Natural history of histologically benign PIRADS 4-5 lesions in multiparametric MRI: Real-life experience in an academic center.

INTRODUCTION: The follow-up findings of patients who underwent prostate biopsy for prostate image reporting and data system (PIRADS) 4 or 5 multiparametric magnetic resonance imaging (mpMRI) findings and had benign histology were retrospectively reviewed. METHODS: There were 190 biopsy-naive patients. Patients with at least 12 months of follow-up between 2012 and 2023 were evaluated. All MRIs were interpreted by two very experienced uroradiologists. Of the patients, 125 had either cognitive or software fusion MR-targeted biopsies with 4 + 8/10 cores. The remaining 65 patients had in-bore biopsies with 4-5 cores. Prostate-specific antigen (PSA) levels below 4 ng/mL were defined as PSA regression following biopsy. PIRADS 1-3 lesions on new MRI images were classified as MRI regression. RESULTS: Median patient age and PSA were 62 (39-82) years and six (0.4-33) ng/mL, respectively, at the initial work-up. During a median follow-up period of 44 months, 37 (19.4%) patients were lost to follow-up. Of the remaining 153 patients, 82 (53.6%) had persistently high PSA. Among them, 72 (87.8%) had repeat mpMRI within 6-24 months which showed regressive findings (PIRADS 1-3) in 53 patients (73.6%) and PIRADS 4-5 index lesion persistence in 19 cases (26.4%). The latter group was recommended to have rebiopsy. Of these 19 patients, 16 underwent MRI-targeted rebiopsy. Prostate cancer was diagnosed in six (37.5%) patients and of these four (25%) were clinically significant (>Grade Group 1). Totally, clinically significant prostate cancer was detected in 4/153 (2.6%) patients followed up. CONCLUSION: Patients should be warned against the relative relaxing effect of a negative biopsy after identification of PIRADS 4-5 index lesion. While PSA decrease was observed in many patients during follow-up, persistent MRI findings were present in nearly a quarter of patients with persistently high PSA. A rebiopsy is warranted in these patients, with significant prostate cancer diagnosed in a quarter of patients with rebiopsy.

Can the Briganti 2019 nomogram be modified to predict lymph node metastasis risk in patients with prostate cancer detected with in-bore biopsy?

OBJECTIVES: We aimed to modify the Briganti 2019 nomogram and to test whether it is valid for patients who were diagnosed with prostate cancer through in-bore prostate biopsies. METHODS: Data for 204 patients with positive multiparametric prostate MRI and prostate cancer identified either by mpMRI-cognitive/software fusion or in-bore biopsy and who underwent robot-assisted radical prostatectomy and extended pelvic lymph node dissection between 2012 and 2023 were retrospectively analyzed. The Briganti 2019 nomogram was applied to the mpMRI-cognitive/software fusion biopsy group (142 patients) in the original form, and then, two modifications were tested for the targeted component. Original and modified scores were compared. These modifications were adapted for the in-bore biopsy group (62 patients). The final histopathologic stage was regarded as the gold standard. RESULTS: Nodal metastases were identified in 18/142 (12.6%) of mpMRI-cognitive/software fusion biopsy patients and 8/62 (12.9%) of the in-bore biopsy patients. In the mpMRI-cognitive/software fusion biopsy group, tumor size/core size (%) of targeted biopsy cores and positive core percentage on systematic biopsy were significant parameters for lymph node metastasis based on univariate logistic regression analyses (p < 0.05). With the modifications of these parameters for the in-bore biopsy group, V1 modification of the Briganti 2019 nomogram provided 100% sensitivity and 31.5% specificity (AUC:0.627), while V2 modification provided 75% sensitivity and 46.3% specificity (AUC:0.645). CONCLUSIONS: Briganti 2019 nomogram may be modified by utilizing tumor size/core size (%) for targeted biopsy cores instead of positive core percentage on systematic biopsy or by not taking both parameters into consideration to detect node metastasis risk of patients diagnosed with in-bore biopsies.

The role of the size and number of index lesion in the diagnosis of clinically significant prostate cancer in patients with PI-RADS 4 lesions who underwent in-bore MRI-guided prostate biopsy.

