalities that correspond to clinically significant prostate cancer. All tumor foci were recorded accord- ing to zone (central, peripheral, or transition zone), sec- tor (anterior or posterior), regional part (apex, mid, or base), and laterality (left or right) using 41 sector maps in PI-RADS v2.1. To make sure that all readers were scoring the same area; each reader drew on the 41 sec- tor map. The dimensions of the lesion(maximal axial, Letter 242 Table 1. Imaging parameters of mpMRI Figure 1. Correlations of ADCmean and ADCmin values between cribriform and non-cribriform areas within the primary index lesion in cases with single MRI lesion visible on mpMRI Unclassified 461 Multiparametric MRI and cribriform pattern prostate adenocarcinoma-Tuna et al. Vol 20 No 1 January-February 2023 35 Unclassified 461 perpendicular to axial plane, and coronal plane if pos- sible) were calculated individually. All of the lesions PI-RADS ≥ 3 were scored by a radiologist according to the PI-RADS v2.1. The ADC values for suspicious le- sions were measured by marking these areas as a region of interest(ROIs) on the ADC map. Mean and minimum ADC values were recorded without knowing the patho- logical results after the consensus of all lesions. Lastly, all of the ROIs were depicted manually based on tumor foci and cribriform pattern positive areas depending on the final pathology specimen with knowledge of the pathology findings. The mpMRI index lesion was defined as the target with the highest PI-RADS score. In case of 2 or more lesions with the same PI-RADS score exists; the one regarded as clinically more suspicious by the radiologist was re- corded as an index lesion. The pathology index lesion was defined as the lesion with the highest ISUP Grade score. Whole-Mount Histopathology Radical prostatectomy specimens were sliced at 3 mm intervals from the apex to the base. Two experienced genitourinary pathologists reexamined all whole-mount step-section pathological slices according to the 2014 ISUP modified prostate cancer criteria. The patholog- ical workup was blinded to radiology findings. Both pathologists looked at all cases and the consensus was reached. All tumor foci and cribriform pattern areas within each radical prostatectomy specimen were determined and mapped in different colors(blue&red) to a gross histo- pathology image that is routinely saved for each patient. From the total pathology specimen, the largest diameter of each lesion, histological type and grade, location of tumor foci, tumor spread, tumor volume, surgical mar- gin status, lymph node involvement, and staging were documented. Cribriform pattern tumor burden ratio is defined as the percentage of cribriform pattern positive tumors in the total cancer amount(including ≥ Gleason 3) of the final pathology specimen. 2.4 Statistical Analysis SPSS v.21 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Shapiro-Wilk tests, histograms, and probability plots were used for assessing normality,. Results were presented as mean ± standard deviation for normally distributed variables, and median (IQR(Inter- quartile range)) for non-normally distributed variables. Categorical variables were presented with frequency and percentage. Comparisons of the groups for contin- uous variables were made by the Mann-Whitney U test. Differences between the two paired groups were tested using the Wilcoxon test. The Chi-square test or Fisher’s Exact test was used to analyze categorical variables. Correlation coefficients were determined using Spear- man rho. All tests are two-sided and the significance level was accepted as P < .05. Unclassified 408 Age (years), Mean ± Std.deviation 63.6 ± 6.9 Time from MRI to Robot Assisted Radical Prostatectomy (days), Median (IQR) 51 (48-62.5) PSA level (ng/mL), Median (IQR) 6.5 (4.9-10.3) Final Pathologic Specimen (ISUP Grade), n (%) ISUP Grade 2 18 (54.5%) ISUP Grade 3 11 (33.3%) ISUP Grade 4 1 (3%) ISUP Grade 5 3 (9.1%) Prostate Volume (cm3), Median (IQR) 45 (36-53.5) Tumor volume (cm3), Median (IQR) 4 (2.3-6.3) Tumor ratio (tumor volume/prostate volume), Median (IQR) 9 % (3.6-15.8) Cribriform morphology tumor burden (%), Median (IQR) 25% (12.5-50) pT-stage, n (%) pT2 21 (63.6%) pT3a 6 (18.1%) pT3b 6 (18.1%) pN-stage, n (%) n0 30 (90.9%) n1 3 (9.1%) Surgical Margin Positivity, n (%) Negative 28 (84.8%) Positive 5 (15.1%) Table 2. Clinical and pathologic characteristics of the study population Multiparametric MRI and cribriform pattern prostate adenocarcinoma-Tuna et al. Categories All tumors foci visible on mpMRI (53) Cribriform foci visible on mpMRI (36) Non-Cribriform foci visible on mpMRI (17) P Diameter (MRI) (mm), Median (IQR) 12 (9-16) 13 (9.3-18.8) 10 (8.5-13) .0541 Diameter (final pathology) (mm) Median (IQR) 13.3 (10.5-17.3) 14.5 (11.6-20.5) 10.8 (8.9-13.3) .0021 mpMRI lesions, n (%) PI-RADS 3 6 (11.3%) 2 (5.3%) 4 (23.5%) .0763 PI-RADS 4 31 (58.5%) 19 (52.8%) 12 (70.6%) .2192 PI-RADS 5 16 (31.4%) 15 (44.1%) 1 (5.9%) .0092 Localization, n (%) Basis 17 (32.1%) 12 (33.3%) 5 (29.4%) .7212 Mid 24 (45.3%) 15 (41.7%) 9 (52.9%) Apex 12 (22.6%) 9 (25%) 3 (17.6%) Peripheral Zone 50 (94.3%) 36 (100%) 14 (82.4%) .0293 Transitional Zone 3 (5.7%) 0 (0%) 3 (17.6%) Table 3. MpMRI characteristics of the cribriform and non-cribriform tumor foci that were visible on mpMRI 1Mann Whitney U test, 2Chi square test, 3Fisher exact test Urological Oncology 36 Results In 33 patients a total of 58 PCa foci were(38 cribriform, 20 non-cribriform foci) identified on the final patholo- gy specimen obtained after robot-assisted radical pros- tatectomy. The clinical and pathological characteristics of the whole study group are shown in Table 2. MpMRI index lesion was accordant with the prostatectomy in- dex lesion in 31 of 33 cases (94%). MpMRI precisely identified 36 of the 38 cribriform morphology harbor- ing tumors with a sensitivity of 94.7% (95% confidence interval 82.7–98.5%) in 31 of 33 patients (94%). On the other hand; mpMRI identified 17 of the 20 non-cribri- form morphology tumors precisely. When the diame- ters of non-cribriform and cribriform tumor foci that were visible on mpMRI were examined, no difference was found with mpMRI, but the mean diameters of cri- briform pattern harboring tumor foci were higher in the final pathology (respectively P = .054, P = .002). In our whole study group; cribriform pattern harboring tumor foci is more frequently located in PI-RADS 5 le- sions compared to non-cribriform tumor foci (P = .009). ISUP Grade of the cribriform pattern positive tumors visible on mpMRI was 2 in 18 foci, 3 in 13 foci, 4 in 2 foci, and 5 in 3 foci. ISUP Grade of the non-cribriform pattern positive tumors visible on mpMRI was 1 in 6 foci, 3 in 7 foci,3 in 3 foci, and 5 in 1 focus. All of the cribriform morphology positive and mpMRI visible tu- mor foci were located in the peripheral zone. Non-Cri- briform morphology positive and mpMRI visible tumor foci were located in the transitional zone for 3 (17,6%) foci and peripheral zone for 14 (82,4%) foci. MpMRI characteristics of the cribriform and non-cribriform tumor foci that were visible on mpMRI are shown in Table 3. In 2 of the 33 cases, mpMRI could not detect cribri- form morphology positive areas. One of these patients' pre-operative mpMRI detected mid anterior located PI- RADS 4 lesion with a 9x8 mm diameter. In this case, final pathology revealed; pT2, ISUP Grade 2 prostate adenocarcinoma with a total of 1.6 cm3 tumor volume. Although preoperative mpMRI was concordant with the primary index lesion of the final pathology; mp- MRI could not detect the apical anterior located small cribriform morphology positive area. For this case, the cribriform tumor burden ratio was 5%. The other pa- tient’s pre-operative mpMRI detected a mid-anterior located 10x7 mm PI-RADS 4 lesion and final pathol- ogy revealed pT2, ISUP Grade 2 prostate adenocarci- noma with a total of 6.1 cm3 tumor volume. For this patient, pre-operative mpMRI was accordant to the primary index lesion of the final pathologic specimen, but could not detect cribriform morphology positive small area that was located at the left apical region of the prostate. In this case, the cribriform tumor burden was 10%. On the other hand, 2 in the 33 cases mpMRI could not identify the primary index lesion of the final pathology specimen. In one of these cases, pre-opera- tive mpMRI detected a mid posterior located