Using Prostate Imaging-Reporting and Data System (PI-RADS) Scores to Select an Optimal Prostate Biopsy Method: A Secondary Analysis of the Trio Study.

BACKGROUND: While magnetic resonance imaging (MRI)-targeted biopsy (TBx) results in better prostate cancer (PCa) detection relative to systematic biopsy (SBx), the combination of both methods increases clinically significant PCa detection relative to either Bx method alone. However, combined Bx subjects patients to higher number of Bx cores and greater detection of clinically insignificant PCa. OBJECTIVE: To determine if prebiopsy prostate MRI can identify men who could forgo combined Bx without a substantial risk of missing clinically significant PCa (csPC). DESIGN, SETTING, AND PARTICIPANTS: Men with MRI-visible prostate lesions underwent combined TBx plus SBx. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcomes were detection rates for grade group (GG) ≥2 and GG ≥3 PCa by TBx and SBx, stratified by Prostate Imaging-Reporting and Data System (PI-RADS) score. RESULTS AND LIMITATIONS: Among PI-RADS 5 cases, nearly all csPCs were detected by TBx, as adding SBx resulted in detection of only 2.5% more GG ≥2 cancers. Among PI-RADS 3-4 cases, however, SBx addition resulted in detection of substantially more csPCs than TBx alone (8% vs 7.5%). Conversely, TBx added little to detection of csPC among men with PI-RADS 2 lesions (2%) relative to SBx (7.8%). CONCLUSIONS: While combined Bx increases the detection of csPC among men with MRI-visible prostate lesions, this benefit was largely restricted to PI-RADS 3-4 lesions. Using a strategy of TBx only for PI-RADS 5 and combined Bx only for PI-RADS 3-4 would avoid excess biopsies for men with PI-RADS 5 lesions while resulting in a low risk of missing csPC (1%). PATIENT SUMMARY: Our study investigated an optimized strategy to diagnose aggressive prostate cancer in men with an abnormal prostate MRI (magnetic resonance imaging) scan while minimizing the risk of excess biopsies. We used a scoring system for MRI scan images called PI-RADS. The results show that MRI-targeted biopsies alone could be used for men with a PI-RADS score of 5, while men with a PI-RADS score of 3 or 4 would benefit from a combination of MRI-targeted biopsy and systematic biopsy. This trial is registered at ClinicalTrials.gov as NCT00102544.

Why Does Magnetic Resonance Imaging-Targeted Biopsy Miss Clinically Significant Cancer?

PURPOSE: Multiple studies demonstrate magnetic resonance imaging (MRI)-targeted biopsy detects more clinically significant cancer than systematic biopsy; however, some clinically significant cancers are detected by systematic biopsy only. While these events are rare, we sought to perform a retrospective analysis of these cases to ascertain the reasons that MRI-targeted biopsy missed clinically significant cancer which was subsequently detected on systematic prostate biopsy. MATERIALS AND METHODS: Patients were enrolled in a prospective study comparing cancer detection rates by transrectal MRI-targeted fusion biopsy and systematic 12-core biopsy. Patients with an elevated prostate specific antigen (PSA), abnormal digital rectal examination, or imaging findings concerning for prostate cancer underwent prostate MRI and subsequent MRI-targeted and systematic biopsy in the same setting. The subset of patients with grade group (GG) ≥3 cancer found on systematic biopsy and GG ≤2 cancer (or no cancer) on MRI-targeted biopsy was classified as MRI-targeted biopsy misses. A retrospective analysis of the MRI and MRI-targeted biopsy real-time screen captures determined the cause of MRI-targeted biopsy miss. Multivariable logistic regression analysis compared baseline characteristics of patients with MRI-targeted biopsy misses to GG-matched patients whose clinically significant cancer was detected by MRI-targeted biopsy. RESULTS: Over the study period of 2007 to 2019, 2,103 patients met study inclusion criteria and underwent combined MRI-targeted and systematic prostate biopsies. A total of 41 (1.9%) men were classified as MRI-targeted biopsy misses. Most MRI-targeted biopsy misses were due to errors in lesion targeting (21, 51.2%), followed by MRI-invisible lesions (17, 40.5%) and MRI lesions missed by the radiologist (3, 7.1%). On logistic regression analysis, lower Prostate Imaging-Reporting and Data System (PI-RADSTM) score was associated with having clinically significant cancer missed on MRI-targeted biopsy. CONCLUSIONS: While uncommon, most MRI-targeted biopsy misses are due to errors in lesion targeting, which highlights the importance of accurate co-registration and targeting when using software-based fusion platforms. Additionally, some patients will harbor MRI-invisible lesions which are untargetable by MRI-targeted platforms. The presence of a low PI-RADS score despite a high PSA is suggestive of harboring an MRI-invisible lesion.

