Ultrasonographic Halo Score in giant cell arteritis: association with intimal hyperplasia and ischaemic sight loss.

OBJECTIVES: We investigated the relationship between the ultrasonographic Halo Score and temporal artery biopsy (TAB) findings in GCA. METHODS: This is a prospective study including 90 patients suspected of having GCA. Ultrasonography of temporal/axillary arteries and a TAB were obtained in all patients at baseline. An experienced pathologist evaluated whether TAB findings were consistent with GCA, and whether transmural inflammation, giant cells and intimal hyperplasia were present. Ultrasonographic Halo Scores were determined. Receiver operating characteristic analysis was performed. RESULTS: Twenty-seven patients had a positive TAB, while 32 patients with a negative TAB received a clinical diagnosis of GCA after 6 months of follow-up. Patients with a positive TAB showed higher Halo Scores than patients with a negative TAB. The presence of intimal hyperplasia in the biopsy, rather than the presence of transmural inflammation or giant cells, was associated with elevated Halo Scores in patients with GCA. The Halo Score discriminated well between TAB-positive patients with and without intimal hyperplasia, as indicated by an area under the curve of 0.82 in the receiver operating characteristic analysis. Patients with a positive TAB and intimal hyperplasia more frequently presented with ocular ischaemia (40%) than the other patients with GCA (13-14%). CONCLUSION: The ultrasonographic Halo Score may help to identify a subset of GCA patients with intimal hyperplasia, a TAB feature associated with ischaemic sight loss.

Diagnostic accuracy of magnetic resonance imaging (MRI) prostate imaging reporting and data system (PI-RADS) scoring in a transperineal prostate biopsy setting.

OBJECTIVES: To determine the sensitivity and specificity of multiparametric magnetic resonance imaging (mpMRI) for significant prostate cancer with transperineal sector biopsy (TPSB) as the reference standard. PATIENTS AND METHODS: The study included consecutive patients who presented for TPSB between July 2012 and November 2013 after mpMRI (T2- and diffusion-weighted images, 1.5 Tesla scanner, 8-channel body coil). A specialist uro-radiologist, blinded to clinical details, assigned qualitative prostate imaging reporting and data system (PI-RADS) scores on a Likert-type scale, denoting the likelihood of significant prostate cancer as follows: 1, highly unlikely; 3, equivocal; and 5, highly likely. TPSBs sampled 24-40 cores (depending on prostate size) per patient. Significant prostate cancer was defined as the presence of Gleason pattern 4 or cancer core length ≥6 mm. RESULTS: A total of 201 patients were included in the analysis. Indications were: a previous negative transrectal biopsy with continued suspicion of prostate cancer (n = 103); primary biopsy (n = 83); and active surveillance (n = 15). Patients' mean (±sd) age, prostate-specific antigen and prostate volumes were 65 (±7) years, 12.8 (±12.4) ng/mL and 62 (±36) mL, respectively. Overall, biopsies were benign, clinically insignificant and clinically significant in 124 (62%), 20 (10%) and 57 (28%) patients, respectively. Two of 88 men with a PI-RADS score of 1 or 2 had significant prostate cancer, giving a sensitivity of 97% (95% confidence interval [CI] 87-99) and a specificity of 60% (95% CI 51-68) at this threshold. Receiver-operator curve analysis gave an area under the curve of 0.89 (95% CI 0.82-0.92). The negative predictive value of a PI-RADS score of ≤2 for clinically significant prostate cancer was 97.7% CONCLUSION: We found that PI-RADS scoring performs well as a predictor for biopsy outcome and could be used in the decision-making process for prostate biopsy.

A rare case of postmenopausal hyperandrogenism due to ovarian hyperthecosis and hilus cell hyperplasia.

Postmenopausal hyperandrogenism is rare, and without consensus on specific investigative indices, diagnosis is challenging. A 77-year-old woman had a three-year history of hirsutism, male-pattern baldness and increased libido alongside elevated androstenedione, total testosterone and free androgen index levels. A magnetic resonance imaging (MRI) scan showed bilateral ovarian lesions, suggesting ovarian hyperthecosis. Histopathology obtained after a laparoscopic bilateral salpingo-oophorectomy confirmed ovarian hyperthecosis and hilus cell hyperplasia. We believe it's the first time they have been reported to occur in combination. The symptoms resolved within a month of surgery. This case highlights the difficulties of diagnosis alongside demonstrating the importance of management by a multidisciplinary team.

