Natural language processing pipeline to extract prostate cancer-related information from clinical notes.

OBJECTIVES: To develop an automated pipeline for extracting prostate cancer-related information from clinical notes. MATERIALS AND METHODS: This retrospective study included 23,225 patients who underwent prostate MRI between 2017 and 2022. Cancer risk factors (family history of cancer and digital rectal exam findings), pre-MRI prostate pathology, and treatment history of prostate cancer were extracted from free-text clinical notes in English as binary or multi-class classification tasks. Any sentence containing pre-defined keywords was extracted from clinical notes within one year before the MRI. After manually creating sentence-level datasets with ground truth, Bidirectional Encoder Representations from Transformers (BERT)-based sentence-level models were fine-tuned using the extracted sentence as input and the category as output. The patient-level output was determined by compilation of multiple sentence-level outputs using tree-based models. Sentence-level classification performance was evaluated using the area under the receiver operating characteristic curve (AUC) on 15% of the sentence-level dataset (sentence-level test set). The patient-level classification performance was evaluated on the patient-level test set created by radiologists by reviewing the clinical notes of 603 patients. Accuracy and sensitivity were compared between the pipeline and radiologists. RESULTS: Sentence-level AUCs were ≥ 0.94. The pipeline showed higher patient-level sensitivity for extracting cancer risk factors (e.g., family history of prostate cancer, 96.5% vs. 77.9%, p < 0.001), but lower accuracy in classifying pre-MRI prostate pathology (92.5% vs. 95.9%, p = 0.002) and treatment history of prostate cancer (95.5% vs. 97.7%, p = 0.03) than radiologists, respectively. CONCLUSION: The proposed pipeline showed promising performance, especially for extracting cancer risk factors from patient's clinical notes. CLINICAL RELEVANCE STATEMENT: The natural language processing pipeline showed a higher sensitivity for extracting prostate cancer risk factors than radiologists and may help efficiently gather relevant text information when interpreting prostate MRI. KEY POINTS: When interpreting prostate MRI, it is necessary to extract prostate cancer-related information from clinical notes. This pipeline extracted the presence of prostate cancer risk factors with higher sensitivity than radiologists. Natural language processing may help radiologists efficiently gather relevant prostate cancer-related text information.

Decreased prostate MRI cancer detection rate due to moderate to severe susceptibility artifacts from hip prosthesis.

OBJECTIVES: To evaluate the impact of susceptibility artifacts from hip prosthesis on cancer detection rate (CDR) in prostate MRI. MATERIALS AND METHODS: This three-center retrospective study included prostate MRI studies for patients without known prostate cancer between 2017 and 2021. Exams with hip prosthesis were searched on MRI reports. The degree of susceptibility artifact on diffusion-weighted images was retrospectively categorized into mild, moderate, and severe (> 66%, 33-66%, and < 33% of the prostate volume are evaluable) by blind reviewers. CDR was defined as the number of exams with Gleason score ≥7 detected by MRI (PI-RADS ≥3) divided by the total number of exams. For each artifact grade, control exams without hip prosthesis were matched (1:6 match), and CDR was compared. The degree of CDR reduction was evaluated with ratio, and influential factors were evaluated by expanding the equation. RESULTS: Hip arthroplasty was present in 548 (4.8%) of the 11,319 MRI exams. CDR of the cases and matched control exams for each artifact grade were as follows: mild (n = 238), 0.27 vs 0.25, CDR ratio = 1.09 [95% CI: 0.87-1.37]; moderate (n = 143), 0.18 vs 0.27, CDR ratio = 0.67 [95% CI: 0.46-0.96]; severe (n = 167), 0.22 vs 0.28, CDR ratio = 0.80 [95% CI: 0.59-1.08]. When moderate and severe artifact grades were combined, CDR ratio was 0.74 [95% CI: 0.58-0.93]. CDR reduction was mostly attributed to the increased frequency of PI-RADS 1-2. CONCLUSION: With moderate to severe susceptibility artifacts from hip prosthesis, CDR was decreased to 74% compared to the matched control. CLINICAL RELEVANCE STATEMENT: Moderate to severe susceptibility artifacts from hip prosthesis may cause a non-negligible CDR reduction in prostate MRI. Expanding indications for systematic prostate biopsy may be considered when PI-RADS 1-2 was assigned. KEY POINTS: • We proposed cancer detection rate as a diagnostic performance metric in prostate MRI. • With moderate to severe susceptibility artifacts secondary to hip arthroplasty, cancer detection rate decreased to 74% compared to the matched control. • Expanding indications for systematic prostate biopsy may be considered when PI-RADS 1-2 is assigned.

