Focal therapy with high-intensity focused ultrasound for prostate cancer: 3-year outcomes from a prospective trial.

OBJECTIVE: To assess the oncological and functional outcomes of focal high-intensity focused ultrasound (HIFU) in treating localised prostate cancer (PCa), a 3-year prospective study was undertaken using periodic post-ablation saturation biopsies. PATIENTS AND METHODS: Men with two or fewer lesions of grade group (GG) ≤3 PCa were eligible for participation. Additional criteria included a prostate-specific antigen (PSA) level of ≤15 ng/mL, clinical T1c-T2, and a life expectancy of ≥10 years. The primary endpoint was failure-free survival (FFS), defined as absence of clinically significant PCa (csPCa) in- or out-of-field on protocol-mandated saturation biopsy, no whole-gland or systemic salvage treatment, PCa metastasis, or PCa-related death. Results are reported using two distinct definitions of csPCa: (i) the presence of any GG ≥2 and (ii) any GG ≥3 or core involvement of ≥6 mm. Secondary endpoints were functional patient-reported outcome measures addressing urinary, sexual, and bowel function. RESULTS: A total of 91 patients were included: six (7%) with GG1 and 85 (93%) with GG ≥2. In all, 83 (91%) underwent at least one follow-up biopsy. Biopsy attendance at 6, 12, and 36 months was 84%, 67%, and 51%, respectively. The FFS at these time points for any GG ≥2 PCa was 79% (95% confidence interval [CI] 80-88%), 57% (95% CI 48-69%) and 44% (95% CI 34-56%), respectively. Using the second definition, FFS were 88% (95% CI 81-95%), 70% (95% CI 61-81%) and 65% (95% CI 55-77%), respectively. The 3-year cancer-specific survival was 100%, and freedom from metastasis was 99%. Magnetic resonance imaging (MRI) (negative predictive value of up to 89%, 95% CI 84-93%) and relative decrease of PSA values (P = 0.4) performed poorly in detecting residual disease. Urinary and bowel assessment returned to baseline questionnaire scores within 3 months. In all, 17 (21%) patients reported meaningful worsening in erectile function. A significant decrease of PCa related anxiety was observed. CONCLUSIONS: Focal HIFU treatment for localised PCa shows excellent functional outcomes with half of the patients remaining cancer-free after 3 years. Whole-gland treatment was avoided in 81%. Early follow-up biopsies are crucial to change or continue the treatment modality at the right time, while the use of MRI and PSA in detecting PCa recurrence is uncertain.

Diagnostic performance of 68Ga-PSMA-11 PET/MRI-guided biopsy in patients with suspected prostate cancer: a prospective single-center study.

PURPOSE: Ultrasound-guided biopsy (US biopsy) with 10-12 cores has a suboptimal sensitivity for clinically significant prostate cancer (sigPCa). If US biopsy is negative, magnetic resonance imaging (MRI)-guided biopsy is recommended, despite a low specificity for lesions with score 3-5 on Prostate Imaging Reporting and Data System (PIRADS). Screening and biopsy guidance using an imaging modality with high accuracy could reduce the number of unnecessary biopsies, reducing side effects. The aim of this study was to assess the performance of positron emission tomography/MRI with 68Ga-labeled prostate-specific membrane antigen (PSMA-PET/MRI) to detect and localize primary sigPCa (ISUP grade group 3 and/or cancer core length ≥ 6 mm) and guide biopsy. METHODS: Prospective, open-label, single-center, non-randomized, diagnostic accuracy study including patients with suspected PCa by elevation of prostate-specific antigen (PSA) level and a suspicious lesion (PIRADS ≥3) on multiparametric MRI (mpMRI). Forty-two patients underwent PSMA-PET/MRI followed by both PSMA-PET/MRI-guided and section-based saturation template biopsy between May 2017 and February 2019. Primary outcome was the accuracy of PSMA-PET/MRI for biopsy guidance using section-based saturation template biopsy as the reference standard. RESULTS: SigPCa was found in 62% of the patients. Patient-based sensitivity, specificity, negative and positive predictive value, and accuracy for sigPCa were 96%, 81%, 93%, 89%, and 90%, respectively. One patient had PSMA-negative sigPCa. Eight of nine false-positive lesions corresponded to cancer on prostatectomy and one in six false-negative lesions was negative on prostatectomy. CONCLUSION: PSMA-PET/MRI has a high accuracy for detecting sigPCa and is a promising tool to select patients with suspicion of PCa for biopsy. TRIAL REGISTRATION: This trial was retrospectively registered under the name "Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI) Guided Biopsy in Men with Elevated PSA" (NCT03187990) on 06/15/2017 ( https://clinicaltrials.gov/ct2/show/NCT03187990 ).

[PI-RADS 2.1 and structured reporting of magnetic resonance imaging of the prostate]. / PI-RADS 2.1 und strukturierte Befundung der Magnetresonanztomographie der Prostata.