PI-RADS 4 lesion with an 8x5 mm diameter. For this case; the final pathology revealed pT2, ISUP Grade 2 prostate adenocarcinoma with a total of 0.6 cm3 tumor volume. In this case, pre-operative mpMRI could not detect the primary index lesion that was located in the mid apical posterior aspect of the prostate but only identified the cribriform morphology positive area that was located at the mid posterior part of the prostate. In this case; the cribriform tumor burden was 10%. The other pa- tient's pre-operative mpMRI detected a right mid-lateral located PI-RADS 4 lesion with a 6x4 mm diameter. In this case, the final pathology revealed pT2, ISUP Grade 4 prostate adenocarcinoma with a total of 1.5 cm3 tu- mor volume. For this case; the final pathology revealed multiple tumor foci that were located at the left mid, right mid posterior, right mid-lateral, and right apical region of the prostate and mpMRI detected only cri- briform morphology positive area located at the right mid-lateral region of the prostate. The cribriform tumor burden ratio of this case was 45%. In 17 of the 33 cas- es, mpMRI detected a single lesion (6 PI-RADS 5, 11 PI-RADS 4) and among these cases, mpMRI identified cribriform morphology positive areas precisely in 15 patients. These cribriform positive area’s ADCmean and ADCmin values were significantly low compared to the non-cribriform cancer areas within the primary index lesion. For the remaining 16 patients with multi- ple lesions (10 PI-RADS 5, 20 PI-RADS 4, 6 PI-RASD 3); all of the tumor foci that harbored cribriform mor- phology were identified by mpMRI but in none of them any ADCmean and ADCmin value divergence were de- tected between the cribriform pattern tumor foci within the primary index lesion and primary index tumor. When the median ADCmean and ADCmin values in the cribriform and non-cribriform areas were exam- ined in these 15 patients with single mpMRI lesion, it was found that the median ADCmean and ADCmin values in the cribriform areas were significantly low (retrospectively P < .001, P < .001) when compared to the non-cribriform tumor areas within the primary Unclassified 463 Categories (n) Cribriform areas Non-Cribriform areas p Correlation Median (IQR) Median (IQR) r p All cases (n=31) ADCmean (μm2/s), 730 (643-848) 802 (700-991) < .0011 0.834 < .0012 ADCmin (μm2/s), 611 (469-756) 721 (611-878) < .0011 0.620 < .0012 Cribriform Pattern mpMRI visible cases with single mpMRI lesion (n=15) ADCmean (μm2/s) 726 (538-810) 848 (725-1018) < .0011 0.771 .0012 ADCmin (μm2/s) 496 (388-720) 743 (656-897) < .0011 0.588 .0212 Cases with Multiple mpMRI lesion (n=16) ADCmean (μm2/s) 755 (673-937.3) 755 (673-937,3) 1.001 1.00 - ADCmin (μm2/s) 666 (519.3-756) 666 (519.3-756) 1.001 1.00 - Table 4. Comparison of cribriform and non-cribriform areas in cribriform pattern visible cases on mpMRI with single mpMRI lesion and cases with multipl mpMRI lesion 1Wilcoxon test, 2Spearman correlation Multiparametric MRI and cribriform pattern prostate adenocarcinoma-Tuna et al. Vol 20 No 1 January-February 2023 37 index lesion. In these 15 patients with single mpMRI lesion; there was a high positive correlation (r = 0.771, P < .001) between ADCmean values in cribriform and non-cribriform areas, and a moderate positive corre- lation between ADCmin values (r = 0.588, P = .012) (Table 4, Figure 1). For the remaining 16 patients with multiple lesions (10 PI-RADS 5, 20 PI-RADS 4, 6 PI- RASD 3); all of the tumor foci that harbored cribriform morphology were identified by mpMRI but in none of them any ADCmean and ADCmin value divergence were detected between the cribriform pattern tumor foci and non-cribriform pattern tumor foci within the prima- ry index lesion. On the other hand; the median cribri- form pattern tumor burden ratio was 40% (IQR 25-50) in cases with mp MRI visible cases with single mpMRI lesion and 17.5% (IQR 10-57.5) in cases with multiple mpMRI lesions and no statistical difference was found between them (P = .106). DISCUSSSION In the PI-RADS v2.1 era; the pooled sensitivity and specificity of mpMRI for detecting prostate cancer are 89% and 73% respectively.