Co-Occurrence of Familial Hemophagocytic Lymphohistiocytosis Type 2 and Chronic Active Epstein-Barr Virus in Adulthood.

We report, to the best of our best knowledge, the oldest individual to ever be diagnosed with Familial Hemophagocytic Lymphohistiocytosis (FHL) Type 2 from homozygous c.1349C>T (p.T450M) missense variants in the PRF1 gene. This rare case advanced in complexity with a simultaneous diagnosis of Chronic Active Epstein-Barr Virus (CAEBV) - a distinct clinical entity from acute EBV infections and a well-described trigger of Hemophagocytic Lymphohistiocytosis (HLH). This is, to the best of our knowledge, the only individual to ever be diagnosed with CAEBV in the setting of this specific variant and the oldest to be diagnosed with a coexisting perforin variant. This case provides understanding of EBV, human genetics, and lymphoproliferative disorders while adding a unique differential diagnosis to adults who present with fever of unknown origin and diffuse lymphadenopathy without evidence of malignancy. This report explores the diagnosis and treatment of both HLH and CAEBV, encouraging discussion regarding current clinical management and future research needs.

Portable Perfusion Phantom Offers Quantitative Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Accurate Prostate Cancer Grade Stratification: A Pilot Study.

RATIONALE AND OBJECTIVES: The study goal was to test whether the improved accuracy in quantitative dynamic contrast-enhanced magnetic resonance imaging measurement using a point-of-care portable perfusion phantom (P4) leads to better stratification of prostate cancer grade. MATERIALS AND METHODS: A prospective clinical study was conducted recruiting 44 patients scheduled for multi-parameter MRI prostate exams. All participants were imaged with the P4 placed under their pelvic regions. Tissue sampling was carried out for 25 patients at 22 ± 18 (mean ± SD) days after multi-parameter MRI. On histologic examination, a total of 31 lesions were confirmed as prostate cancer. Tumors were classified into low grade (n = 14), intermediate grade (n = 10), and high grade (n = 7). Tumor perfusion was assessed by volume transfer constant, Ktrans, before and after P4-based error correction, and the Ktrans of low, intermediate and high-grade tumors were statistically compared. RESULTS: After P4-based error correction, the Ktrans of low, intermediate, and high-grade tumors were 0.109 ± 0.026 min-1 (95% CI: 0.0094 to 0.124 min-1), 0.163 ± 0.049 min-1 (95% CI: 0.129 to 0.198 min-1) and 0.356 ± 0.156 min-1 (95% CI: 0.215 to 0.495 min-1), respectively, with statistically significant difference among the groups (low vs intermediate: p = 0.002; intermediate vs high: p = 0.002; low vs high: p < 0.001). The sensitivity and specificity of Ktrans value, 0.14 min-1, to detect the clinically significant prostate cancer were 88% and 93%, respectively, after P4 based error correction, but those before error correction were 88% and 86%, respectively. CONCLUSION: The P4 allows to reduce errors in quantitative dynamic contrast-enhanced magnetic resonance imaging measurement, enhancing accuracy in stratification of prostate cancer grade.

Utility of 18F-Fluciclovine PET/MRI for Staging Newly Diagnosed High-Risk Prostate Cancer and Evaluating Response to Initial Androgen Deprivation Therapy: A Prospective Single-Arm Pilot Study.