MRI-Targeted, Systematic, and Combined Biopsy for Prostate Cancer Diagnosis.

BACKGROUND: The use of 12-core systematic prostate biopsy is associated with diagnostic inaccuracy that contributes to both overdiagnosis and underdiagnosis of prostate cancer. Biopsies performed with magnetic resonance imaging (MRI) targeting may reduce the misclassification of prostate cancer in men with MRI-visible lesions. METHODS: Men with MRI-visible prostate lesions underwent both MRI-targeted and systematic biopsy. The primary outcome was cancer detection according to grade group (i.e., a clustering of Gleason grades). Grade group 1 refers to clinically insignificant disease; grade group 2 or higher, cancer with favorable intermediate risk or worse; and grade group 3 or higher, cancer with unfavorable intermediate risk or worse. Among the men who underwent subsequent radical prostatectomy, upgrading and downgrading of grade group from biopsy to whole-mount histopathological analysis of surgical specimens were recorded. Secondary outcomes were the detection of cancers of grade group 2 or higher and grade group 3 or higher, cancer detection stratified by previous biopsy status, and grade reclassification between biopsy and radical prostatectomy. RESULTS: A total of 2103 men underwent both biopsy methods; cancer was diagnosed in 1312 (62.4%) by a combination of the two methods (combined biopsy), and 404 (19.2%) underwent radical prostatectomy. Cancer detection rates on MRI-targeted biopsy were significantly lower than on systematic biopsy for grade group 1 cancers and significantly higher for grade groups 3 through 5 (P<0.01 for all comparisons). Combined biopsy led to cancer diagnoses in 208 more men (9.9%) than with either method alone and to upgrading to a higher grade group in 458 men (21.8%). However, if only MRI-target biopsies had been performed, 8.8% of clinically significant cancers (grade group ≥3) would have been misclassified. Among the 404 men who underwent subsequent radical prostatectomy, combined biopsy was associated with the fewest upgrades to grade group 3 or higher on histopathological analysis of surgical specimens (3.5%), as compared with MRI-targeted biopsy (8.7%) and systematic biopsy (16.8%). CONCLUSIONS: Among patients with MRI-visible lesions, combined biopsy led to more detection of all prostate cancers. However, MRI-targeted biopsy alone underestimated the histologic grade of some tumors. After radical prostatectomy, upgrades to grade group 3 or higher on histopathological analysis were substantially lower after combined biopsy. (Funded by the National Institutes of Health and others; Trio Study ClinicalTrials.gov number, NCT00102544.).

Rosai-Dorfman Disease: Manifestations Outside of the Head and Neck.

OBJECTIVE: Rosai-Dorfman disease (RDD) is an uncommon benign histiocytic disorder. Extranodal involvement occurs in 43% and most commonly involves the head and neck, skin, and bones. We review less common imaging findings outside the head and neck. CONCLUSION: The imaging manifestations of RDD overlap with a variety of neoplastic and nonneoplastic conditions. Confirmation of an RDD diagnosis is based on specific histologic features. Radiologic assessment is used to rule out multifocality on initial workup and to evaluate treatment response.

Improved Image Quality of Low-Dose CT Pulmonary Angiograms.

OBJECTIVE: The use of CT pulmonary angiography (CTPA) to evaluate for pulmonary embolism has been increasing, and carries a significant radiation dose. We evaluate image quality of lower-dose images, taking into account patient size as well as the effects of image postprocessing. METHODS: A total of 250 CTPAs were retrospectively reviewed. The following parameters were obtained: kVp, mA, dose length product, Hounsfield units (HU) with standard deviation in the main pulmonary artery, transverse scout measurement, and subjective image quality. RESULTS: Radiation dose decreased 55% by reducing kVp from 120 to 100, and 60% from 100 to 80 kVp. Radiation dose decreased 82% from 120 to 80 kVp. Noise increased 38% from 120 kVp to 100 kVp, and increased 23% from 100 kVp to 80 kVp. Adding an overlapped reconstructed image decreased noise by 16% to 21%. Despite the increase in image noise, diagnostic quality was significantly improved at 80 and 100 kVp, compared with 120 kVp, with an average subjective quality rating of 3.8, 4.0, and 3.2, respectively, and an average pulmonary artery density of 536, 423, and 278 HU. Even in larger patients, qualitative image quality was better at 100 kVp compared with 120 kVp, with an average quality rating of 3.6 versus 2.9, respectively. CONCLUSIONS: Radiation dose exposure can be easily reduced on CTPA by lowering kVp, which at the same time improves image quality. Studies using a lower kVp were of significantly higher diagnostic quality. This held true even in larger patients.