Testicular adrenal rest tumours in an adult patient with congenital adrenal hyperplasia.

Testicular adrenal rest tumours (TART) are found in patients with congenital adrenal hyperplasia (CAH) with the severity of testicular infiltration linearly related to the degree of enzymatic defect and subsequent compliance with treatment. We report a highly unusual case of TART in an adult patient with CAH caused by 21-hydroxylase deficiency who had not engaged with health services over a 3-year period. Typical imaging features of TART include bilateral well-defined lesions adjacent to the rete testes. However, in this rare case, the follow-up imaging found that the entirety of the testicular parenchyma had been replaced with TART and the patient had gone on to develop an adrenal nodule. As these testicular tumours are commonly misdiagnosed as primary germ tumours and tend respond well to treatment with circadian or reverse glucocorticoids, it is essential for the radiologist to be aware of both the common and more unusual imaging features appearances of TART in patients with CAH in order to facilitate early diagnosis and thus timely initiation of treatment.

Can contrast enhanced ultrasound differentiate benign cystic nephroma from malignant multicystic renal lesions? A case report.

Multicystic renal lesions pose a diagnostic dilemma and standard imaging may not be able to differentiate between benign or malignant lesions. Adult cystic nephroma and multicystic renal cell carcinoma are two such cystic renal lesions. We describe the appearance of cystic nephroma using contrast enhanced ultrasound. We hypothesize how quantitative parameters using time intensity curves appear to be able to distinguish between cystic nephroma and other malignant lesions such as multicystic renal cell carcinoma. This differentiation is of importance as it may obviate the need for tissue sampling and allow the clinician to recommend conservative management rather than nephrectomy.

Perineal recurrence of prostate cancer post-brachytherapy.

We present a rare case of perineal recurrence of prostate cancer post low dose rate brachytherapy. Increased levels of prostate-specific antigen were recorded 12 years post brachytherapy. Pelvic CT and MRI visualized a nodular lesion in the perineum, and positron emission tomography demonstrated choline-avidity. Ultrasound-guided biopsy of the nodule was performed, yielding histology consistent with prostatic adenocarcinoma. Metastatic prostatic seeding to the perineum is a rare complication of brachytherapy. We discuss the putative mechanism, approach to diagnosis, and management.

Multiparametric MRI appearances of primary granulomatous prostatitis.

OBJECTIVE: Radiological features of granulomatous prostatitis (GP) overlap with those of prostate adenocarcinoma. Identification of specific GP features may aid diagnosis. We aimed to evaluate the multiparametric MRI (mpMRI) features of GP. METHODS: We retrospectively reviewed 16 patients from a cohort undergoing mpMRI and transperineal sector-guided prostate biopsies between July 2012 and May 2017. Images were analysed for lesion location, shape, size, extracapsular extension, signal intensity (SI), apparent diffusion coefficient (ADC) values, dynamic contrast enhancement (DCE) pattern and PI-RADS (Prostate Imaging - Reporting and Data System) v2 score. RESULTS: Histology revealed 13 cases of nonspecific GP and 3 cases of xanthogranulomatous prostatitis. GP lesions were diffuse involving > 50% of the prostate ( n = 13) or nodular ( n = 3). Signal intensity on T 2 weighted imaging was low and high on diffusion-weighted imaging. ADC values were low (mean 702 ± 79 × 10-6 mm/s2 ). Five patients had DCE imaging with all cases 'positive' as per PI-RADS scoring, with two cases displaying further ring enhancement consistent with abscess formation. Overall PI-RADS score for all cases was 5, indicating high suspicion of prostate cancer. CONCLUSION: GP is difficult to differentiate from prostate cancer, but typically gives diffuse changes involving > 50% of the gland on mpMRI, with extracapsular extension and rim-enhancing areas. It should be considered a differential diagnosis in patients with recent urinary tract infection (UTI) or prior Bacillus Calmette-Guerin (BCG) treatment. ADVANCES IN KNOWLEDGE: Prostate MRI imaging features including diffuse changes, extracapsular extension and rim-enhancing areas, in patients with recent UTI or BCG treatment may help identify granulomatous prostatitis cases.