PURPOSE: To evaluate the contribution of the size and number of the sampled lesions to the diagnosis of clinically significant prostate cancer (CSPC) in patients who had PI-RADS 4 lesions. METHODS: In this retrospective study, a total of 159 patients who had PI-RADS 4 lesions and underwent In-bore MRI-Guided prostate biopsy were included. Patients with a lesion classified as Grade Group 2 and above were considered to have CSPC. Univariate and multivariate regression analyses were used to evaluate the factors affecting the diagnosis of prostate cancer (PCa) and CSPC. RESULTS: A great majority (86.8%) of the patients were biopsy-naïve. About three-fourths (71.7%) had PCa, and half (54.1%) had CSPC. When the patients were divided into three groups according to the index lesion size (< 5 mm, 5-10 mm, and > 10 mm), the prevalence of PCa was 64.3, 67.5, and 82.4% and the prevalence of CSPC was 42.9, 51.2, and 64.7%, respectively. In multivariate analysis, age, index lesion size, prostate volume (< 50 ml) and being biopsy-naïve were found significant for PCa, while age and prostate volume (< 50 ml) were significant for CSPC. CONCLUSION: The number of lesions was found to be insignificant in predicting PCa and CSPC. While the size of PI-RADS 4 lesions was significant in predicting PCa, it had no significance in detecting CSPC.

Histologically benign PI-RADS 4 and 5 lesions contain cancer-associated epigenetic alterations.

BACKGROUND: The detection rate of clinically significant prostate cancer has improved with the use of multiparametric magnetic resonance imaging (mpMRI). Yet, even with MRI-guided biopsy 15%-35% of high-risk lesions (Prostate Imaging-Reporting and Data System [PI-RADS] 4 and 5) are histologically benign. It is unclear if these false positives are due to diagnostic/sampling errors or pathophysiological alterations. To better understand this, we tested histologically benign PI-RAD 4 and 5 lesions for common malignant epigenetic alterations. MATERIALS AND METHODS: MRI-guided in-bore biopsy samples were collected from 45 patients with PI-RADS 4 (n = 31) or 5 (n = 14) lesions. Patients had a median clinical follow-up of 3.8 years. High-risk mpMRI patients were grouped based on their histology into biopsy positive for tumor (BPT; n = 28) or biopsy negative for tumor (BNT; n = 17). From these biopsy samples, DNA methylation of well-known tumor suppressor genes (APC, GSTP1, and RARß2) was quantified. RESULTS: Similar to previous work we observed high rates of promoter methylation at GSTP1 (92.7%), RARß2 (57.3%), and APC (37.8%) in malignant BPT samples but no methylation in benign TURP chips. Interestingly, similar to the malignant samples the BNT biopsies also had increased methylation at the promoter of GSTP1 (78.8%) and RARß2 (34.6%). However, despite these epigenetic alterations none of these BNT patients developed prostate cancer, and those who underwent repeat mpMRI (n = 8) demonstrated either radiological regression or stability. CONCLUSIONS: Histologically benign PI-RADS 4 and 5 lesions harbor prostate cancer-associated epigenetic alterations.

The clinical impact of Prostate Imaging-Reporting and Data System classification in patients with haemospermia undergoing multiparametric magnetic resonance imaging of the prostate.

In this study, we evaluated the role of the Prostate Imaging-Reporting and Data System (PI-RADS) classification of multiparametric magnetic resonance imaging (mpMRI) to determine the likelihood of prostate cancer (PCa) in patients with haemospermia. Fifty-one patients presenting with haemospermia between 2018 and 2020 were included in this retrospective study. Forty-two of the patients (82.4%) were over 40 years, and the median prostate-specific antigen (PSA) level was 1.4 ng/ml. Fourteen of the patients (27.5%) had recurrent haemospermia. All patients underwent mpMRI, and assessments were classified according to PI-RADS v2. The mpMRI revealed PI-RADS one to four lesions in 10 (19.6%), 30 (58.8%), 6 (11.8%) and 5 (9.8%) patients respectively. One patient with PI-RADS 3 and five with PI-RADS 4 lesions underwent cognitive fusion prostate biopsy depending on MRI findings, and two patients with PI-RADS 4 lesions were diagnosed with PCa. Patients with haemospermia and risk factors, that is aged over 40 years, a high PSA level or familial history of PCa, need a more thorough evaluation with mpMRI.

Can Extraprostatic Extension Be Predicted by Tumor-Capsule Contact Length in Prostate Cancer? Relationship With International Society of Urological Pathology Grade Groups.

