MRI-guided in-bore biopsy for prostate cancer: what does the evidence say? A case series of 554 patients and a review of the current literature.

PURPOSE: To review our experience with MRI-guided in-bore prostate biopsy (MRGB) and present a review of the literature on MRGB. METHODS: A retrospective review of patients presenting for MRGB between 2013 and 2018. Diagnostic and biopsy MRI scans were reviewed to collect data on scan dates, procedure times, characteristics of MRI targets (PI-RADS™ score, target size, ADC value and location). A review of the literature on MRGB for the period 2013-2018 was performed. RESULTS: 607 targets in 554 men were biopsied. Overall and significant cancer detection rate were 80% and 55% at a patient level, and 76 and 59% at the target level, respectively. Prostate cancer (CaP) detection in men with prior negative biopsy was 60% while 50% of men on active surveillance were upgraded to clinically significant disease (CSD). Lesion location did not predict for presence of CaP or CSD. PI-RADS™ score, age and PSAD were predictors of CSD at biopsy on multivariate analysis. Literature review identified 23 reports reporting on MRGB cohorts (~ 4000 patients). Overall cancer detection ranged from 23 to 74% and CSD in 63% overall. CaP detection in PI-RADS™ 3 targets was substantially lower in our series and the literature than for PI-RADS™ 4-5 targets. CONCLUSIONS: MRGB in PI-RADS™ 3-5 targets yields high rates of cancer diagnosis. High detection rates are also seen in men with prior negative biopsy and AS cohorts. PI-RADS™ score, age and PSAD can reliably predict CSD detection. The number of published series is small and the role of MRGB in PI-RADS™ 3 targets needs further study.

Osteogenic Sarcoma in an Adolescent With Cystic Fibrosis: Successful Treatment Despite Significant Obstacles.

Introduction: We describe the case of a 16-year old male with cystic fiborosis (CF) who presented with an osteosarcoma of his right distal tibia. Case Report: Treatment consisted of neoadjuvant chemotherapy of cisplatin, doxorubicin and high dose methotrexate followed by distal tibial resection and free fibula flap reconstruction and consolidation chemotherapy. Treatment was complicated by a pulmonary exacerbation, where Pseudomonas aeruginosa (PsA) and Staphylococcus aureus were grown on sputum culture which was treated with a 2-week course of intravenous piptazobactam and tobramycin. Mycobacterium intracellulare and Mycobacterium abscessus were also cultured following commencement of chemotherapy and successfully treated with a 6-month course of oral azithromycin, ethambutol, and moxifloxacin along with a 1-month course of inhaled amikacin. Pulmonary function improved during his treatment from baseline FEV1 of 3.8 l (93.9%) to 4.15 l (102.3% predicted) whilst nutritional status remained stable. Discussion: The combination of CF and osteosarcoma is rare with only one previous case reported (1). Our case is instructive as the patient faced the challenge of chronic PsA and the first reported culturing and successful treatment of non-tuberculous mycobacterium (NTM) during chemotherapy. Fatal outcomes have been reported previously for CF patients during immunosuppression (2). In concordance with our findings, a recent report noted an improvement in respiratory function in a child treated for leukemia (3). The anti-inflammatory nature of some chemotherapy agents could be responsible for the observed clinical improvement in CF with low dose methotrexate having been shown to increase FEV1 in adolescents with advanced CF (4). Whilst doxorubicin could improve pulmonary outcomes through increased total cellular CFTR protein expression and CFTR associated chloride secretion (5). It is hypothesized that the improved pulmonary function in patients with CF who require chemotherapy could be due to increased production of Multi-Drug Resistance Proteins (MDR) and Multi-Drug Resistant Associated Proteins (MRP) that may complement the depleted CFTR protein (6). Concluding Remarks: We report the well-tolerated management of osteosarcoma in a patient with CF including the first reported identification and eradication of NTM during chemotherapy. The observed positive pulmonary outcome following chemotherapy highlights several potential cellular mechanisms that deserve to be explored.

Diagnosis in subdural myeloid sarcoma.

Introduction A 74-year-old man presented to hospital with a headache, thrombocytopaenia and an acute deterioration in cognition on a background of acute monocytic leukaemia in remission. Method This is a case report with computed tomography (CT), magnetic resonance (MR) and histopathology imaging. Results Preoperative CT and limited MR demonstrated a subdural lesion with marked midline shift. Craniotomy performed for evacuation of the presumed subdural haematoma revealed a solid tumour-like lesion. Histopathology identified the presence of a myeloid sarcoma (chloroma). Postoperative MRI with contrast revealed the solid nature of the mass. Conclusion The use of contrast is critical in the assessment of intracranial lesions to distinguish myeloid sarcoma from subdural haematoma in the context of leukaemia and a neurologically deteriorating patient.

Septic Arthritis of the Temporomandibular Joint in an Infant.

Infantile temporomandibular joint septic arthritis is an uncommon paediatric infection, but one which carries the potential for severe morbidity and mortality. Early diagnosis and aggressive medical and possibly surgical management is indicated for the best outcomes. The presenting clinical features are non-specific in a neonate and an infant; as such a high degree of clinical suspicion is required. We present the case of an eleven-month-old boy who has made a full recovery from an acute temporomandibular joint septic arthritis and review the relevant literature.