Assessment of PSMA Expression of Healthy Organs in Different Stages of Prostate Cancer Using [68Ga]Ga-PSMA-11-PET Examinations.

The efficacy of radioligand therapy (RLT) targeting prostate-specific membrane antigen (PSMA) is currently being investigated for its application in patients with early-stage prostate cancer (PCa). However, little is known about PSMA expression in healthy organs in this cohort. Collectively, 202 [68Ga]Ga-PSMA-11 positron emission tomography (PET) scans from 152 patients were studied. Of these, 102 PET scans were from patients with primary PCa and hormone-sensitive biochemically recurrent PCa and 50 PET scans were from patients with metastatic castration-resistant PCa (mCRPC) before and after three cycles of [177Lu]Lu-PSMA-RLT. PSMA-standardized uptake values (SUV) were measured in multiple organs and PSMA-total tumor volume (PSMA-TTV) was determined in all cohorts. The measured PET parameters of the different cohorts were normalized to the bloodpool and compared using t- or Mann-Whitney U tests. Patients with early-stage PCa had lower PSMA-TTVs (10.39 mL vs. 462.42 mL, p < 0.001) and showed different SUVs in the thyroid, submandibular glands, heart, liver, kidneys, intestine, testes and bone marrow compared to patients with advanced CRPC, with all tests showing p < 0.05. Despite the differences in the PSMA-TTV of patients with mCRPC before and after [177Lu]Lu-PSMA-RLT (462.42 mL vs. 276.29 mL, p = 0.023), no significant organ differences in PET parameters were detected. These suggest different degrees of PSMA-ligand binding among patients with different stages of PCa that could influence radiotoxicity during earlier stages of disease in different organs when PSMA-RLT is administered.

Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses.

Background: Economic evaluations have become an accepted methodology for decision makers to allocate resources in healthcare systems. Particularly in screening, where short-term costs are associated with long-term benefits, and adverse effects of screening intermingle, cost-effectiveness analyses provide a means to estimate the economic value of screening. Purpose: To introduce the methodology of economic evaluations and to review the existing evidence on cost-effectiveness of MR-based breast cancer screening. Materials and methods: The various concepts and techniques of economic evaluations critical to the interpretation of cost-effectiveness analyses are briefly introduced. In a systematic review of the literature, economic evaluations from the years 2000-2022 are reviewed. Results: Despite a considerable heterogeneity in the reported input variables, outcome categories and methodological approaches, cost-effectiveness analyses report favorably on the economic value of breast MRI screening for different risk groups, including both short- and long-term costs and outcomes. Conclusion: Economic evaluations indicate a strongly favorable economic value of breast MRI screening for women at high risk and for women with dense breast tissue.

Economic potential of abbreviated breast MRI for screening women with dense breast tissue for breast cancer.

OBJECTIVES: Abbreviated breast MRI (AB-MRI) was introduced to reduce both examination and image reading times and to improve cost-effectiveness of breast cancer screening. The aim of this model-based economic study was to analyze the cost-effectiveness of full protocol breast MRI (FB-MRI) vs. AB-MRI in screening women with dense breast tissue for breast cancer. METHODS: Decision analysis and a Markov model were designed to model the cumulative costs and effects of biennial screening in terms of quality-adjusted life years (QALYs) from a US healthcare system perspective. Model input parameters for a cohort of women with dense breast tissue were adopted from recent literature. The impact of varying AB-MRI costs per examination as well as specificity on the resulting cost-effectiveness was modeled within deterministic sensitivity analyses. RESULTS: At an assumed cost per examination of $ 263 for AB-MRI (84% of the cost of a FB-MRI examination), the discounted cumulative costs of both MR-based strategies accounted comparably. Reducing the costs of AB-MRI below $ 259 (82% of the cost of a FB-MRI examination, respectively), the incremental cost-effectiveness ratio of FB-MRI exceeded the willingness to pay threshold and the AB-MRI-strategy should be considered preferable in terms of cost-effectiveness. CONCLUSIONS: Our preliminary findings indicate that AB-MRI may be considered cost-effective compared to FB-MRI for screening women with dense breast tissue for breast cancer, as long as the costs per examination do not exceed 82% of the cost of a FB-MRI examination. KEY POINTS: • Cost-effectiveness of abbreviated breast MRI is affected by reductions in specificity and resulting false positive findings and increased recall rates. • Abbreviated breast MRI may be cost-effective up to a cost per examination of 82% of the cost of a full protocol examination. • Abbreviated breast MRI could be an economically preferable alternative to full protocol breast MRI in screening women with dense breast tissue.

Rectal preparation significantly improves prostate imaging quality: Assessment of the PI-QUAL score with visual grading characteristics.

