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Purpose: Multiparametric MRI (mpMRI) improves detection of clinically significant prostate cancer (csPCa), but the qualitative PI-RADS system and quantitative apparent diffusion coefficient (ADC) yield inconsistent results. An advanced Restrictrion Spectrum Imaging (RSI) model may yield a better quantitative marker for csPCa, the RSI restriction score (RSIrs). We evaluated RSIrs for patient-level detection of csPCa. Materials and Methods: Retrospective analysis of men who underwent mpMRI with RSI and prostate biopsy for suspected prostate cancer from 2017-2019. Maximum RSIrs within the prostate was assessed by area under the receiver operating characteristic curve (AUC) for discriminating csPCa (grade group [&ge;]2) from benign or grade group 1 biopsies. Performance of RSIrs was compared to minimum ADC and PI-RADS v2-2.1via bootstrap confidence intervals and bootstrap difference (two-tailed =0.05). We also tested whether the combination of PI-RADS and RSIrs (PI-RADS+RSIrs) was superior to PI-RADS, alone. Results: 151 patients met criteria for inclusion. AUC values for ADC, RSIrs, and PI-RADS were 0.50 [95% confidence interval: 0.41, 0.60], 0.76 [0.68, 0.84], and 0.78 [0.71, 0.85], respectively. RSIrs (p=0.0002) and PI-RADS (p<0.0001) were superior to ADC for patient-level detection of csPCa. The performance of RSIrs was comparable to that of PI-RADS (p=0.6). AUC for PI-RADS+RSIrs was 0.84 [0.77, 0.90], superior to PI-RADS or RSIrs, alone (p=0.008, p=0.009). Conclusions: RSIrs was superior to conventional ADC and comparable to (routine, clinical) PI-RADS for patient-level detection of csPCa. The combination of PI-RADS and RSIrs was superior to either alone. RSIrs is a promising quantitative marker worthy of prospective study in the setting of csPCa detection.

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