OBJECTIVE. The objective of our study was to evaluate the relationship between the tumor-capsule contact length, defined as tumor contact length (TCL), and extraprostatic extension (EPE) using the MRI-based TCL measurements and the real TCL measurements from pathology and to determine whether the International Society of Urological Pathology (ISUP) grade group of the tumors influenced this relationship. MATERIALS AND METHODS. In this retrospective study, we reviewed prostate multiparametric MRI (mpMRI) studies performed between 2012 and 2018 of 1576 patients and found that 134 patients also underwent radical prostatectomy (RP) after mpMRI. Finally, 86 patients with index lesions in contact with the prostate capsule in RP specimens were enrolled in the study. ROC analysis was used to evaluate the cutoff values of TCLs measured at pathology and TCLs measured on MRI in terms of EPE according to ISUP grade groups. RESULTS. There was no statistically significant cutoff value for pathology-based TCL measurements in individual ISUP grade groups and subgroups. Although not statistically significant, pathology-based TCL cutoff values decreased (from 21.0 to 11.0 mm) as ISUP grade group increased in terms of EPE positivity. When the relationship between MRI-based TCL measurements and EPE was considered, statistically significant cutoff values (range, 14.5-16.6 mm) could be determined in many groups and subgroups with low ISUP grades (sensitivity, 66.7-100%; specificity, 52.8-93.0%; p = 0.006-0.042). However, no statistically significant cutoff value was found for high ISUP grades. CONCLUSION. ISUP grade groups may have an effect on the TCL-EPE relationship. When the MRI-based TCL and EPE relationship is evaluated independent of ISUP grade group, a cutoff value around 15-16 mm may be usable to predict EPE.

Do we need to clamp the renal hilum liberally during the initial phase of the learning curve of robot-assisted nephron-sparing surgery?

OBJECTIVE: We aimed to compare the results of our initial robot-assisted nephron-sparing surgeries (RANSS) performed with or without hilar clamping. MATERIAL AND METHOD: Charts of the initial RANSSs (n = 44), which were performed by a single surgeon, were retrospectively reviewed. R.E.N.A.L. nephrometry system, modified Clavien classification, and M.D.R.D. equation were used to record tumoral complexity, complications, and estimated glomerular filtration rate (eGFR), respectively. Outcomes of the clamped (group 1, n = 14) versus off-clamp (group 2, n = 30) RANSSs were compared. RESULTS: The difference between the two groups was insignificant regarding mean patient age, mean tumor size, and mean R.E.N.A.L. nephrometry score. Mean operative time, mean estimated blood loss amount, and mean length of hospitalization were similar between groups. A total of 4 patients in each group suffered 11 Clavien grade ≥ 2 complications early postoperatively. Open conversion rates were similar. The difference between the 2 groups in terms of the mean postoperative change in eGFR was insignificant. We did not encounter any local recurrence after a mean follow-up of 18.9 months. CONCLUSIONS: Creating warm-ischemic conditions during RANSS should not be a liberal decision, even in the initial phases of the learning curve for a highly experienced open surgeon.

Natural history of PIRADS-2 lesions on serial multiparametric magnetic resonance imaging: Real-life data from an Academic Center.

INTRODUCTION/BACKGROUND: The natural history of prostate imaging reporting and data system (PIRADS) score 2 lesions on serial mpMRIs is largely unknown. Herein, we aimed to evaluate the patients with PIRADS-2 index lesions by using serial mpMRI scans to reveal the rates of mpMRI upgrade in PIRADS score and prostate cancer (PCa) detection. METHODS/MATERIALS: All mpMRI scans with a PIRADS-2 index lesion from our mpMRI database were evaluated retrospectively. Data from 214 biopsy-naïve patients with a PIRADS-2 index lesion on the initial mpMRI who then underwent at least 1 follow-up mpMRI were reevaluated by an experienced uroradiologist and only those (n = 172) who had a PIRADS-2 index lesion on the initial mpMRI according to PIRADS v2.1 were included in the study. mpMRI progression was defined as the detection of any PIRADS ≥3 lesion at follow-up mpMRI. Histopathological results were evaluated in patients undergoing biopsy upon mpMRI progression. RESULTS: A total of 172 patients with a mean age of 60.1 ± 8.6 years were evaluated. The median PSA at baseline mpMRI was 4.7 (IQR; 3.3-6.7) ng/dl. Overall mpMRI progression was detected in 54 patients (31.4%), 37 were upgraded to PIRADS-3, 16 to PIRADS-4, and one to PIRADS-5. Multivariate logistic regression analysis revealed that a PSA increase of ≥25% during follow-up was the only predictor of mpMRI upgrade (P = 0.019, OR: 2.384). 30 out of 54 patients underwent a prostate biopsy and PCa was detected in 15 patients; 5 with ISUP grade 1, 10 with ISUP grade 2. CONCLUSIONS: Almost half of the patients with a PIRADS-2 index lesion were upgraded to PIRADS ≥3 when evaluated with serial mpMRI when a PSA increase of ≥25% was observed during follow-up. PCa was detected in half of the patients who underwent a biopsy. Serial mpMRI can be recommended when monitoring patients with elevating PSA ≥25%, a prostate biopsy can be considered upon a mpMRI progression.