PURPOSE: To investigate the effects of a rectal preparation regimen, that consisted of a rectal cleansing enema and an endorectal gel filling protocol, on prostate imaging quality (PI-QUAL). METHODS: Multiparametric MRI (mpMRI) was performed in 150 consecutive patients divided into two groups of 75 patients. One group received a rectal preparation with a cleansing enema and endorectal gel filling (median age 65.3 years, median PSA level 6 ng/ml). The other patient group did not receive such a preparation (median age 64 years, median PSA level 6 ng/ml). Two uroradiologists independently rated general image quality and lesion visibility on diffusion-weighted imaging (DWI), T2-weighted (T2w), and dynamic contrast-enhanced (DCE) images using a five-point ordinal scale. In addition, two uroradiologists assigned PI-QUAL scores, using the dedicated scoring sheet. Data sets were compared using visual grading characteristics (VGC) and receiver operating characteristics (ROC)/ area under the curve (AUC) analysis. RESULTS: VGC revealed significantly better general image quality for DWI (AUC R1 0.708 (0.628-0.779 CI, p < 0.001; AUC R2 0.687 (0.606-0.760 CI, p < 0.001) and lesion visibility for both readers (AUC R1 0.729 (0.607-0.831 CI, p < 0.001); AUC R2 0.714 (0.590-0.818CI, p < 0.001) in the preparation group. For T2w imaging, rectal preparation resulted in significantly better lesion visibility for both readers (R1 0.663 (0.537-0.774 CI, p = 0.014; R2 0.663 (0.537-0.774 CI, p = 0.014)). Averaged PI-QUAL scores were significantly improved with rectal preparation (AUC R3/R4 0.667, CI 0.581-0.754, p < 0.001). CONCLUSION: Rectal preparation significantly improved prostate imaging quality (PI-QUAL) and lesion visibility. Hence, a rectal preparation regimen consisting of a rectal cleansing enema and an endorectal gel filling could be considered.

One view or two views for wide-angle tomosynthesis with synthetic mammography in the assessment setting?

OBJECTIVES: To evaluate the diagnostic performance in the assessment setting of three protocols: one-view wide-angle digital breast tomosynthesis (WA-DBT) with synthetic mammography (SM), two-view WA-DBT/SM, and two-view digital mammography (DM). METHODS: Included in this retrospective study were patients who underwent bilateral two-view DM and WA-DBT. SM were reconstructed from the WA-DBT data. The standard of reference was histology and/or 2 years follow-up. Included were 205 women with 179 lesions (89 malignant, 90 benign). Four blinded readers randomly evaluated images to assess density, lesion type, and level of suspicion according to BI-RADS. Three protocols were evaluated: two-view DM, one-view (mediolateral oblique) WA-DBT/SM, and two-view WA-DBT/SM. Detection rate, sensitivity, specificity, and accuracy were calculated and compared using multivariate analysis. Reading time was assessed. RESULTS: The detection rate was higher with two-view WA-DBT/SM (p = 0.063). Sensitivity was higher for two-view WA-DBT/SM compared to two-view DM (p = 0.001) and one-view WA-DBT/SM (p = 0.058). No significant differences in specificity were found. Accuracy was higher with both one-view WA-DBT/SM and two-view WA-DBT/SM compared to DM (p = 0.003 and > 0.001, respectively). Accuracy did not differ between one- and two-view WA-DBT/SM. Two-view WA-DBT/SM performed better for masses and asymmetries. Reading times were significantly longer when WA-DBT was evaluated. CONCLUSIONS: One-view and two-view WA-DBT/SM can achieve a higher diagnostic performance compared to two-view DM. The detection rate and sensitivity were highest with two-view WA-DBT/SM. Two-view WA-DBT/SM appears to be the most appropriate tool for the assessment of breast lesions. KEY POINTS: • Detection rate with two-view wide-angle digital breast tomosynthesis (WA-DBT) is significantly higher than with two-view digital mammography in the assessment setting. • Diagnostic accuracy of one-view and two-view WA-DBT with synthetic mammography (SM) in the assessment setting is higher than that of two-view digital mammography. • Compared to one-view WA-DBT with SM, two-view WA-DBT with SM seems to be the most appropriate tool for the assessment of breast lesions.

Cost-Effectiveness of MR-Mammography in Breast Cancer Screening of Women With Extremely Dense Breasts After Two Rounds of Screening.