BACKGROUND. Despite advances in prostate cancer treatment, rates of biochemical recurrence remain high, relating to lack of detection of small-volume metastatic disease using conventional imaging for initial staging. OBJECTIVE. The purpose of this study was to assess the potential use of 18F-fluciclovine PET/MRI for initial staging of high-risk prostate cancer and evaluating response to androgen deprivation therapy (ADT). METHODS. This prospective clinical trial enrolled 14 men with newly diagnosed high-risk prostate cancer and negative or equivocal conventional staging imaging for metastatic disease between January 2018 and February 2019. All patients underwent pretreatment 18F-fluciclovine PET/MRI including multiparametric prostate MRI; 12 underwent 18F-fluciclovine PET/MRI after surgery or between ADT and radiotherapy. Confidence in identification of the primary intraprostatic lesion and nodal metastases was independently rated on a 0-3 Likert scale by three readers with nuclear medicine experience for 18F-fluciclovine PET/MRI and three readers with abdominal imaging experience for MRI alone. Findings scored as 2 or 3 by at least two readers of a given modality were considered positive. A single reader measured SUVmean, SUVmax, and volume of the MRI-defined intraprostatic lesion and SUVmax of suspicious lymph nodes on PET before and after initiation of ADT. Changes in SUV were analyzed using nonparametric Wilcox-on signed-rank tests. RESULTS. The biopsy-proven lesion in the prostate gland was accurately identified in all 14 patients on both MRI and 18F-fluciclovine PET/MRI. Suspected nodal metastases were detected in three patients on MRI and seven patients on 18F-fluciclovine PET/MRI. After ADT, all patients showed decreased activity within the intraprostatic lesion and/or all suspicious lymph nodes. The primary lesion SUVmean was 4.5 ± 1.1 (range, 2.7-6.5) before treatment and 2.4 ± 1.1 (range, 0.0-3.6) after initiation of ADT (p = .008). For suspicious lymph nodes, the pretreatment SUVmax was 5.5 ± 3.7 (range, 2.8-12.7) and the post-treatment SUVmax was 2.8 ± 1.4 (range, 1.4-5.5) (p = .03). CONCLUSION.18F-labeled fluciclovine PET/MRI shows potential utility in initial staging of high-risk prostate cancer and in evaluating response to ADT. CLINICAL IMPACT. Given the FDA approval and widespread availability of 18F-fluciclovine, the findings could have an impact in the immediate future in guiding initial management of patients with prostate cancer. TRIAL REGISTRATION. ClinicalTrials.gov NCT03264456.

MR Imaging Texture Analysis in the Abdomen and Pelvis.

Add "which is a" before "distribution"? Texture analysis (TA) is a form of radiomics that refers to quantitative measurements of the histogram, distribution and/or relationship of pixel intensities or gray scales within a region of interest on an image. TA can be applied to MR images of the abdomen and pelvis, with the main strength quantitative analysis of pixel intensities and heterogeneity rather than subjective/qualitative analysis. There are multiple limitations of MRTA. Despite these limitations, there is a growing body of literature supporting MRTA. This review discusses application of MRTA to the abdomen and pelvis.

Associations between the National Walkability Index and walking among US Adults - National Health Interview Survey, 2015.

The Environmental Protection Agency created the National Walkability Index (Index) to compare and analyze walkability among US communities. Index elements include design, distance to transit, and diversity of land uses. Associations between the Index and walking behavior have not been examined. This study describes associations between the Index and transportation and leisure walking among US adults. Past week self-reported participation in transportation and leisure walking among adults (n = 33,672) was obtained from the 2015 Cancer Control Supplement of the National Health Interview Survey (NHIS) and analysis completed in 2019. Index scores were linked to NHIS data based on the respondent's residence and classified into least, below average, above average, and most walkable communities. Associations between Index categories and walking were examined with regression models. Overall, the Index was associated with a higher likelihood of walking, especially for transportation. Transportation walking was more common in areas with higher walkability (21.6%-51.6%, least to most walkable). Leisure walking was also more common with greater walkability (48.4%-56.5%, least to most walkable). Transportation and leisure walking by Index categories in urban areas were similar to the overall population; however, it was not associated with walking in rural areas. US adults living in more walkable areas report more transportation and leisure walking, especially among urban areas. Consistent with elements in the Index, associations were stronger for transportation than leisure walking. Findings support the use of the Walkability Index by researchers, professionals, and other relevant stakeholders as a viable indicator of walkability.