Sonography of female genital hernias presenting as labia majora masses.

Inguinal herniation of the ovary or uterus presenting as a labia majora mass is a rare congenital condition that may be complicated by strangulation, torsion, and infertility. A labial mass in a prepubertal female patient can represent an inguinal hernia, a hydrocele of the canal of Nuck, a congenital labial cyst, leiomyoma, an abscess, lipoma, or lymphangioma. With a large differential diagnosis and an often limited physical examination, imaging plays an importance diagnostic role. We present 3 cases in which a labial mass contained an ovary alone and both ovaries and the uterus. We demonstrate sonographic findings and discuss the utility of sonography in the diagnosis of genital hernias and in detecting potential complications.

Primary renal candidiasis: importance of imaging and clinical history in diagnosis and management.

OBJECTIVE: Primary renal candidiasis is rare but increasing in incidence. The purpose of this series is to provide imaging and clinical findings for diagnosing candidiasis and to discuss imaging in the management of this disease. METHODS: Ten sonographic, 8 retrograde pyelographic, 2 intravenous pyelographic, 2 antegrade pyelographic, and 2 computed tomographic examinations of 5 patients (4 adult male patients and 1 16-year-old female patient) were reviewed. RESULTS: The clinical presentation was variable. Sonography showed renal pelvic wall thickening (n = 5), echogenic debris (n = 4), and fungus balls (n = 2). Papillary necrosis (n = 4), filling defects due to debris (n = 3), and fungus balls (n = 2) were seen on retrograde pyelography. CONCLUSIONS: Untreated candidiasis may progress to fungus ball or abscess formation. Sonography is commonly used as the initial imaging procedure. Retrograde and antegrade pyelography are used for biopsy, diagnosis, and treatment. Awareness of this condition and knowledgeable imaging evaluation can help detect and define the site, infection severity, and subsequent therapy.

Effects of extensive splenomegaly in patients with myelofibrosis undergoing a reduced intensity allogeneic stem cell transplantation.

Changes in spleen size postallogeneic haematopoietic stem cell transplantation (HSCT) in patients with primary myelofibrosis have been poorly characterized. We analysed 10 patients with myelofibrosis and splenomegaly following a reduced-intensity allogeneic HSCT. All patients fully engrafted donor cells including five patients with extensive splenomegaly. Extensive splenomegaly was associated with a prolonged time to neutrophil and platelet recovery. In all 10 patients, a progressive reduction of splenomegaly was documented within 12 months post-transplant and paralleled the reduction of marrow fibrosis. These findings suggest that myelofibrosis patients with extensive splenomegaly may proceed with allogeneic HSCT without prior splenectomy.

Ultrasound-detected thyroid nodules in radiation-exposed patients: changes over time.

The relationship between radiation exposure and thyroid cancer is well known, but whether all irradiated patients should have thyroid ultrasounds is unresolved. We have performed follow-up ultrasound examinations of patients in a cohort who were exposed to conventional external radiation during 1939-63 for benign conditions of the head and neck area prior to their 16th birthday. Of 54 subjects who had normal radionuclide scans in 1974-76 and were reexamined in 1996-97 by thyroid ultrasonography, 42 remained eligible and 34 agreed to participate in the present ultrasound study. After an additional 4-8 years of follow-up and using an ultrasound machine with increased resolution, we found 160 nodules (in 33 of these 34 subjects), compared with 96 nodules (in 29 of the 34 subjects) detected in the previous examination. Only four of the new nodules were > or =10 mm. Of the previously diagnosed large (> or =10 mm) nodules, four nodules in four subjects resolved; nine nodules in six subjects regressed to <10 mm; 14 nodules in 13 subjects remained at > or =10 mm. The four new large nodules appeared in four subjects, and six small nodules increased to > or =10 mm in six other subjects. The total volume of the thyroid nodules decreased in the 13 subjects on thyroid hormone (by 0.20 cm(3)) and increased in the 21 subjects who were not (by 0.34 cm(3), p < 0.05 by unpaired t-test). In summary, thyroid nodules are extremely common in irradiated subjects. Many new ones may be observed over time, but most are small and seen because of the increased resolution of ultrasound machines. Compared to patients on no medication, nodules in patients on thyroid hormone tended to regress. Since FNA of all thyroid nodules in irradiated patients is not feasible, ultrasound is useful in identifying those lesions that are growing.