CLINICAL/METHODOLOGICAL ISSUE: The detection of clinically significant prostate cancers while simultaneously avoiding over-diagnosing tumors with low malignant potential is a challenge in clinical practice. STANDARD RADIOLOGICAL METHODS: Multiparametric prostate magnetic resonance imaging (MRI) in accordance with the Prostate Imaging Reporting and Data System (PI-RADS) guidelines is accepted as standard-of-care with both urologists and radiologists. METHODOLOGICAL INNOVATIONS: The PI-RADS guidelines have been updated to version 2.1, including revised technical recommendations and changes to the scoring of lesions. PERFORMANCE: The PI-RADS guidelines have had great impact on the standardization of multiparametric prostate MRI and offer templates for structured reporting. This simplifies communication with the referring physician. ACHIEVEMENTS: The new version 2.1 of the guidelines represents an evolutionary improvement of the widely accepted version 2.0. Several aspects of reporting have been revised-however, some pre-known limitations persist, which will require further refinement in the future.

External Validation and Comparison of Prostate Cancer Risk Calculators Incorporating Multiparametric Magnetic Resonance Imaging for Prediction of Clinically Significant Prostate Cancer.

PURPOSE: We sought to externally validate recently published prostate cancer risk calculators incorporating multiparametric magnetic resonance imaging to predict clinically significant prostate cancer. We also compared the performance of these calculators to that of multiparametric magnetic resonance imaging naïve prostate cancer risk calculators. MATERIALS AND METHODS: We identified men without a previous prostate cancer diagnosis who underwent transperineal template saturation prostate biopsy with fusion guided targeted biopsy between November 2014 and March 2018 at our academic tertiary referral center. Any Gleason pattern 4 or greater was defined as clinically significant prostate cancer. Predictors, which were patient age, prostate specific antigen, digital rectal examination, prostate volume, family history, previous prostate biopsy and the highest region of interest according to the PI-RADS™ (Prostate Imaging Reporting and Data System), were retrospectively collected. Four multiparametric magnetic resonance imaging prostate cancer risk calculators and 2 multiparametric magnetic resonance imaging naïve prostate cancer risk calculators were evaluated for discrimination, calibration and the clinical net benefit using ROC analysis, calibration plots and decision curve analysis. RESULTS: Of the 468 men 193 (41%) were diagnosed with clinically significant prostate cancer. Three multiparametric magnetic resonance imaging prostate cancer risk calculators showed similar discrimination with a ROC AUC significantly higher than that of the other prostate cancer risk calculators (AUC 0.83-0.85 vs 0.69-0.74). Calibration in the large showed 2% deviation from the true amount of clinically significant prostate cancer for 2 multiparametric magnetic resonance imaging risk calculators while the other calculators showed worse calibration at 11% to 27%. A clinical net benefit was observed only for 3 multiparametric magnetic resonance imaging risk calculators at biopsy thresholds of 15% or greater. None of the 6 investigated prostate cancer risk calculators demonstrated clinical usefulness against a biopsy all strategy at thresholds less than 15%. CONCLUSIONS: The performance of multiparametric magnetic resonance imaging prostate cancer risk calculators varies but they generally outperform multiparametric magnetic resonance imaging naïve prostate cancer risk calculators in regard to discrimination, calibration and clinical usefulness. External validation in other biopsy settings is highly encouraged.

Manual prostate cancer segmentation in MRI: interreader agreement and volumetric correlation with transperineal template core needle biopsy.

OBJECTIVES: To assess interreader agreement of manual prostate cancer lesion segmentation on multiparametric MR images (mpMRI). The secondary aim was to compare tumor volume estimates between MRI segmentation and transperineal template saturation core needle biopsy (TTSB). METHODS: We retrospectively reviewed patients who had undergone mpMRI of the prostate at our institution and who had received TTSB within 190 days of the examination. Seventy-eight cancer lesions with Gleason score of at least 3 + 4 = 7 were manually segmented in T2-weighted images by 3 radiologists and 1 medical student. Twenty lesions were also segmented in apparent diffusion coefficient (ADC) and dynamic contrast enhanced (DCE) series. First, 20 volumetric similarity scores were computed to quantify interreader agreement. Second, manually segmented cancer lesion volumes were compared with TTSB-derived estimates by Bland-Altman analysis and Wilcoxon testing. RESULTS: Interreader agreement across all readers was only moderate with mean T2 Dice score of 0.57 (95%CI 0.39-0.70), volumetric similarity coefficient of 0.74 (0.48-0.89), and Hausdorff distance of 5.23 mm (3.17-9.32 mm). Discrepancy of volume estimate between MRI and TTSB was increasing with tumor size. Discrepancy was significantly different between tumors with a Gleason score 3 + 4 vs. higher grade tumors (0.66 ml vs. 0.78 ml; p = 0.007). There were no significant differences between T2, ADC, and DCE segmentations. CONCLUSIONS: We found at best moderate interreader agreement of manual prostate cancer segmentation in mpMRI. Additionally, our study suggests a systematic discrepancy between the tumor volume estimate by MRI segmentation and TTSB core length, especially for large and high-grade tumors. KEY POINTS: • Manual prostate cancer segmentation in mpMRI shows moderate interreader agreement. • There are no significant differences between T2, ADC, and DCE segmentation agreements. • There is a systematic difference between volume estimates derived from biopsy and MRI.