Multi-institutional Clinical Tool for Predicting High-risk Lesions on 3Tesla Multiparametric Prostate Magnetic Resonance Imaging.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) for prostate cancer detection without careful patient selection may lead to excessive resource utilization and costs. OBJECTIVE: To develop and validate a clinical tool for predicting the presence of high-risk lesions on mpMRI. DESIGN, SETTING, AND PARTICIPANTS: Four tertiary care centers were included in this retrospective and prospective study (BiRCH Study Collaborative). Statistical models were generated using 1269 biopsy-naive, prior negative biopsy, and active surveillance patients who underwent mpMRI. Using age, prostate-specific antigen, and prostate volume, a support vector machine model was developed for predicting the probability of harboring Prostate Imaging Reporting and Data System 4 or 5 lesions. The accuracy of future predictions was then prospectively assessed in 214 consecutive patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Receiver operating characteristic, calibration, and decision curves were generated to assess model performance. RESULTS AND LIMITATIONS: For biopsy-naïve and prior negative biopsy patients (n=811), the area under the curve (AUC) was 0.730 on internal validation. Excellent calibration and high net clinical benefit were observed. On prospective external validation at two separate institutions (n=88 and n=126), the machine learning model discriminated with AUCs of 0.740 and 0.744, respectively. The final model was developed on the Microsoft Azure Machine Learning platform (birch.azurewebsites.net). This model requires a prostate volume measurement as input. CONCLUSIONS: In patients who are naïve to biopsy or those with a prior negative biopsy, BiRCH models can be used to select patients for mpMRI. PATIENT SUMMARY: In this multicenter study, we developed and prospectively validated a calculator that can be used to predict prostate magnetic resonance imaging (MRI) results using patient age, prostate-specific antigen, and prostate volume as input. This tool can aid health care professionals and patients to make an informed decision regarding whether to get an MRI.

MRI findings guiding selection of active surveillance for prostate cancer: a review of emerging evidence.

Active surveillance (AS) for prostate cancer (PCa) is generally considered to be a safe strategy for men with low-risk, localized disease. However, as many as 1 in 4 patients may be incorrectly classified as AS-eligible using traditional inclusion criteria. The use of multiparametric magnetic resonance imaging (mpMRI) may offer improved risk stratification in both the initial diagnostic and disease monitoring setting. We performed a review of recently published studies to evaluate the utility of this imaging modality for this clinical setting. An English literature search was conducted on PubMed for original investigations on localized PCa, AS, and magnetic resonance imaging. Our Boolean criteria included the following terms: PCa, AS, imaging, MRI, mpMRI, prospective, retrospective, and comparative. Our search excluded publication types such as comments, editorials, guidelines, reviews, or interviews. Our literature review identified 71 original investigations. Among these, 52 met our inclusion criteria. Evidence suggests mpMRI improves characterization of clinically significant prostate cancer (csPCa) foci, and the enhanced detection and risk-stratification afforded by this modality may keep men from being inappropriately placed on AS. Use of serial mpMRI may also permit longer intervals between confirmatory biopsies. Multiple studies demonstrate the benefit of MRI-targeted biopsies. The use of mpMRI of the prostate offers improved confidence in risk-stratification for men with clinically low-risk PCa considering AS. While on AS, serial mpMRI and MRI-targeted biopsy aid in the detection of aggressive disease transformation or foci of clinically-significant cancer undetected on prior biopsy sessions.

How Would MRI-targeted Prostate Biopsy Alter Radiation Therapy Approaches in Treating Prostate Cancer?

OBJECTIVE: To determine if magnetic resonance imaging (MRI)/ultrasound fusion-targeted prostate biopsy (TB) would lead to increased recommendations of aggressive radiotherapy treatments for higher risk prostate cancer compared to systematic biopsy (SB) results. METHODS: Clinicopathologic data of 533 men who underwent both TB and SB from 2014 to 2017 was analyzed. TB was performed in addition to SB in patients with detection of MRI suspicious lesions. Three patient cohorts were established: (1) biopsy naïve (80/533, 15.0%), (2) active surveillance (185/533, 34.7%), and (3) prior negative biopsy (268/533, 50.3%). Cancer risk categorical criteria were established with recommended radiotherapy treatment for each. Variation of risk classification due to biopsy method for all patients and within each cohort was analyzed using either a chi-squared statistic or Fisher's exact test. McNemar's pairwise analyses were performed for all risk categories between TB and SB to assess the effects of TB on high-risk cancer identification and subsequent radiotherapy recommendations. RESULTS: Number of patients within cancer risk categories (1. "No Cancer or Low-Risk"; 2. "More Favorable Intermediate-Risk"; 3. "Less Favorable Intermediate-Risk"; 4. "High-Risk") varied significantly based on TB and SB pathology among all patients combined (P <.0001), in cohort 2 (P = .0005), and in cohort 3 (P <0.0001). Further, among all patients, TB increased cancer risk classification and correspondingly would result in more aggressive radiotherapy recommendations: "No Cancer or Low-Risk" to "Less Favorable Intermediate-Risk" (30/343, P <0.0001) and "No Cancer or Low-Risk" to "High-Risk" (31/353, P <.0001). CONCLUSION: Among men with prostate cancer, TB commonly led to reclassification to a higher risk group, which is accompanied by more aggressive radiotherapy treatment recommendations when compared with SB findings alone.

