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Signal intensities (SI) on dynamic contrast-enhanced magnetic resonance images (DCE-MRI) were normalized to the obturator internus muscle. For reproducibility, 20 patients had repeat FD extracted by an independent observer. FD was correlated with ISUP-GG. Previously determined thresholds were applied to determine diagnostic accuracy of FD for separating ISUP-GGs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>After image normalization, tumor SI values showed similar distributions between scanners. There was a significant correlation between FD and ISUP-GG (R\u2009=\u20090.87, P\u2009&amp;lt;\u2009.000001). FD was 2.17\u2009\u00b1\u20090.01 in ISUP-GG1, 2.26\u2009\u00b1\u20090.04 in ISUP-GG2, 2.34\u2009\u00b1\u20090.04 in ISUP-GG3, 2.41\u2009\u00b1\u20090.03 in ISUP-GG4, and 2.42\u2009\u00b1\u20090.04 in ISUP-GG5. In 20 randomly selected cases, mean inter-reader FD difference was \u22120.01, Bland-Altman limits of agreement \u22120.08 to +0.05. A pre-specified threshold from previous datasets of 2.31 separated ISUP-GG1-2 from 3 to 5 with 95.2% sensitivity, 92.9% specificity, and 94.1% diagnostic accuracy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>FD is an accurate biomarker for grading PCa using standard clinical DCE-MRI with differing fat-saturation schemes that affect SI.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Advances in knowledge<\/jats:title>\n                    <jats:p>Fractal dimension of DCE-MRI allows for non-invasive stratification of PCa and generalizes to different MRI scanners and fat-saturation protocols.<\/jats:p>\n                  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