Machine learning prediction of Gleason grade group upgrade between in-bore biopsy and radical prostatectomy pathology.

This study aimed to enhance the accuracy of Gleason grade group (GG) upgrade prediction in prostate cancer (PCa) patients who underwent MRI-guided in-bore biopsy (MRGB) and radical prostatectomy (RP) through a combined analysis of prebiopsy and MRGB clinical data. A retrospective analysis of 95 patients with prostate cancer diagnosed by MRGB was conducted where all patients had undergone RP. Among the patients, 64.2% had consistent GG results between in-bore biopsies and RP, whereas 28.4% had upgraded and 7.4% had downgraded results. GG1 biopsy results, lower biopsy core count, and fewer positive cores were correlated with upgrades in the entire patient group. In patients with GG > 1 , larger tumor sizes and fewer biopsy cores were associated with upgrades. By integrating MRGB data with prebiopsy clinical data, machine learning (ML) models achieved 85.6% accuracy in predicting upgrades, surpassing the 64.2% baseline from MRGB alone. ML analysis also highlighted the value of the minimum apparent diffusion coefficient ( ADC min ) for GG > 1 patients. Incorporation of MRGB results with tumor size, ADC min value, number of biopsy cores, positive core count, and Gleason grade can be useful to predict GG upgrade at final pathology and guide patient selection for active surveillance.

Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process.

BACKGROUND: Nephrometric scoring systems aim to improve the manner in which tumoral complexity is measured and reported. Each system provides a way to objectively measure specific tumor features that influence technical feasibility. In this study we aimed to determine how nephrometric scoring systems tailored our approach to the surgical treatment of localised renal masses. METHODS: Charts of the patients with localised renal tumors, who were managed by either open or robot-assisted nephron-sparing surgery between May 2010 and June 2012, were retrospectively reviewed. Nephrometric scores [radius, exophytic/endophytic, nearness, anterior/posterior, location (R.E.N.A.L.) score, preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification and centrality index (C-index)] were calculated based on preoperative imaging findings. Perioperative data were recorded. Morphometric characteristics of the renal masses were compared. Additionally, the difference between surgical alternative subgroups in terms of morphometric variables and the predictive power of each scoring system in determining the details of the surgical plan were investigated. Furthermore, surgical preferences in different nephrometric categories were compared. RESULTS: Mean R.E.N.A.L. and P.A.D.U.A. scores of the tumors treated with robotic surgery were significantly lower than those managed by open surgery. R.E.N.A.L. nephrometry score showed significant differences between most of the surgical alternative subgroups. P.A.D.U.A. and C-index differences were significant only between robotic off-clamp and open clamped cases. Tumors that required open conversion had significantly higher mean R.E.N.A.L. and P.A.D.U.A. score. High R.E.N.A.L. score (cut-off: 6.5) and high P.A.D.U.A. score (cut-off: 7.5) were found to be significant predictors of the surgical route. Significantly more tumors with moderate R.E.N.A.L. score were managed through the open approach, while the significant majority of those with low R.E.N.A.L. and low P.A.D.U.A. score were operated by robotic assistance. CONCLUSIONS: R.E.N.A.L. and P.A.D.U.A. scores influenced our surgical treatment strategy for localized renal masses. High R.E.N.A.L. and P.A.D.U.A. scores increased the likelihood of an open NSS.

Intraoperative Frozen Section via Neurosafe During Robotic Radical Prostatectomy in the Era of Preoperative Risk Stratifications and Primary Staging With mpMRI and PSMA-PET CT: Is There a Perfect Candidate?