Targets missed: predictors of MRI-targeted biopsy failing to accurately localize prostate cancer found on systematic biopsy.

BACKGROUND: Magnetic resonance imaging (MRI)/ultrasound (US) fusion-guided biopsy has improved the ability to localize and detect prostate cancer (PCa) with efficiency surpassing systematic biopsy. Nevertheless, some patients have PCa missed using the MRI-targeted biopsy sampling alone. We aim to identify clinical and imaging parameters associated with cases where targeted biopsy did not detect PCa compared to systematic biopsy. METHODS: We conducted a retrospective review of patients who underwent MRI/US fusion-guided biopsy in addition to concurrent systematic, extended-sextant biopsy between 2014 and 2017. For patients with PCa detected on systematic biopsy not properly localized by MRI/US fusion-guided biopsy, the sextant distance from MRI-targeted lesion to the cancer-positive sextant was calculated and parameters potentially predicting this targeting miss were evaluated. RESULTS: In all, 35/127 (27.6%) patients with single-session MRI/US fusion-guided biopsy plus standard biopsy finding PCa had lesions incorrectly localized. Of these, 15/35 (42.9%) were identified as possible fusion-software misregistrations. The remainder, 12/35 (34.3%), represented targeted biopsies one sextant away from the cancer focus and 8/35 (22.9%) targeted biopsies two sextants away from the cancer focus. Only 7/35 (20.0%) patients were determined to have clinically significant PCa, which represents 7/127 (5.5%) of the overall population. Lower MRI lesion volumes (p = 0.022), lesion density (p < 0.001), and PI-RADS scores (p < 0.001) were significantly associated with targeted biopsy missing PCa detected on systematic biopsy. CONCLUSION: Clinically significant PCa is rarely missed utilizing MRI/US fusion-guided biopsy. With the majority of missed tumors representing targeting misregistrations or cases of low-grade cancer in sextants immediately adjacent to MRI suspicious lesions. Lower MRI lesion volumes, lesion density, and PI-RADS are predictors of cases with targeted biopsies missing cancer, for which systematic sampling of the sextants containing MRI targets and adjacent sextants would most optimize PCa detection.

MRI/US fusion-guided prostate biopsy allows for equivalent cancer detection with significantly fewer needle cores in biopsy-naive men.

PURPOSE: We aimed to investigate the efficiency and cancer detection of magnetic resonance imaging (MRI) / ultrasonography (US) fusion-guided prostate biopsy in a cohort of biopsy-naive men compared with standard-of-care systematic extended sextant transrectal ultrasonography (TRUS)-guided biopsy. METHODS: From 2014 to 2016, 72 biopsy-naive men referred for initial prostate cancer evaluation who underwent MRI of the prostate were prospectively evaluated. Retrospective review was performed on 69 patients with lesions suspicious for malignancy who underwent MRI/US fusion-guided biopsy in addition to systematic extended sextant biopsy. Biometric, imaging, and pathology data from both the MRI-targeted biopsies and systematic biopsies were analyzed and compared. RESULTS: There were no significant differences in overall prostate cancer detection when comparing MRI-targeted biopsies to standard systematic biopsies (P = 0.39). Furthermore, there were no significant differences in the distribution of severity of cancers based on grade groups in cases with cancer detection (P = 0.68). However, significantly fewer needle cores were taken during the MRI/US fusion-guided biopsy compared with systematic biopsy (63% less cores sampled, P < 0.001) CONCLUSION: In biopsy-naive men, MRI/US fusion-guided prostate biopsy offers equal prostate cancer detection compared with systematic TRUS-guided biopsy with significantly fewer tissue cores using the targeted technique. This approach can potentially reduce morbidity in the future if used instead of systematic biopsy without sacrificing the ability to detect prostate cancer, particularly in cases with higher grade disease.