Dynamic contrast enhancement in prostate MRI as predictor of erectile function and recovery after radical prostatectomy.

PURPOSE: To analyze routine preoperative prostate MRI to predict erectile function (EF) before and after radical prostatectomy (RP). METHODS: Patients who underwent RP with an existing preoperative MRI including dynamic contrast-enhanced images and completed International Index of Erectile Function (IIEF-5) questionnaires at baseline and 12 months postoperative. They were divided into four erectile dysfunction (ED) groups according to preoperative IIEF-5 score. The perfusion quality was measured in the peripheral zone of the prostate by the ratio of signal increase 120 s after wash-in of contrast agent (Ratio120) in preoperative MRI and compared between the ED groups. RESULTS: Ratio120 showed differences among the preoperative ED groups (p = .020) in 97 patients. According to IIEF-5 at 12 months postoperative, 43 patients were dichotomized into "no to mild" (≥17 points) and "moderate to severe" (≤16) ED groups. Ratio120 revealed differences among the postoperative ED groups (128.84% vs. 101.95%; p = .029) and stayed an independent predictor for ED in the multivariable regression analysis (adjusted for age, nerve-sparing and preoperative IIEF-5). ROC curves demonstrated an additional diagnostic benefit. CONCLUSIONS: Preoperative MRI of the prostate may be used for the prediction of EF and postsurgical recovery after RP. This may serve as important tool in preoperative patient counseling and management of expectations.

Diagnostic Accuracy of Multiparametric MRI versus 68Ga-PSMA-11 PET/MRI for Extracapsular Extension and Seminal Vesicle Invasion in Patients with Prostate Cancer.

Background Recent studies have reported the additive value of combined gallium 68 (68Ga)-labeled Glu-urea-Lys (Ahx)-HBED-CC ligand targeting the prostate-specific membrane antigen (PSMA) (hereafter called 68Ga-PSMA-11) PET/MRI for the detection and localization of primary prostate cancer compared with multiparametric MRI. Purpose To compare the diagnostic accuracy and interrater agreement of multiparametric MRI and 68Ga-PSMA-11 PET/MRI for the detection of extracapsular extension (ECE) and seminal vesicle infiltration (SVI) in patients with prostate cancer. Materials and Methods Retrospective analysis of 40 consecutive men who underwent multiparametric MRI and 68Ga-PSMA-11 PET/MRI within 6 months for suspected prostate cancer followed by radical prostatectomy between April 2016 and July 2018. Four readers blinded to clinical and histopathologic findings rated the probability of ECE and SVI at multiparametric MRI and PET/MRI by using a five-point Likert-type scale. The prostatectomy specimen served as the reference standard. Accuracy was assessed with a multireader multicase analysis and by calculating reader-average areas under the receiver operating characteristics curve (AUCs), sensitivity, and specificity for ordinal and dichotomized data in a region-specific and patient-specific approach. Interrater agreement was assessed with the Fleiss multirater κ. Results For multiparametric MRI versus PET/MRI in ECE detection, respectively, AUC, sensitivity, and specificity in the region-specific analysis were 0.67 and 0.75 (P = .07), 28% (21 of 76) and 47% (36 of 76) (P = .09), and 94% (529 of 564) and 90% (509 of 564) (P = .007). For the patient-specific analysis, AUC, sensitivity, and specificity were 0.66 and 0.73 (P = .19), 46% (22 of 48) and 69% (33 of 48) (P = .04), and 75% (84 of 112) and 67% (75 of 112) (P = .19), respectively. For multiparametric MRI versus PET/MRI in SVI detection, respectively, AUC, sensitivity, and specificity of the region-specific analysis were 0.66 and 0.74 (P = .21), 35% (seven of 20) and 50% (10 of 20) (P = .25), and 98% (295 of 300) and 94% (282 of 300) (P < .001). For the patient-specific analysis, AUC, sensitivity, and specificity were 0.65 and 0.79 (P = .25), 35% (seven of 20) and 55% (11 of 20) (P = .20), and 98% (137 of 140) and 94% (131 of 140) (P = .07), respectively. Interrater reliability for multiparametric MRI versus PET/MRI did not differ for ECE (κ, 0.46 vs 0.40; P = .24) and SVI (κ, 0.23 vs 0.33; P = .39). Conclusion Our results suggest that gallium 68 (68Ga)-labeled Glu-urea-Lys (Ahx)-HBED-CC ligand targeting the prostate-specific membrane antigen (PSMA) (68Ga-PSMA-11) PET/MRI and multiparametric MRI perform similarly for local staging of prostate cancer in patients with intermediate-to-high-risk prostate cancer. The increased sensitivity of 68Ga-PSMA-11 PET/MRI for the detection of extracapsular disease comes at the cost of a slightly reduced specificity. © RSNA, 2019.

Extensive Histological Sampling following Focal Therapy of Clinically Significant Prostate Cancer with High Intensity Focused Ultrasound.