BACKGROUND: We aimed to analyze the effect of preoperative risk assessment including Ga-68 PSMA PET and multiparametric magnetic resonance imaging (mpMRI) on nerve sparing practices, positive surgical margin (PSM) rates and oncological outcomes based on a comparison between patients underwent RARP with and without Neurosafe (NS). METHODS: Patients underwent RARP with NS (RARP-NS) or without (RARP-only) NS retrospectively evaluated. Suspicion for extracapsular extension on mpMRI and/or Ga-68 PSMA PET was recorded as i(imaging)T3. NS was performed according to the Martini-Klinik technique. PSM at preserved bundle side were called PSM at region of interest (ROI) while the others were elsewhere. RESULTS: A total of 208 patients (90 in RARP-NS, 118 in RARP-only groups) were included. Preoperatively the RARP-only group showed significantly higher mean PSA (p = .01) and PIRADS 5 (p = .002) findings and had more D'Amico high risk (DAHR) patients (p = .08). The overall PSM rates for pT2 versus pT3 disease were 7.5% versus 21.6 and 15.6% versus 55% in RARP-NS and RARP-only groups, respectively. NS resulted in more bilaterally preserved bundles (81.1% vs. 66.3%) and less PSM at the ROI (3.3% vs. 23.4%) than RARP-only group. NS outperformed RARP-only in all clinical settings had its highest differential benefit in more bilateral nerve sparing and less PSM at ROI in patients with both DAHR and iT3 disease. BCR rates were 2.2% and 2.5% for RARP-NS and RARP only groups, respectively (p = .4). One patient in RARP-NS and 9 in RARP-only groups had PSA persistence (p = .02). CONCLUSION: RARP-NS led to more preserved bundles with less PSM. It was especially useful in DAHR patients with preoperative extracapsular extension suspicion in imaging simultaneously.

Pathological Accuracy in Prostate Cancer: Single-Center Outcomes of 3 Different Magnetic Resonance Imaging-Targeted Biopsy Techniques and Random Systematic Biopsy.

OBJECTIVE: The aim of this study is to compare systematic, cognitive fusion, in-bore, and software fusion prostate biopsies regarding rates of and risk factors for pathological upgrading. MATERIAL AND METHODS: Charts of 291 patients with systematic biopsy (n = 105), magnetic resonance imaging- targeted cognitive fusion (n = 58), in-bore (n = 68), and software fusion biopsy (n = 60), and who subsequently underwent radical prostatectomy were retrospectively evaluated. The degree of similarity between the grade groups reported in the biopsy and radical prostatectomy pathology results was recorded. Analyses of the associated factors for concordance and discordance were performed with univariate and multivariate methods. RESULTS: The concordance rates were as follows: systematic biopsy = 42.8%, cognitive fusion-targeted biopsy = 50%, in-bore fusion-targeted biopsy = 61.8, and software fusion biopsy = 58.4%. The upgrade rate of systematic biopsy (46.6%) was higher than cognitive fusion-targeted biopsy (27.6%), in-bore fusiontargeted biopsy (26.4%), and software fusion-targeted biopsy (18.3%). The number of positive cores was significantly associated with grade group concordance for the systematic biopsy group (P = .040). Within the cognitive fusion-targeted biopsy cohort, number of positive cores was the only parameter that exhibited a significant association with grade group concordance in multivariate analysis (P = .044). Considering the in-bore fusion-targeted biopsy group, maximum tumor length was statistically significant (P = .021). In the software fusion-targeted biopsy group, low prostate volume was found to be the only significant predictor for grade group accordance (P = .021). CONCLUSION: Magnetic resonance imaging-targeted biopsy techniques showed higher concordance and lower upgrade rates compared to systematic biopsy. For systematic biopsy and cognitive fusion-targeted biopsy, the number of positive cores was associated with grade group concordance, while maximum tumor length in in-bore fusion-targeted biopsy and low prostate volume for in-bore fusion-targeted biopsy were associated with grade group concordance. Among the MRI-targeted biopsy methods, in-bore fusion-targeted biopsy and software fusion-targeted biopsy were more accurate than cognitive fusion-targeted biopsy in terms of grade group.

Spontaneous pyogenic spinal epidural abscess.