Defining the optimal method for reporting prostate cancer grade and tumor extent on magnetic resonance/ultrasound fusion-targeted biopsies.

Magnetic resonance (MR)/ultrasound fusion-targeted biopsy (TB) routinely samples multiple cores from each MR lesion of interest. Pathologists can evaluate the extent of cancer involvement and grade using an individual core (IC) or aggregate (AG) method, which could potentially lead to differences in reporting. We reviewed patients who underwent TB followed by radical prostatectomy (RP). TB cores were evaluated for grade and tumor extent by 2 methods. In the IC method, the grade for each TB lesion was based on the core with the highest Gleason score. Tumor extent for each TB was based on the core with the highest percent of tumor involvement. In the AG method, the tumor from all cores within each TB lesion was aggregated to determine the final composite grade and percentage of tumor involvement. Each method was compared with MR lesional volume, MR lesional density (lesion volume/prostate volume), and RP. Fifty-five patients underwent TB followed by RP. Extent of tumor by the AG method showed a better correlation with target lesion volume (r= 0.27,P= .022) and lesional density (r = 0.32, P = .008) than did the IC method (r= 0.19 [P = .103] andr= 0.22 [P = .062]), respectively. Extent of tumor on TB was associated with extraprostatic extension on RP by the AG method (P= .04), but not by the IC method. This association was significantly higher in patients with a grade group (GG) of 3 or higher (P= .03). A change in cancer grade occurred in 3 patients when comparing methods (2 downgraded GG3 to GG2, 1 downgraded GG4 to GG3 by the AG method). For multiple cores obtained via TB, the AG method better correlates with target lesion volume, lesional density, and extraprostatic extension.

A Magnetic Resonance Imaging-Based Prediction Model for Prostate Biopsy Risk Stratification.

Importance: Multiparametric magnetic resonance imaging (MRI) in conjunction with MRI-transrectal ultrasound (TRUS) fusion-guided biopsies have improved the detection of prostate cancer. It is unclear whether MRI itself adds additional value to multivariable prediction models based on clinical parameters. Objective: To determine whether an MRI-based prediction model can reduce unnecessary biopsies in patients with suspected prostate cancer. Design, Setting, and Participants: Patients underwent MRI, MRI-TRUS fusion-guided biopsy, and 12-core systematic biopsy in 1 session. The development cohort used to derive the prediction model consisted of 400 patients from 1 institution enrolled between May 14, 2015, and August 31, 2016, and the validation cohort included 251 patients from 2 independent institutions who underwent biopsies between April 1, 2013, and June 30, 2016, at 1 institution and between July 1, 2015, and October 31, 2016, at the other institution. The MRI model included MRI-derived parameters in addition to clinical variables. Area under the curve of receiver operating characteristic curves and decision curve analysis were performed. Main Outcomes and Measures: Risk of clinically significant prostate cancer on biopsy, defined as a Gleason score of 3 + 4 or higher in at least 1 biopsy core. Results: Overall, 193 (48.3%) of the 400 patients in the development cohort (mean [SD] age at biopsy, 64.3 [7.1] years) and 96 (38.2%) of the 251 patients in the validation cohort (mean [SD] age at biopsy, 64.9 [7.2] years) had clinically significant prostate cancer, defined as a Gleason score greater than or equal to 3 + 4. By applying the model to the external validation cohort, the area under the curve increased from 64% to 84% compared with the baseline model (P < .001). At a risk threshold of 20%, the MRI model had a lower false-positive rate than the baseline model (46% [95% CI, 32%-66%] vs 92% [95% CI, 70%-100%]), with only a small reduction in the true-positive rate (89% [95% CI, 85%-96%] vs 99% [95% CI, 89%-100%]). Eighteen of 100 fewer biopsies could have been performed, with no increase in the number of patients with missed clinically significant prostate cancers. Conclusions and Relevance: The inclusion of MRI-derived parameters in a risk model could reduce the number of unnecessary biopsies while maintaining a high rate of diagnosis of clinically significant prostate cancers.