(1-3) Despite these advantag- es; tumor volume, tumor density, Gleason score, and tumor heterogeneity with underlying clinical features (presence of cribriform and intraductal carcinoma) can affect the tumor visibility.(2,11-13) Cribriform morphology can be defined as having mod- erately differentiated glands ranging from small to large, growing in spaced-out infiltrative patterns.(14) Moreover; the ISUP conference in 2014 arrived at a consensus that; cribriform glands should be assigned as Gleason pattern 4, regardless of morphology.(15) In addition to that; to improve the prostate cancer screen- ing for initial prostate biopsy; the ERSPC Rotterdam risk calculator was updated in 2014 and stated that: the presence of cribriform or intraductal carcinoma should be defined as high-risk prostate cancer.(16) The visibility of the Gleason 4 pattern varies depending on the morphologic features. Recently Aydan et. report- ed their experience in 58 men with 112 clinically sig- nificant prostate cancer foci to investigate the MpMRI visibility of prostate cancer according to the underlying histopathological variances. They concluded that; al- though statistically not significant, clinically significant prostate cancer with cribriform component and without any intraductal or cribriform component are more likely to harbor mpMRI invisible features than the intraductal pattern.(13) Moreover; it is noteworthy to mention recent reports on larger cohorts of patients highlighting the relatively high incidence of high-grade prostate can- cer with cribriform morphology in patients with neg- ative mpMRI. According to recent studies, cribriform pattern dominant prostate cancer is usually not visible at imaging and even on diffusion-weighted images of mpMRI. In this respect; quantitative analyses of mpM- RI has shown encouraging results in peripheral tumor characterization.(17) The visibility of pure cribriform pattern tumors is reported % at 17 on MRI, which was significantly lower than other Gleason 4 pattern sub- types independent of tumor size.(10) The mechanism of the decreased visibility is unknown but theoretically at- tributed to the relatively larger luminal perforations and fewer epithelial cells of cribriform morphology.(9) Gao J. et al. retrospectively collected the data of 215 prostate cancer patients who received mpMRI exami- nation, systematic biopsy combined with targeted biop- sy, radical prostatectomy, and final ISUP scores 2 and 3. In this study; cribriform morphology was detected in 110 of 215 patients (51.2%). They concluded that: prostate-specific antigen density (P = .003), Prostate Imaging Reporting and Data System score (P < .001) and maximal biopsy Gleason score (P = .004) were independent predictors for presence of cribriform mor- phology.(18) Prendeville et al. reported their prospective study that compares biopsy detection of intraductal and cribriform pattern prostate cancer in MpMRI positive and negative regions of the prostate in 151 patients. In- traductal/cribriform positive tumor was detected in 23 cases. For these cases; the prior 12-core systematic bi- opsy was negative in 8 and ISUP Grade 1 in 11 cases. They concluded that; the intraductal/cribriform pattern was significantly associated with PI-RADS score 5 and decreasing ADC values. This study shows the ability of MpMRI targeted biopsy to detect high-risk intraductal/ cribriform Gleason pattern 4 prostate cancer.(19) Com- puter aided diagnostic (CAD) system assistance for fusion prostate biopsy has shown to be more effective in identification of clinically significant prostate can- cers. CAD-assisted analyses provide enhanced graphic visualization and more precise spatial contouring of the lesion. These advantages of this system; instantly facil- itate the detection of targeted areas; particularly in PI- RADS ≤ 3 lesions.(20) Moreover; Tonttila et al; report- ed their experience to assess the diagnostic ability for detecting cribriform patterns and intraductal carcinoma in 124 patients that underwent mpMRI before radical prostatectomy. They showed that mpMRI detected cri- briform pattern and intraductal carcinoma with 90.5% sensitivity.