AIM: Spontaneous pyogenic spinal epidural abscess (SEA) is a rare condition but might be devastating and fatal. Traditional treatment is surgical decompression and antibiotics. A retrospective study was designed to assess the eff ect of clinical findings and treatment methods on the outcome. MATERIAL AND METHODS: 14 patients were reviewed (10 male, 4 female, mean age 59.14). Six dorsal, seven ventral and one dorsal with ventral SEA were observed. SEA found in thoracal (5), lumbar (4), cervical (3) regions. One patient showed both cervical and thoracal and one patient showed cervical, thoracal and lumbar involvement. All patients received minimum 3 weeks of I.V., followed by minimum 3 weeks of oral antibiotics. All patients complained of spinal pain. Ten patients presented with fever. Neurological deficit was observed in 9 cases. RESULTS: A total of 22 interventions was performed. Instrumentation was applied in 5 cases. Full recovery was achieved in 7 patients, significant improvement was observed in 5 patients. The neurological findings did not change in one patient. One mortality and one morbidity were observed. CONCLUSION: Spontaneous SEA is a rare disease but might result in catastrophic neurological deficits and fatal even with prompt treatment. Therefore, one should always keep SEA in mind if a patient presents with fever, vague and spinal pain.

In-bore MRI-guided prostate biopsy in a patient group with PI-RADS 4 and 5 targets: A single center experience.

PURPOSE: To determine the diagnostic yield of magnetic resonance imaging (MRI) guided in-bore biopsy in patients with high likelihood multiparametric MRI (mpMRI) findings, regarding overall and clinically significant prostate cancer (csPCa) detection rates and concordance of biopsy and radical prostatectomy (RP) Gleason scores (GS). METHODS: This retrospective study consisted of 277 Prostate Imaging Reporting and Data System (PI-RADS) assessment category 4 and 5 targets in 246 patients (mean age, 65.7 years; median prostate specific antigen value, 7.75 ng/mL) who had undergone in-bore biopsy at our institution between 2012 and 2020. Eighty-one patients who underwent RP were eligible for the concordance analysis of biopsy and RP specimen GS. RESULTS: Overall PCa detection rates were 80.5 % per patient (198/246) and 78 % per target (216/277) and 83.5 % and 67.4 % in primary (biopsy naive) and secondary (at least one negative prior biopsy) settings. csPCa was found in 63 % overall, 66 % of patients (132/200) in the primary, and 50 % of patients (23/46) in the secondary biopsy settings (p < 0.001). The prostate cancer detection rate was 68 % and 92 % in PI-RADS 4 and 5, respectively (p < 0.001). In the radical prostatectomy subcohort, 27.2 % of patients were upgraded, 8.6 % of patients were downgraded from needle biopsy. Significant complications occurred in 1.2 % of patients. CONCLUSIONS: MRI-guided in-bore prostate biopsy has a high detection rate of csPCa in primary and secondary biopsy cohorts. Biopsy results were satisfactory in terms of the number of positive cores, cancer percentage in positive cores, and concordance of GS in needle biopsy and RP specimen.

Diagnostic ability of Ga-68 PSMA PET to detect dominant and non-dominant tumors, upgrading and adverse pathology in patients with PIRADS 4-5 index lesions undergoing radical prostatectomy.

BACKGROUND: To evaluate the additive role of Ga-68 PSMA PET as a primary staging tool in patients bearing prostate cancer in single PIRADS 4 or 5 index lesions. METHODS: Eighty-one biopsy-naive patients with preoperative mpMRI and Ga-68 PSMA PET who underwent radical prostatectomy (RP) were evaluated retrospectively. Forty-nine patients had PIRADS 4 and 32 had PIRADS 5 index lesions. The localization, grade, and volumetric properties of dominant (DT) and non-dominant tumors (NDT) in RP were compared to the index lesions of mpMRI and Ga-68 PSMA PET. RESULTS: The median age and PSA level were 62 (IQR; 59-69) years and 7 (IQR; 2-8) ng/ml, respectively. Ga-68 PSMA PET detected DTs in 100% of the patients including 13 patients in whom mpMR failed. In 45 patients an NDT was reported in RP. Ga-68 PSMA PET accurately detected NDT in 24 of 45 (53.3%) patients. Six patients (12.2%) in PIRADS 4 and 8 (25%) in PIRADS 5 group showed upgrading. In PIRADS 4, Ga-68 PSMA PET localized DT in all patients with upgraded tumors whereas mpMRI missed exact location in 2 of 6 (33.3%). In PIRADS 5 both mpMRI and Ga-68 PSMA PET accurately located all DTs. Overall detection rates of extracapsular extension (ECE) and seminal vesicle invasion (SVI) by mpMRI were 51.1% and 53.8%, respectively. Ga-68 PSMA PET detected ECE and SVI in 27.9% and 30.7%, respectively. When mpMRI and Ga-68 PSMA PET were used in combination detection rates of ECE and SVI increased to 65.1 and 61.5%. Ga-68 PSMA PET-detected six of ten patients with positive lymph nodes whereas mpMRI could not identify any. CONCLUSIONS: Ga-68 PSMA PET has a better diagnostic accuracy in detecting DT, NDT, upgrading, adverse pathology in patients with PIRADS 4 index lesions. However, mpMRI better predicted ECE and SVI than Ga-68 PSMA PET.