Metastatic Hurthle Cell Carcinoma of the thyroid presenting as a Breast Lump: A Case Report.

BACKGROUND: Hurthle cell carcinoma of the thyroid is a rare form of thyroid cancer. It may present as a low grade tumour or can present as a more aggressive metastatic carcinoma. Hurthle cell carcinoma has the highest incidence of metastasis among all differentiated thyroid cancers. Most commonly haematogenous spread to lungs, bones and brain, however spread to regional lymph nodes is not uncommon. The breast is a rare site for metastasis from extramammary sources. We present the first case of breast metastasis from Hurthle cell carcinoma of the thyroid. CASE PRESENTATION: We report a 77 year old lady who had total thyroidectomy and bilateral neck dissection followed by radiotherapy for a high grade metastatic Hurthle cell carcinoma of the thyroid. Ten months later she presented to the breast clinic with left breast lump and a lump at the left axilla. Fine needle aspiration cytology of the lumps and histology after wide local excision of the breast lump confirmed metastatic Hurthle cell carcinoma. CONCLUSION: The presence of breast lumps in patients with history of extramammary cancer should raise the possibility of metastasis.

Multiparametric ultrasound findings of tuberculous orchitis following bacillus Calmette-Guérin therapy.

Granulomatous bacillus Calmette-Guérin (BCG) infection, both localized and disseminated, as a complication of intravesical therapy for transitional cell carcinoma of the bladder is a recognized but highly unusual phenomenon. We report the case of an 89-year-old gentleman with a history of bladder transitional cell carcinoma and subsequent intravesical BCG instillation of the bladder who presented to his general practitioner with a non-tender lump in his left testis. Histopathologic and microbiological evaluation of the subsequent orchidectomy specimen revealed granuloma formation secondary to BCG infection. The use of bubble contrast agents and elastography in ultrasound to evaluate focal testicular lesions is a relatively novel concept, and we aim to highlight the imaging features of testicular BCG infection using these techniques.

Triparametric ultrasound in differentiating multicystic renal masses: a rare presentation of unilateral focal renal lymphangioma.

We describe a rare case of renal lymphangioma presenting as a focal unilateral multicystic renal mass and document the first reported use of triparametric ultrasound (B-mode, Doppler, and contrast-enhanced ultrasound) in its diagnosis and discrimination from other focal multicystic lesions. Renal lymphangiomas are rare, benign, typically developmental lesions composed of cystic dilatation of the lymphatic ducts, usually occurring bilaterally as perinephric collections or parapelvic cysts mimicking hydronephrosis. Radiologists have an important role in suggesting the diagnosis, as clinical presentation can be nonspecific. Management is usually conservative; however, nephron-sparing surgery may be recommended in symptomatic individuals.

Toward an MRI-based nomogram for the prediction of transperineal prostate biopsy outcome: A physician and patient decision tool.

PURPOSE: To develop and internally validate a nomogram using biparametric magnetic resonance imaging (B-MRI)-derived variables for the prediction of prostate cancer at transperineal sector-guided prostate biopsy (TPSB). SUBJECTS/PATIENTS AND METHODS: Consecutive patients referred to our institution with raised prostate-specific antigen (PSA), abnormal prostate examination, or persistent suspicion of prostate cancer after previous transrectal biopsy between July 2012 and November 2015 were reviewed from a prospective database. All patients underwent prebiopsy B-MRI with T2-weighted and diffusion-weighted imaging sequences, followed by 24 to 40 core TPSB with additional targeted cores using cognitive registration. Univariable and multivariable logistic regression analysis was used to determine predictors of prostate cancer outcomes. Multivariable coefficients were used to construct 2 MRI-based nomograms to predict any and significant (Gleason 4 or maximum cancer core length ≥6mm) prostate cancer at TPSB. Bootstrap resamples were used for internal validation. Accuracy was assessed by calculating the concordance index. RESULTS: In total, 615 men were included in the study. Prostate cancer was diagnosed in 317 (51.5%) men with significant cancer diagnosed in 237 (38.5%) men. Age, Prostate Imaging Reporting and Data System (PI-RADS) score, PSA, PSA density, and primary biopsy were predictors of prostate cancer at TPSB on univariable analysis (P<0.0001). PSA showed strong correlation with PSA density and was excluded. The remaining variables were all independent predictors of prostate cancer on multivariable analysis (P<0.0001) and used to generate the nomograms. Both nomograms showed good discrimination for prostate cancer, with a concordance index of 87% for any cancer and 92% for significant disease. Using a nomogram-derived probability threshold of<15%, 111 (18.0%) biopsies can be saved, at the expense of 3 missed significant prostate cancers. CONCLUSIONS: These internally validated MR-based nomograms were able to accurately predict TPSB outcomes for prostate cancer, especially significant disease. Our findings support the combination of prebiopsy MRI results and clinical factors as part of the biopsy decision-making process.