PURPOSE: Clinically significant, localized prostate cancer is currently treated with whole gland therapy. This approach is effective but associated with genitourinary and rectal side effects. Focal therapy of prostate cancer has been proposed as an alternative. The aim of this study was to determine the oncologic and functional outcomes of focal high intensity focused ultrasound therapy of prostate cancer. MATERIALS AND METHODS: In this single center, prospective study 75 men were treated between April 2014 and April 2018. Multiparametric magnetic resonance imaging and transperineal template saturation prostate biopsy were performed to localize prostate cancer, followed by focal ablation with high intensity focused ultrasound. The study primary end point was the detection of clinically significant prostate cancer, defined as Gleason score 7 or greater, at 6-month followup transperineal template saturation prostate biopsy. Genitourinary side effects were of secondary interest. RESULTS: Median patient age was 67 years (IQR 60-71) and median prostate specific antigen was 5.87 ng/ml (IQR 4.65-7.44). There were 5 low risk (6.7%) and 70 intermediate risk (93.3%) cancers. Clinically significant prostate cancer was detected in 41% of the men (95% CI 30.3-53.0) who underwent biopsy at 6 months and the median number of sampled cores was 44 (IQR 36-44). Prostate specific antigen (OR 1.17, IQR 0.49-2.85, p=0.71) and multiparametric magnetic resonance imaging (14.3% sensitivity, IQR 6.7-31.5) performed poorly to predict positive biopsies. Pad-free continence and erection sufficient for penetration were preserved in 63 of 64 (98.4%) and 31 of 45 patients (68.9%), respectively. CONCLUSIONS: Focal therapy with high intensity focused ultrasound leads to a low rate of genitourinary side effects. Followup biopsy of treated and untreated prostates remains the only modality to adequately select men in need of early salvage treatment.

Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging and Fusion Guided Targeted Biopsy Evaluated by Transperineal Template Saturation Prostate Biopsy for the Detection and Characterization of Prostate Cancer.

PURPOSE: We evaluated the diagnostic accuracy of multiparametric magnetic resonance imaging and multiparametric magnetic resonance imaging/transrectal ultrasound fusion guided targeted biopsy against that of transperineal template saturation prostate biopsy to detect prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed the records of 415 men who consecutively presented for prostate biopsy between November 2014 and September 2016 at our tertiary care center. Multiparametric magnetic resonance imaging was performed using a 3 Tesla device without an endorectal coil, followed by transperineal template saturation prostate biopsy with the BiopSee® fusion system. Additional fusion guided targeted biopsy was done in men with a suspicious lesion on multiparametric magnetic resonance imaging, defined as Likert score 3 to 5. Any Gleason pattern 4 or greater was defined as clinically significant prostate cancer. The detection rates of multiparametric magnetic resonance imaging and fusion guided targeted biopsy were compared with the detection rate of transperineal template saturation prostate biopsy using the McNemar test. RESULTS: We obtained a median of 40 (range 30 to 55) and 3 (range 2 to 4) transperineal template saturation prostate biopsy and fusion guided targeted biopsy cores, respectively. Of the 124 patients (29.9%) without a suspicious lesion on multiparametric magnetic resonance imaging 32 (25.8%) were found to have clinically significant prostate cancer on transperineal template saturation prostate biopsy. Of the 291 patients (70.1%) with a Likert score of 3 to 5 clinically significant prostate cancer was detected in 129 (44.3%) by multiparametric magnetic resonance imaging fusion guided targeted biopsy, in 176 (60.5%) by transperineal template saturation prostate biopsy and in 187 (64.3%) by the combined approach. Overall 58 cases (19.9%) of clinically significant prostate cancer would have been missed if fusion guided targeted biopsy had been performed exclusively. The sensitivity of multiparametric magnetic resonance imaging and fusion guided targeted biopsy for clinically significant prostate cancer was 84.6% and 56.7% with a negative likelihood ratio of 0.35 and 0.46, respectively. CONCLUSIONS: Multiparametric magnetic resonance imaging alone should not be performed as a triage test due to a substantial number of false-negative cases with clinically significant prostate cancer. Systematic biopsy outperformed fusion guided targeted biopsy. Therefore, it will remain crucial in the diagnostic pathway of prostate cancer.

Detection of Clinically Significant Prostate Cancer: Short Dual-Pulse Sequence versus Standard Multiparametric MR Imaging-A Multireader Study.