(21) Our results correspond with their find- ings. In our study; we determined that; MpMRI pre- cisely identified 36 of the 38 cribriform morphology harboring tumors (%94.7) in 31 of 33 patients (94%). There is a close inverse correlation between quantita- tive ADC measurement and clinical aggressiveness and Gleason Score. However, literature to date advocates that; there is no significant difference between the AD- Cmean between the cribriform-positive and non-cribri- form prostate cancer. Tonttila et al. noticed a similar correlation between ADC values and clinical adverse events, but the range was so wide to show its clinical value. They stated that; the ADC value is not a marker to differentiate ISUP group 2 tumors with cribriform and intraductal carcinoma.(21) Similarly; Hurrel SL et al. did not find a correlation between the ADC values for Gleason pattern 4 with and without cribriform architec- ture and intraductal carcinoma.(22) Gao et al. retrospec- tively reported their data to investigate the diagnostic performance of Ga68 PSMA PET/CT in a total of 49 patients with 62 lesions. From these lesions, 37(59.7%) in 34 patients (69.4%) they detected cribriform mor- phology. Although they found that; ADCmean and ADC10% of were similar between cribriform posi- tive and non-cribriform groups (P > .05); they showed that PSMA was significantly overexpressed in cribri- form-positive prostate cancer (P = .003) and SUVmax was a significant predictor of cribriform morphology (P < .001).(23) Our results do not correspond with the pre- vious studies on some points. In 17 of the 33 patients with a single mpMRI lesion; mpMRI detected a single lesion (6 PI-RADS 5, 11 PI-RADS 4), and for these le- sions; mpMRI identified cribriform morphology posi- Vol 19 No 6 November-December 2022 464 Multiparametric MRI and cribriform pattern prostate adenocarcinoma-Tuna et al. Urological Oncology 38 Unclassified 410 tive areas precisely in 15 patients. For these 15 cases; the cribriform positive area’s ADCmean and ADCmin values were significantly low compared to the non-cri- briform cancer areas within the primary index lesion. On the other hand, in 16 patients with multiple lesions (10 PI-RADS 5, 20 PI-RADS 4, 6 PIRASD 3); all of the tumor foci that harbored cribriform morphology were identified but in none of them any ADCmean and ADC- min value divergence were detected between the cribri- form pattern tumor foci within the primary index lesion and primary index tumor. This may be explained by the clustering of the cribriform pattern cells in a single le- sion rather than dispersing around into multiple lesions. The strengths of our study are the detailed MRI analysis by two experienced radiologists and whole-mount his- topathology of the primary tumor including cribriform architecture. Moreover, whole-Mount histopathology was evaluated based on identifying cribriform morphol- ogy by two experienced genitourinary pathologists to provide interobserver reliability. The main limitation of this study was the small (n = 33 men) sample size de- rived from a single tertiary center; therefore, adoption of our outcomes may not apply to community-based ra- diology and urology practice. CONCLUSIONS Despite reports of diminished visibility in the literature, multiparametric prostate MRI has high sensitivity and is an effective diagnostic technique for detecting cribri- form pattern prostate cancer. In patients with a single lesion on pre-operative mpMRI, areas with lower AD- Cmean and ADCmin within the primary index lesion compared to the primary index lesion should be consid- ered for cribriform pattern existence at the final pathol- ogy specimen. More randomized multi-center trials are needed to back up our findings. CONFLICT OF INTEREST None FINANCIAL DISCLOSURE None REFERENCES 1. Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS Prostate Imaging - Reporting and Data System: 2015, Version 2. Eur Urol. 2016 Jan;69(1):16-40. doi: 10.1016/j. eururo.2015.08.052. Epub 2015 Oct 1. PMID: 26427566; PMCID: PMC6467207. 2. Ahmed HU, El-Shater Bosaily A, et al.; PROMIS study group. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017 Feb 25;389(10071):815-822. doi: 10.1016/S0140- 6736(16)32401-1. Epub 2017 Jan 20. PMID: 28110982. 3. 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