Practical Considerations for Clinical PET/MR Imaging.

Clinical PET/MR imaging is currently performed at a number of centers around the world as part of routine standard of care. This article focuses on issues and considerations for a clinical PET/MR imaging program, focusing on routine standard-of-care studies. Although local factors influence how clinical PET/MR imaging is implemented, the approaches and considerations described here intend to apply to most clinical programs. PET/MR imaging provides many more options than PET/computed tomography with diagnostic advantages for certain clinical applications but with added complexity. A recurring theme is matching the PET/MR imaging protocol to the clinical application to balance diagnostic accuracy with efficiency.

Multi-institutional nomogram predicting benign prostate pathology on magnetic resonance/ultrasound fusion biopsy in men with a prior negative 12-core systematic biopsy.

BACKGROUND: Prostate multiparametric magnetic resonance imaging (mpMRI) may be recommended for patients with a prior negative systematic biopsy (SB). However, a proportion of these patients will continue to have no prostate cancer (PCa) identified on magnetic resonance/ultrasound fusion biopsy (FB) despite abnormal mpMRI findings. METHODS: In this multi-institutional, retrospective study, clinical and mpMRI parameters were assessed for 285 consecutive patients with at least 1 prior negative biopsy who underwent FB for a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 to 5 at the University of Rochester Medical Center from December 2014 to December 2016, or at the University of Alabama at Birmingham from February 2014 to February 2017. Nomograms were generated for predicting benign prostate pathology on both the targeted biopsy and the concurrent SB. RESULTS: Benign pathology was found in 132 of 285 patients (46.3%). In a multivariate analysis, the predictors of benign prostate pathology on FB were age, prostate-specific antigen, prostate volume, and PI-RADS score. The predicted probabilities were plotted on a receiver operating characteristic curve, and the area under the curve was 0.825. The nomogram demonstrated excellent calibration and a high net benefit in a decision curve analysis. With a theoretical cutoff probability of ≥0.7 used to recommend deferment of FB, 61 of 285 patients (21.4%) would have avoided an unnecessary biopsy, and only 4 of 285 patients (1.4%) with PCa with a Gleason score ≥ 3 + 4 would have been missed. CONCLUSIONS: False-positive mpMRI examinations may occur in up to 46.3% of patients with a prior negative biopsy. Thus, a multi-institutional nomogram has been developed and validated for predicting benign pathology after FB in patients with a prior negative biopsy, and this may help to reduce the number of unnecessary biopsies in the setting of abnormal mpMRI findings. Cancer 2018;124:278-85. © 2017 American Cancer Society.

Incidental findings on multiparametric MRI performed for evaluation of prostate cancer.

PURPOSE: Multiparametric magnetic resonance imaging (mp-MRI) and MRI/Ultrasound (US) fusion-guided biopsy are relatively new techniques for improved detection, staging, and active surveillance of prostate cancer (PCa). As with all imaging modalities, MRI reveals incidental findings (IFs) which carry the risk of increased cost, patient anxiety, and iatrogenic morbidity due to workup of IFs. Herein, we report the IFs from 684 MRIs for evaluation of PCa and consider their characteristics and clinical significance. METHODS: Patients underwent mp-MRI prostate protocol incorporating triplanar T2-weighted, diffusion-weighted, and dynamic contrast-enhanced pelvic MRI as well as a post-contrast abdominopelvic MRI with the primary indication of detection or evaluation of PCa. A total of 684 consecutive prostate MRI reports performed in a series of 580 patients were reviewed. All extraprostatic findings reported were logged and then categorized by organ system and potential clinical significance. RESULTS: There were 349 true IFs found in 233 (40%) of the 580 patients. One hundred nineteen additional extraprostatic findings were unsuspected but directly related to PCa staging, while the 349 IFs were unrelated and thus truly incidental beyond study indication. While the majority of true IFs were non-urologic, only 6.6% of IFs were considered clinically significant, non-urologic findings, and more than a third of MRI reports had urologic IFs not related to PCa. CONCLUSIONS: Rates of incidental findings on prostate indication MRI are similar to other abdominopelvic imaging studies. However, only 6.6% of the IFs were considered to be clinically significant non-urologic findings. Further investigations are needed to assess downstream workup of these IFs and resulting costs.