Diagnostic value of MRI-based PSA density in predicting transperineal sector-guided prostate biopsy outcomes.

PURPOSE: Prostate-specific antigen (PSA) density (PSAD) has potential to increase the diagnostic utility of PSA, yet has had poor uptake in clinical practice. We aimed to determine the diagnostic value of magnetic resonance imaging-derived PSAD (MR-PSAD) in predicting transperineal sector-guided prostate biopsy (TPSB) outcomes. MATERIALS AND METHODS: Men presenting for primary TPSB from 2007 to 2014 were considered. Histological outcomes were assessed and defined as: presence of any cancer or significant cancer defined as presence of Gleason 4 and/or maximum tumour core length (MCCL) ≥ 4 mm (G4); or Gleason 4 and/or MCCL ≥ 6 mm (G6). Sensitivity, specificity and positive and negative predictive values were calculated, and receiver operating characteristics (ROC) curves were generated to compare MR-PSAD and PSA. RESULTS: Six hundred fifty-nine men were evaluated with mean age 62.5 ± 9 years, median PSA 6.7 ng/ml (range 0.5-40.0), prostate volume 40 cc (range 7-187) and MR-PSAD 0.15 ng/ml/cc (range 0.019-1.3). ROC area under the curve (95% CI) was significantly better for MR-PSAD than PSA for all cancer definitions (p < 0.001): 0.73 (0.70-0.76) versus 0.61 (0.57-0.64) for any cancer; 0.75 (0.71-0.78) versus 0.66 (0.62-0.69) for G4; and 0.77 (0.74-0.80) versus 0.68 (0.64-0.71) for G6. Sensitivities for MR-PSAD < 0.1 ng/ml/cc were 85.0, 89.9 and 91.9% for any, G4 and G6 cancer, respectively. CONCLUSION: MR-PSAD may be better than total PSA in determining risk of positive biopsy outcome. Its use may improve risk stratification and reduce unnecessary biopsies.

Radiologic presentation of chronic granulomatous prostatitis mimicking locally advanced prostate adenocarcinoma.

We present a case of nonspecific granulomatous prostatitis (GP), a clinical mimic of prostate adenocarcinoma. A 54-year-old man presented with lower urinary tract symptoms and raised prostate-specific antigen. Magnetic resonance imaging showed features consistent with prostate cancer, including low T2-signal intensity in the peripheral and transition zones with signs of extracapsular extension. Diffusion-weighted imaging showed high-signal intensity, with low apparent diffusion coefficient values, whereas dynamic contrast enhancement demonstrated a type 3 washout curve, similar to that found in prostate cancer. Transperineal sector-guided prostate biopsy confirmed nonspecific GP, and the patient was treated conservatively. We discuss and compare nonspecific, chronic GP as a radiologic mimic of prostate adenocarcinoma patient.

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study.

BACKGROUND: Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9-61% of true cases. OBJECTIVE: To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. DESIGN: Prospective multicentre cohort study. SETTING: Secondary care. PARTICIPANTS: A total of 381 patients referred with newly suspected GCA. MAIN OUTCOME MEASURES: Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. RESULTS: We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician's assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). LIMITATIONS: There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. CONCLUSION: We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. FUTURE WORK: Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. FUNDING: The National Institute for Health Research Health Technology Assessment programme.