Purpose To compare the diagnostic performance of a short dual-pulse sequence magnetic resonance (MR) imaging protocol versus a standard six-pulse sequence multiparametric MR imaging protocol for detection of clinically significant prostate cancer. Materials and Methods This HIPAA-compliant study was approved by the regional ethics committee. Between July 2013 and March 2015, 63 patients from a prospectively accrued study population who underwent MR imaging of the prostate including transverse T1-weighted; transverse, coronal, and sagittal T2-weighted; diffusion-weighted; and dynamic contrast material-enhanced MR imaging with a 3-T imager at a single institution were included in this retrospective study. The short MR imaging protocol image set consisted of transverse T2-weighted and diffusion-weighted images only. The standard MR imaging protocol image set contained images from all six pulse sequences. Three expert readers from different institutions assessed the likelihood of prostate cancer on a five-point scale. Diagnostic performance on a quadrant basis was assessed by using areas under the receiver operating characteristic curves, and differences were evaluated by using 83.8% confidence intervals. Intra- and interreader agreement was assessed by using the intraclass correlation coefficient. Transperineal template saturation biopsy served as the standard of reference. Results At histopathologic evaluation, 84 of 252 (33%) quadrants were positive for cancer in 38 of 63 (60%) men. There was no significant difference in detection of tumors larger than or equal to 0.5 mL for any of the readers of the short MR imaging protocol, with areas under the curve in the range of 0.74-0.81 (83.8% confidence interval [CI]: 0.64, 0.89), and for readers of the standard MR imaging protocol, areas under the curve were 0.71-0.77 (83.8% CI: 0.62, 0.86). Ranges for sensitivity were 0.76-0.95 (95% CI: 0.53, 0.99) and 0.76-0.86 (95% CI: 0.53, 0.97) and those for specificity were 0.84-0.90 (95% CI: 0.79, 0.94) and 0.82-0.90 (95% CI: 0.77, 0.94) for the short and standard MR protocols, respectively. Ranges for interreader agreement were 0.48-0.60 (83.8% CI: 0.41, 0.66) and 0.49-0.63 (83.8% CI: 0.42, 0.68) for the short and standard MR imaging protocols. Conclusion For the detection of clinically significant prostate cancer, no difference was found in the diagnostic performance of the short MR imaging protocol consisting of only transverse T2-weighted and diffusion-weighted imaging pulse sequences compared with that of a standard multiparametric MR imaging protocol. © RSNA, 2017 Online supplemental material is available for this article.

Comparison of Intravoxel Incoherent Motion Parameters across MR Imagers and Field Strengths: Evaluation in Upper Abdominal Organs.

Purpose To determine the reproducibility of intravoxel incoherent motion (IVIM) parameters measured in upper abdominal organs with magnetic resonance (MR) imagers from different vendors and with different field strengths. Materials and Methods This prospective study was approved by the independent ethics committees of Kanton Bern and Kanton Zurich, and signed informed consent was obtained from all participants. Abdominal diffusion-weighted images in 10 healthy men (mean age, 37 years ± 8 [standard deviation]) were acquired by using 1.5- and 3.0-T MR imagers from three different vendors. Two readers independently delineated regions of interest that were used to measure IVIM parameters (diffusion coefficient [Dt], perfusion fraction [Fp], and pseudodiffusion coefficient [Dp]) in the left and right lobes of the liver, and in the pancreas, spleen, renal cortex, and renal medulla. Measurement reproducibility between readers was assessed with intraclass correlation coefficients (ICCs). Variability across MR imagers was analyzed by using between- and within-subject coefficients of variation (CVs) and analysis of variance (ANOVA). Results Between-reader reproducibility was high for Dt (ICC, 94.6%), intermediate for Fp (ICC, 81.7%), and low for Dp (ICC, 69.5%). Between- and within-subject CVs of Dt were relatively high (>20%) in the left lobe of the liver and relatively low (<10%) in the renal cortex and renal medulla. CVs generally exceeded 15% for Fp values and 20% for Dp. ANOVA indicated significant differences (P < .05) between MR imagers. Conclusion IVIM parameters in the upper abdomen may differ substantially across MR imagers. (©) RSNA, 2015 Online supplemental material is available for this article.

Impact of the calculation algorithm on biexponential fitting of diffusion-weighted MRI in upper abdominal organs.

PURPOSE: To compare the variability, precision, and accuracy of six different algorithms (Levenberg-Marquardt, Trust-Region, Fixed-Dp , Segmented-Unconstrained, Segmented-Constrained, and Bayesian-Probability) for computing intravoxel-incoherent-motion-related parameters in upper abdominal organs. METHODS: Following the acquisition of abdominal diffusion-weighted magnetic resonance images of 10 healthy men, six distinct algorithms were employed to compute intravoxel-incoherent-motion-related parameters in the left and right liver lobe, pancreas, spleen, renal cortex, and renal medulla. Algorithms were evaluated regarding inter-reader and intersubject variability. Comparability of results was assessed by analyses of variance. The algorithms' precision and accuracy were investigated on simulated data. RESULTS: A Bayesian-Probability based approach was associated with very low inter-reader variability (average Intraclass Correlation Coefficients: 96.5-99.6%), the lowest inter-subject variability (Coefficients of Variation [CV] for the pure diffusion coefficient Dt : 3.8% in the renal medulla, 6.6% in the renal cortex, 10.4-12.1% in the left and right liver lobe, 15.3% in the spleen, 15.8% in the pancreas; for the perfusion fraction Fp : 15.5% on average; for the pseudodiffusion coefficient Dp : 25.8% on average), and the highest precision and accuracy. Results differed significantly (P < 0.05) across algorithms in all anatomical regions. CONCLUSION: The Bayesian-Probability algorithm should be preferred when computing intravoxel-incoherent-motion-related parameters in upper abdominal organs.