Discal cysts of the lumbar spine: report of five cases and review of the literature.

Discal cysts are rare causes of low back pain and radiculopathy. Only few reports in the literature describe these pathologies. In this article, the authors report five cases (3 males and 2 females) of lumbar discal cysts treated surgically by microdiscectomy. These patients were admitted with a history of back pain and/or sciatalgia. Magnetic resonance imaging of the lumbar spine of all patients revealed lumbar discal cysts, causing compression to the spinal dura and roots. All patients were treated by partial hemilaminectomy and microscopic cyst resection. Postoperatively, the complaints showed improvement, and the patients were discharged with no complications. The cases of lumbar discal cysts are described in the literature as individual case reports, therefore; the authors performed a wide systemic review of all these cases published in PubMed and MedLine, including the patients in the present report. The data of all patients were analyzed to obtain statistically based estimated information about the incidence, the epidemiology, the natural history and the optimum management of these lesions.

Accuracy of Sampling PI-RADS 4-5 Index Lesions Alone by MRI-guided In-bore Biopsy in Biopsy-naive Patients Undergoing Radical Prostatectomy.

BACKGROUND: Targeting multiparametric magnetic resonance imaging (MP-MRI)-suspicious regions alone in biopsy-naive patients is not common practice, since it may miss clinically significant prostate cancer (PCa). OBJECTIVE: To investigate the accuracy of in-bore MRI-guided biopsy of Prostate Imaging Reporting and Data System (PI-RADS) 4 and 5 index lesions alone in biopsy-naive patients undergoing radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS: A total of 170 patients underwent MRI-guided in-bore biopsy for PI-RADS 4 and 5 index lesions alone between 2013 and 2018, of whom 136 patients were diagnosed with PCa. Fifty-two patients without prior biopsy who underwent RP were included in this study. MP-MRI findings, biopsy results, and whole-mount step-section specimen evaluation were retrospectively analyzed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Continuous variables were reported as mean (standard deviation) or median (range). Differences in parametric variables were calculated by Student t test. RESULTS AND LIMITATIONS: Overall International Society of Urological Pathology grade group (GG) up- and downgrading rates were 23.0% and 7.6% per patient and 24.5% and 6.5% per focus, respectively. Ten of 12 biopsy-detected GG 1 foci were upgraded in the final pathology. In 30 patients, a total of 43 different tumor foci were identified outside the sampled index lesion. Average biopsied and nonbiopsied tumor volumes were found to be 2.02 and 0.45 cm³, respectively (p < 0.001). The index lesion was the largest focus of tumor in all patients' final histopathological examination; upgrading was identified in only one nonbiopsied focus in a single patient. Limitations include retrospective design and nonstandard indications of in-bore MRI biopsy. CONCLUSIONS: In-bore MRI-guided biopsy of PI-RADS 4-5 index lesions alone in biopsy-naive patients is a safe and accurate diagnostic modality allowing appropriate patient selection for individualized treatment. PATIENT SUMMARY: In-bore magnetic resonance imaging-guided prostate biopsy of suspicious lesions alone allows accurate risk stratification of patients and reduces the detection of insignificant prostate cancer.

The role of T2-weighted images in assessing the grade of extraprostatic extension of the prostate carcinoma.