OBJECTIVES: To evaluate the cost-effectiveness of MR-mammography (MRM) vs. x-ray based mammography (XM) in two-yearly screening women of intermediate risk for breast cancer in the light of recent literature. METHODS: Decision analysis and Markov modelling were used to compare cumulative costs (in US-$) and outcomes (in QALYs) of MRM vs. XM over the model runtime of 20 years. The perspective of the U.S. healthcare system was selected. Incremental cost-effectiveness ratios (ICER) were calculated and related to a willingness to pay-threshold of $ 100,000 per QALY in order to evaluate the cost-effectiveness. Deterministic and probabilistic sensitivity analyses were conducted to test the impact of variations of the input parameters. In particular, variations of the rate of false positive findings beyond the first screening round and their impact on cost-effectiveness were assessed. RESULTS: Breast cancer screening with MRM resulted in increased costs and superior effectiveness. Cumulative average costs of $ 6,081 per woman and cumulative effects of 15.12 QALYs were determined for MRM, whereas screening with XM resulted in costs of $ 5,810 and 15.10 QALYs, resulting in an ICER of $ 13,493 per QALY gained. When the specificity of MRM in the second and subsequent screening rounds was varied from 92% to 99%, the ICER resulted in a range from $ 38,849 to $ 5,062 per QALY. CONCLUSIONS: Based on most recent data on the diagnostic performance beyond the first screening round, MRM may remain the economically preferable alternative in screening women of intermediate risk for breast cancer due to their dense breast tissue.

Cost-Effectiveness of Digital Breast Tomosynthesis vs. Abbreviated Breast MRI for Screening Women with Intermediate Risk of Breast Cancer-How Low-Cost Must MRI Be?

BACKGROUND: Digital breast tomosynthesis (DBT) and abbreviated breast MRI (AB-MRI) offer superior diagnostic performance compared to conventional mammography in screening women with intermediate risk of breast cancer due to dense breast tissue. The aim of this model-based economic evaluation was to analyze whether AB-MRI is cost-effective in this cohort compared to DBT. METHODS: Decision analysis and Markov simulations were used to model the cumulative costs and quality-adjusted life-years (QALYs) over a time horizon of 30 years. Model input parameters were adopted from recent literature. Deterministic and probabilistic sensitivity analyses were applied to test the stability of the model. RESULTS: In the base-case scenario, the costs of an AB-MRI examination were defined to equal the costs of a full protocol acquisition. Two-yearly screening of women with dense breasts resulted in cumulative discounted costs of $8798 and $9505 for DBT and AB-MRI, and cumulative discounted effects of 19.23 and 19.27 QALYs, respectively, with an incremental cost-effectiveness ratio of $20,807 per QALY gained in the base-case scenario. By reducing the cost of an AB-MRI examination below a threshold of $241 in sensitivity analyses, AB-MRI would become cost-saving compared to DBT. CONCLUSION: In comparison to DBT, AB-MRI can be considered cost-effective up to a price per examination of $593 in screening patients at intermediate risk of breast cancer.

A Multicentric Comparison of Apparent Diffusion Coefficient Mapping and the Kaiser Score in the Assessment of Breast Lesions.

MATERIALS AND METHODS: In this multicentric study, individual patient data from 3 different centers were analyzed. Consecutive patients receiving standardized multiparametric breast magnetic resonance imaging for standard nonscreening indications were included. At each center, 2 experienced radiologists with more than 5 years of experience retrospectively interpreted the examinations in consensus and applied the KS to every histologically verified lesion. The corresponding mean ADC of each lesion was measured using a Wielema type 4 region of interest. According to established methods, the KS and ADC were combined, yielding the KS+ score. Diagnostic accuracy was evaluated by the area under the receiver operating characteristics curve (AUROC) and compared between the KS, ADC, and KS+ (DeLong test). Likewise, the potential to help avoid unnecessary biopsies was compared between the KS, ADC, and KS+ based on established high sensitivity thresholds (McNemar test). RESULTS: A total of 450 lesions in 414 patients (mean age, 51.5 years; interquartile range, 42-60.8 years) were included, with 219 lesions being malignant (48.7%; 95% confidence interval [CI], 44%-53.4%). The performance of the KS (AUROC, 0.915; CI, 0.886-0.939) was significantly better than that of the ADC (AUROC, 0.848; CI, 0.811-0.880; P < 0.001). The largest difference between these parameters was observed when assessing subcentimeter lesions (AUROC, 0.909 for KS; CI, 0.849-0.950 vs 0.811 for ADC; CI, 0.737-0.871; P = 0.02).The use of the KS+ (AUROC, 0.918; CI, 0.889-0.942) improved the performance slightly, but without any significant difference relative to a single KS or ADC reading (P = 0.64).When applying high sensitivity thresholds for avoiding unnecessary biopsies, the KS and ADC achieved equal sensitivity (97.7% for both; cutoff values, >4 for KS and ≤1.4 × 10-3 mm2/s for ADC). However, the rate of potentially avoidable biopsies was higher when using the KS (specificity: 65.4% for KS vs 32.9% for ADC; P < 0.0001). The KS was superior to the KS+ in avoiding unnecessary biopsies. CONCLUSIONS: Both the KS and ADC may be used to distinguish benign from malignant breast lesions. However, KS proved superior in this task including, most of all, when assessing small lesions less than 1 cm. Using the KS may avoid twice as many unnecessary biopsies, and the combination of both the KS and ADS does not improve diagnostic performance.