Systematic analysis of the intravoxel incoherent motion threshold separating perfusion and diffusion effects: Proposal of a standardized algorithm.

PURPOSE: To systematically evaluate the dependence of intravoxel-incoherent-motion (IVIM) parameters on the b-value threshold separating the perfusion and diffusion compartment, and to implement and test an algorithm for the standardized computation of this threshold. METHODS: Diffusion weighted images of the upper abdomen were acquired at 3 Tesla in eleven healthy male volunteers with 10 different b-values and in two healthy male volunteers with 16 different b-values. Region-of-interest IVIM analysis was applied to the abdominal organs and skeletal muscle with a systematic increase of the b-value threshold for computing pseudodiffusion D*, perfusion fraction Fp, diffusion coefficient D, and the sum of squared residuals to the bi-exponential IVIM-fit. RESULTS: IVIM parameters strongly depended on the choice of the b-value threshold. The proposed algorithm successfully provided optimal b-value thresholds with the smallest residuals for all evaluated organs [s/mm2]: e.g., right liver lobe 20, spleen 20, right renal cortex 150, skeletal muscle 150. Mean D* [10(-3) mm(2)/s], Fp [%], and D [10(-3) mm(2)/s] values (±standard deviation) were: right liver lobe, 88.7 ± 42.5, 22.6 ± 7.4, 0.73 ± 0.12; right renal cortex: 11.5 ± 1.8, 18.3 ± 2.9, 1.68 ± 0.05; spleen: 41.9 ± 57.9, 8.2 ± 3.4, 0.69 ± 0.07; skeletal muscle: 21.7 ± 19.0; 7.4 ± 3.0; 1.36 ± 0.04. CONCLUSION: IVIM parameters strongly depend upon the choice of the b-value threshold used for computation. The proposed algorithm may be used as a robust approach for IVIM analysis without organ-specific adaptation.

Interreader and inter-test agreement in assessing treatment response following transarterial embolization for hepatocellular carcinoma.

PURPOSE: To evaluate interreader and inter-test agreement in applying size- and necrosis-based response assessment criteria after transarterial embolization (TAE) for hepatocellular carcinoma (HCC), applying two different methods of European Association for the Study of the Liver (EASL) criteria. METHODS: Seventy-four patients (median age, 67 years) from a prospectively accrued study population were included in this retrospective study. Four radiologists independently evaluated CT data at 2-3 (1st follow-up, FU) and 10-12 (2nd FU) weeks after TAE and assessed treatment response using size-based (WHO, RECIST) and necrosis-based (mRECIST, EASL) criteria. Enhancing tissue was bidimensionally measured (EASLmeas) and also visually estimated (EASLest). Interreader and inter-test agreements were assessed using intraclass correlation coefficient (ICC) and κ statistics. RESULTS: Interreader agreement for all response assessment methods ranged from moderate to substantial (κ = 0.578-0.700) at 1st FU and was substantial (κ = 0.716-0.780) at 2nd FU. Inter-test agreement was substantial between WHO and RECIST (κ = 0.610-0.799, 1st FU; κ = 0.655-0.782, 2nd FU) and excellent between EASLmeas and EASLest (κ = 0.899-0.918, 1st FU; κ = 0.843-0.877, 2nd FU). CONCLUSION: Size- and necrosis-based criteria both show moderate to excellent interreader agreement in evaluating treatment response after TAE for HCC. Inter-test agreement regarding EASLmeas and EASLest was excellent, suggesting that either may be used. KEY POINTS: • Applying EASL criteria, visual estimation and bidimensional measurements show comparable interreader agreement. • EASL meas and EASL est show substantial interreader agreement for treatment response in HCC. • Agreement was excellent for EASL meas and EASL est after TAE of HCC. • Visual estimation of enhancement is adequate to assess treatment response of HCC.

Prostate cancer aggressiveness: assessment with whole-lesion histogram analysis of the apparent diffusion coefficient.

PURPOSE: To evaluate the relationship between prostate cancer aggressiveness and histogram-derived apparent diffusion coefficient (ADC) parameters obtained from whole-lesion assessment of diffusion-weighted magnetic resonance (MR) imaging of the prostate and to determine which ADC metric may help best differentiate low-grade from intermediate- or high-grade prostate cancer lesions. MATERIALS AND METHODS: The institutional review board approved this retrospective HIPAA-compliant study of 131 men (median age, 60 years) who underwent diffusion-weighted MR imaging before prostatectomy for prostate cancer. Clinically significant tumors (tumor volume > 0.5 mL) were identified at whole-mount step-section histopathologic examination, and Gleason scores of the tumors were recorded. A volume of interest was drawn around each significant tumor on ADC maps. The mean, median, and 10th and 25th percentile ADCs were determined from the whole-lesion histogram and correlated with the Gleason score by using the Spearman correlation coefficient (ρ). The ability of each parameter to help differentiate tumors with a Gleason score of 6 from those with a Gleason score of at least 7 was assessed by using the area under the receiver operating characteristic curve (Az). RESULTS: In total, 116 clinically significant lesions (89 in the peripheral zone, 27 in the transition zone) were identified in 85 of the 131 patients (65%). Forty-six patients did not have a clinically significant lesion. For mean ADC, median ADC, 10th percentile ADC, and 25th percentile ADC, the Spearman ρ values for correlation with Gleason score were -0.31, -0.30, -0.36, and -0.35, respectively, whereas the Az values for differentiating lesions with a Gleason score of 6 from those with a Gleason score of at least 7 were 0.704, 0.692, 0.758, and 0.723, respectively. The Az of 10th percentile ADC was significantly higher than that of the mean ADC for all lesions and peripheral zone lesions (P = .0001). CONCLUSION: When whole-lesion histograms were used to derive ADC parameters, 10th percentile ADC correlated with Gleason score better than did other ADC parameters, suggesting that 10th percentile ADC may prove to be optimal for differentiating low-grade from intermediate- or high-grade prostate cancer with diffusion-weighted MR imaging.