PURPOSE: Extraprostatic extension (EPE) is an unfavorable prognostic factor and the grade of EPE is also shown to be correlated with the prognosis of prostate cancer. The current study assessed the value of prostate magnetic resonance imaging (MRI) in measuring the radial distance (RD) of EPE and the role of T2 WI signs in predicting the grade of EPE. MATERIALS AND METHODS: A total of 110 patients who underwent prostate MRI before radical prostatectomy are enrolled in this retrospective study. Eighty-four patients have organ confined disease and the remaining twenty-six patients have EPE all verified by histopathology. Prostate MRI examinations were conducted with 3T MRI scanner and phased array coil with the following sequences: T2 WI, T1 WI, DCE, DWI with ADC mapping, and high b-value at b = 1500 s/mm2. The likelihood of EPE with 5-point Likert scale was assigned, several MRI features were extracted for each dominant tumor identified by using T2 WI. Tumors with Likert scales 4-5 were evaluated further to obtain MRI-based RD. The relationship between pathological and MRI-determined RD was tested. Univariate and multivariate logistic regression models were developed to detect the grade of pathological EPE. The inputs were among the 2 clinical parameters and 4 MRI features. RESULTS: There is a moderate correlation between pathological RD and MRI-determined RD (ρ = 0.45, P < 0.01). In univariate and multivariate models, MRI features and clinical parameters possess varying significance levels (univariate models; P = 0.048-0.788, multivariate models; P = 0.173-0.769). Multivariate models perform better than the univariate models by offering fair to good performances (AUC = 0.69-0.85). The multivariate model that employs the MRI features offers better performance than the model employs clinical parameters (AUC = 0.81 versus 0.69). CONCLUSION: Co-existence of T2 WI signs provide higher diagnostic value even than clinical parameters in predicting the grade of EPE. Combined use of clinical parameters and MRI features deliver slightly superior performance than MRI features alone.

Idiopathic spinal cord herniation: case report and review of the literature.

BACKGROUND: Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive myelopathy frequently present in Brown-Séquard syndrome. Preoperative diagnosis can be made with magnetic resonance imaging (MRI). Many surgical techniques have been applied by various authors and are usually reversible by surgical treatment. METHODS: Case report and review of the literature. FINDINGS: A 45-year-old woman with Brown-Séquard syndrome underwent thoracic MRI, which revealed transdural spinal cord herniation at T8 vertebral body level. During surgery the spinal cord was reduced and the ventral dural defect was restorated primarily and reinforced with a thin layer of subdermal fat. The dural defect was then closed with interrupted stitches. RESULTS: Although neurologic status improved postoperatively, postsurgical MRI demonstrated swelling and abnormal T2-signal intensity in the reduced spinal cord. Review of the English language literature revealed 100 ISCH cases. CONCLUSIONS: ISCH is a rare clinical entity that should be considered in differential diagnosis of Brown-Séquard syndrome, especially among women in their fifth decade of life. Outcome for patients who initially had Brown-Séquard syndrome was significantly better than for patients who presented with spastic paralysis. Although progression of neurologic deficits can be very slow, reduction of the spinal cord and repair of the defect are crucial in stopping or reversing the deterioration.

Diagnostic Importance of Axial Loaded Magnetic Resonance Imaging in Patients with Suspected Lumbar Spinal Canal Stenosis.

OBJECTIVE AND BACKGROUND: To study the efficacy of lumbar (AL) magnetic resonance imaging (MRI) in patients with suspected lumbar spinal stenosis (LSS), with and without AL compression. Supine MRI is used in the assessment of patients with LSS. However, MRI findings may poorly correlate with neurologic findings because of the morphologic changes of the lumbar spinal canal between upright standing and supine positions. In patients without significant stenosis in routine lumbar MRI, by applying AL, MRI can show significant LSS. METHODS: This study included 103 consecutive patients (188 disc levels) who presented with neurogenic claudication with and without low back pain. AL was performed using a nonmagnetic compression device for 5 minutes. T1- and T2-weighted axial and sagittal sequences were obtained during AL applied to the spine. The dural sac cross-sectional area (DSCA) appeared to be narrow at each disc level of L4-5 to L5-S1 in all patients and was measured using T2-weighted images in routine supine and AL images. RESULTS: The groups included patients with a reduction in the DSCA (>15 mm2) according to patient age and DSCA in routine spine MRI. The mean DSCA of the disc levels without and with AL were 138 mm2 and 123 mm2, with a mean difference of 15 mm2 at L4-5, 134 mm2 and 125 mm2 and a mean difference of 9 mm2 at L5-S1, respectively. CONCLUSIONS: The use of AL MRI in patients with clinically suspected LSS could reduce the risk of misdiagnosis of stenosis, leading to inappropriate treatment.