Lymph node imaging in initial staging of prostate cancer: An overview and update.

Accurate nodal staging at the time of diagnosis of prostate cancer is crucial in determining a treatment plan for the patient. Pelvic lymph node dissection is the most reliable method, but is less than perfect and has increased morbidity. Cross sectional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) are non-invasive tools that rely on morphologic characteristics such as shape and size of the lymph nodes. However, lymph nodes harboring metastatic disease may be normal sized and non-metastatic lymph nodes may be enlarged due to reactive hyperplasia. The optimal strategy for preoperative staging remains a topic of ongoing research. Advanced imaging techniques to assess lymph nodes in the setting of prostate cancer utilizing novel MRI contrast agents as well as positron emission tomography (PET) tracers have been developed and continue to be studied. Magnetic resonance lymphography utilizing ultra-small super paramagnetic iron oxide has shown promising results in detection of metastatic lymph nodes. Combining MRL with diffusion-weighted imaging may also improve accuracy. Considerable efforts are being made to develop effective PET radiotracers that are performed using hybrid-imaging systems that combine PET with CT or MRI. PET tracers that will be reviewed in this article include [18F]fluoro-D-glucose, sodium [18F]fluoride, [18F]choline, [11C]choline, prostate specific membrane antigen binding ligands, [11C]acetate, [18F]fluciclovine, gastrin releasing peptide receptor ligands, and androgen binding receptors. This article will review these advanced imaging modalities and ability to detect prostate cancer metastasis to lymph nodes. While more research is needed, these novel techniques to image lymph nodes in the setting of prostate cancer show a promising future in improving initial lymph node staging.

Benign testicular neoplasm in a human immunodeficiency virus-positive patient masquerading as testicular cancer.

Inflammatory myofibroblastic tumor (IMT) is a rare, benign neoplasm comprising spindle myoepithelial cells in the background of inflammatory cells. It can involve multiple anatomic sites in the body but rarely involves the testis. We report a case of 52-year-old male patient with a history of human immunodeficiency virus who presented with a painless, testicular mass for 2 months. Despite being treated with prolonged antibiotics and nonsteroidal anti-inflammatory drugs, scrotal ultrasound demonstrated an increase in the size of the lesion. With a presumed diagnosis of testicular germ cell tumor, a right radical inguinal orchiectomy was performed. Microscopic and immunohistochemical features were consistent with testicular IMT, a benign neoplastic process.

Contrast-Enhanced Ultrasound Classification of Previously Indeterminate Renal Lesions.

OBJECTIVES: To determine the utility of contrast-enhanced ultrasound (US) for characterizing renal lesions that were indeterminate on prior imaging. METHODS: This Institutional Review Board-approved retrospective diagnostic accuracy study evaluated all patients who underwent renal contrast-enhanced US examinations from 2006 to 2015 at our tertiary care hospital. We compared the number of lesions definitively characterized by contrast-enhanced US with the indeterminate lesions by prior imaging. The accuracy of contrast-enhanced US was compared with the final diagnosis by histologic examination and follow-up (mean, 3.63 years). Accuracy and agreement estimates were compared with the exact binomial distribution to assess statistical significance. RESULTS: A total of 134 lesions were evaluated with contrast-enhanced US, and 106 were indeterminate by preceding computed tomography, magnetic resonance imaging, or US. Only the largest lesion per patient was included in analysis. A total of 95.7% (90 of 94) of the previously indeterminate lesions were successfully classified with contrast-enhanced US. The sensitivity was 100% (20 of 20; 95% confidence interval [CI], 83%-100%; P < .0001); specificity was 85.7% (18 of 21; 95% CI, 62%-97%; P = .0026); positive predictive value was 87.0% (20 of 23; 95% CI, 66%-97%; P = .0005); negative predictive value was 100% (18 of 18; 95% CI, 81%-100%; P < .001); and accuracy was 90.2% (37 of 41; 95% CI, 80%-98%; P < .0001). CONCLUSIONS: Contrast-enhanced US has a high likelihood of definitively classifying a renal lesion that is indeterminate by computed tomography, magnetic resonance imaging, or conventional US.