Diffusion-weighted MR imaging of upper abdominal organs: field strength and intervendor variability of apparent diffusion coefficients.

PURPOSE: To determine the variability of apparent diffusion coefficient (ADC) values in various anatomic regions in the upper abdomen measured with magnetic resonance (MR) systems from different vendors and with different field strengths. MATERIALS AND METHODS: Ten healthy men (mean age, 36.6 years ± 7.7 [standard deviation]) gave written informed consent to participate in this prospective ethics committee-approved study. Diffusion-weighted (DW) MR imaging was performed in each subject with 1.5- and 3.0-T MR systems from each of three vendors at two institutions. Two readers independently measured ADC values in seven upper abdominal regions (left and right liver lobe, gallbladder, pancreas, spleen, and renal cortex and medulla). ADC values were tested for interobserver differences, as well as for differences related to field strength and vendor, with repeated-measures analysis of variance; coefficients of variation (CVs) and variance components were calculated. RESULTS: Interreader agreement was excellent (intraclass coefficient, 0.876). ADC values were (77.5-88.8) ×10(-5) mm(2)/sec in the spleen and (250.6-278.5) ×10(-5) mm(2)/sec in the gallbladder. There were no significant differences between ADC values measured at 1.5 T and those measured at 3.0 T in any anatomic region (P >.10 for all). In two of seven regions at 1.5 T (left and right liver lobes, P < .023) and in four of seven regions at 3.0 T (left liver lobe, pancreas, and renal cortex and medulla, P < .008), intervendor differences were significant. CVs ranged from 7.0% to 27.1% depending on the anatomic location. CONCLUSION: Despite significant intervendor differences in ADC values of various anatomic regions of the upper abdomen, ADC values of the gallbladder, pancreas, spleen, and kidney may be comparable between MR systems from different vendors and between different field strengths.

Association between penile dynamic contrast-enhanced MRI-derived quantitative parameters and self-reported sexual function in patients with newly diagnosed prostate cancer.

INTRODUCTION: The high incidence of prostate cancer, coupled with excellent prostate cancer control rates, has resulted in growing interest in nononcological survivorship issues such as sexual function. Multiparametric magnetic resonance imaging (MRI) is increasingly being performed for local staging of prostate cancer, and due to the close anatomical relationship to the prostate, penile enhancement is often depicted in prostate MRI. AIM: To evaluate the associations between quantitative perfusion-related parameters derived from dynamic contrast-enhanced (DCE)-MRI of the penis and self-reported sexual function in patients with newly diagnosed prostate cancer. METHODS: This retrospective study included 50 patients who underwent DCE-MRI for prostate cancer staging before prostatectomy. The following perfusion-related parameters were calculated: volume transfer constant (K(trans)), rate constant (k(ep)), extracellular-extravascular volume fraction (v(e)), contrast enhancement ratio (CER), area under the gadolinium curve after 180 seconds (AUC180), and slope of the time/signal intensity curve of the corpora cavernosa. Associations between perfusion-related parameters and self-reported sexual function were evaluated using the Wilcoxon Rank-Sum test. MAIN OUTCOME MEASURES: Patient responses to the sexual function domain of the Prostate Quality of Life survey. RESULTS: Five of the six DCE-MRI parameters (K(trans), v(e), CER, AUC180, and slope) were significantly associated with the overall score from the sexual domain of the survey (P = 0.0020-0.0252). CER, AUC180, and slope were significantly associated with the answers to all six questions (P = 0.0020-0.0483), ve was significantly associated with the answers to five of six questions (P = 0.0036-0.1029), and K(trans) was significantly associated with the answers to three of six questions (P = 0.0252-0.1023). k(ep) was not significantly associated with the overall survey score (P = 0.7665) or the answers to any individual questions (P = 0.4885-0.8073). CONCLUSION: Penile DCE-MRI parameters were significantly associated with self-reported sexual function in patients with prostate cancer. These parameters are readily available when performing prostate MRI for staging and may be relevant to the management of patients considering prostate cancer therapies.

AI-based automated evaluation of image quality and protocol tailoring in patients undergoing MRI for suspected prostate cancer.