Multimodality Imaging of Breast Parenchymal Density and Correlation with Risk Assessment.

Purpose of Review: Breast density, or the amount of fibroglandular tissue in the breast, has become a recognized and independent marker for breast cancer risk. Public awareness of breast density as a possible risk factor for breast cancer has resulted in legislation for risk stratification purposes in many US states. This review will provide a comprehensive overview of the currently available imaging modalities for qualitative and quantitative breast density assessment and the current evidence on breast density and breast cancer risk assessment. Recent Findings: To date, breast density assessment is mainly performed with mammography and to some extent with magnetic resonance imaging. Data indicate that computerized, quantitative techniques in comparison with subjective visual estimations are characterized by higher reproducibility and robustness. Summary: Breast density reduces the sensitivity of mammography due to a masking effect and is also a recognized independent risk factor for breast cancer. Standardized breast density assessment using automated volumetric quantitative methods has the potential to be used for risk prediction and stratification and in determining the best screening plan for each woman.

Multiparametric [11C]Acetate positron emission tomography-magnetic resonance imaging in the assessment and staging of prostate cancer.

BACKGROUND: The aim of this study was to evaluate whether MP [11C]Acetate PET-MRI enables an accurate differentiation of benign and malignant prostate tumors as well as local and distant staging. MATERIALS AND METHODS: Fifty-six consecutive patients fulfilling the following criteria were included in this IRB-approved prospective study: elevated PSA levels or suspicious findings at digital rectal examination or TRUS; and histopathological verification. All patients underwent MP [11C]Acetate PET-MRI of the prostate performed on separate scanners with PET/CT using [11C]Acetate and 3T MP MR imaging. Appropriate statistical tests were used to determine diagnostic accuracy, local and distant staging. RESULTS: MP imaging with two MRI parameters (T2w and DWI) achieved the highest sensitivity, specificity, and diagnostic accuracy of 95%, 68.8%, and 88%, with an AUC of 0.82 for primary PCa detection. Neither assessments with a single parameter (AUC, 0.54-0.79), nor different combinations with up to five parameters (AUC, 0.67-0.79) achieved equally good results. MP [11C]Acetate PET-MRI improved local staging with a sensitivity, specificity, and diagnostic accuracy of 100%, 96%, and 97% compared to MRI alone with 72.2%, 100%, and 95.5%. MP [11C]Acetate PET-MRI correctly detected osseous and liver metastases in five patients. CONCLUSIONS: MP [11C]Acetate PET-MRI merges morphologic with functional information, and allows insights into tumor biology. MP [11C]Acetate PET-MRI with two MRI-derived parameters (T2 and DWI) yields the highest diagnostic accuracy. The addition of more parameters does not improve diagnostic accuracy of primary PCa detection. MP [11C]Acetate PET-MRI facilitates improved local and distant staging, providing "one-stop" staging in patients with primary PCa, and therefore has the potential to improve therapy. PATIENT SUMMARY: In this report we investigated MP [11C]Acetate PET-MRI for detection, local and distant staging of prostate cancer. We demonstrate that MP [11C]Acetate PET-MRI with two MRI-derived parameters (T2 and DWI) achieves the best diagnostic accuracy for primary prostate cancer detection and that MP [11C]Acetate PET-MRI enables an improved local and distant staging.

Application of breast MRI for prediction of lymph node metastases - systematic approach using 17 individual descriptors and a dedicated decision tree.

BACKGROUND: The presence of lymph node metastases (LNMs) is one of the most important prognostic factors in breast cancer. PURPOSE: To correlate a detailed catalog of 17 descriptors in breast MRI (bMRI) with the presence of LNMs and to identify useful combinations of such descriptors for the prediction of LNMs using a dedicated decision tree. MATERIAL AND METHODS: A standardized protocol and study design was applied in this IRB-approved study (T1-weighted FLASH; 0.1 mmol/kg body weight Gd-DTPA; T2-weighted TSE; histological verification after bMRI). Two experienced radiologists performed prospective evaluation of the previously acquired examination in consensus. In every lesion 17 previously published descriptors were assessed. Subgroups of primary breast cancers with (N+: 97) and without LNM were created (N-: 253). The prevalence and diagnostic accuracy of each descriptor were correlated with the presence of LNM (chi-square test; diagnostic odds ratio/DOR). To identify useful combinations of descriptors for the prediction of LNM a chi-squared automatic interaction detection (CHAID) decision tree was applied. RESULTS: Seven of 17 descriptors were significantly associated with LNMs. The most accurate were "Skin thickening" (P < 0.001; DOR 5.9) and "Internal enhancement" (P < 0.001; DOR