PURPOSE: To develop and validate an artificial intelligence (AI) application in a clinical setting to decide whether dynamic contrast-enhanced (DCE) sequences are necessary in multiparametric prostate MRI. METHODS: This study was approved by the institutional review board and requirement for study-specific informed consent was waived. A mobile app was developed to integrate AI-based image quality analysis into clinical workflow. An expert radiologist provided reference decisions. Diagnostic performance parameters (sensitivity and specificity) were calculated and inter-reader agreement was evaluated. RESULTS: Fully automated evaluation was possible in 87% of cases, with the application reaching a sensitivity of 80% and a specificity of 100% in selecting patients for multiparametric MRI. In 2% of patients, the application falsely decided on omitting DCE. With a technician reaching a sensitivity of 29% and specificity of 98%, and resident radiologists reaching sensitivity of 29% and specificity of 93%, the use of the application allowed a significant increase in sensitivity. CONCLUSION: The presented AI application accurately decides on a patient-specific MRI protocol based on image quality analysis, potentially allowing omission of DCE in the diagnostic workup of patients with suspected prostate cancer. This could streamline workflow and optimize time utilization of healthcare professionals.

Transition zone prostate cancer: incremental value of diffusion-weighted endorectal MR imaging in tumor detection and assessment of aggressiveness.

PURPOSE: To evaluate the incremental value of using diffusion-weighted magnetic resonance (MR) imaging in addition to T2-weighted imaging for the detection of prostate cancer in the transition zone and the assessment of tumor aggressiveness. MATERIALS AND METHODS: This retrospective HIPAA-compliant institutional review board-approved study included 156 consecutive patients (median age, 59.2 years) who underwent MR imaging before radical prostatectomy. Two readers who were blinded to patient data independently recorded their levels of suspicion on a five-point scale of the presence of transition zone tumors on the basis of T2-weighted imaging alone and then, 4 weeks later, diffusion-weighted imaging and T2-weighted imaging together. Apparent diffusion coefficients (ADCs) were measured in transition zone cancers and glandular and stromal benign prostatic hyperplasia. Areas under the receiver operating characteristic curves were used to evaluate detection accuracy, and generalized linear models were used to test ADC differences between benign and malignant prostate regions. Whole-mount step-section histopathologic examination was the reference standard. RESULTS: In overall tumor detection, addition of diffusion-weighted imaging to T2-weighted imaging improved the areas under the receiver operating characteristic curves for readers 1 and 2 from 0.60 and 0.60 to 0.75 and 0.71, respectively, at the patient level (P = .004 for reader 1 and P = .027 for reader 2) and from 0.64 and 0.63 to 0.73 and 0.68, respectively, at the sextant level (P = .001 for reader 1 and P = .100 for reader 2). Least squares mean ADCs (× 10(-3) mm(2)/sec) in glandular and stromal benign prostatic hyperplasia were 1.44 and 1.09, respectively. Mean ADCs were inversely associated with tumor Gleason scores (1.10, 0.98, 0.87, and 0.75 for Gleason scores of 3 + 3, 3 + 4, 4 + 3, and ≥ 4 + 4, respectively). CONCLUSION: Use of diffusion-weighted imaging in addition to T2-weighted imaging improved detection of prostate cancer in the transition zone, and tumor ADCs were inversely associated with tumor Gleason scores in the transition zone.

Renal cell carcinoma: role of MR imaging in the assessment of muscular venous branch invasion.

PURPOSE: To assess diagnostic performance and interreader agreement of tumor-to-sinus distance measurements and visual assessment of renal sinus fat invasion at T2-weighted magnetic resonance (MR) imaging as predictors of muscular venous branch invasion (MVBI) in patients with renal cell carcinoma (RCC). MATERIALS AND METHODS: The institutional review board approved this retrospective study and waived the informed consent requirement. The study was HIPAA compliant. A total of 186 consecutive patients underwent preoperative 1.5-T MR imaging; 188 RCCs were identified. Blinded to histopathologic information, two readers independently measured the tumor-to-sinus distance and assessed renal sinus fat invasion on transverse and coronal T2-weighted MR images. Interreader agreement (intraclass correlation coefficient, Cohen κ) and performance characteristics of imaging tests were calculated. Histopathologic findings served as the standard of reference. RESULTS: Histopathologic findings indicated MVBI in 35% (66 of 188) of tumors. At imaging, all tumors with MVBI had a tumor-to-sinus distance of 0 mm. All tumors with renal sinus fat invasion at imaging had MVBI. Sensitivity and specificity for the detection of renal sinus fat invasion were 100% (95% confidence interval [CI]: 92%, 100%) and 94% (95% CI: 89%, 98%). In the absence of renal sinus fat invasion at imaging, a tumor-to-sinus distance of 0 mm was associated with MVBI in 21% (18 of 86) of cases. Interreader agreement for quantitative (intraclass correlation coefficient = 0.92; 95% CI: 0.89, 0.94) and qualitative (κ = 0.89; 95% CI: 0.81, 0.96) assessments was excellent. CONCLUSION: Tumor-to-sinus distance measurements and the assessment of renal sinus fat invasion at T2-weighted MR imaging can be used reliably to rule out MVBI in patients with RCC.