The impact of nutritional risk factors and sarcopenia on survival in patients treated with pelvic exenteration for recurrent gynaecological malignancy: a retrospective cohort study.

PURPOSE: The aim of the present study is to investigate the prognostic significance of nutritional risk factors and sarcopenia on the outcome of patients with recurrent gynaecological malignancies treated by pelvic exenteration. METHODS: We retrospectively evaluated muscle body composite measurements based on pre-operative CT scans, nutritional risk factors as assessed by a validated pre-operative questionnaire, and clinical-pathological parameters in 65 consecutive patients with recurrent gynaecological malignancies, excluding ovarian cancer, treated by pelvic exenteration at the Royal Marsden Hospital London. Predictive value for postoperative morbidity was investigated by logistic regression analyses. Relevant parameters were included in uni- and multivariate survival analyses. RESULTS: We found only (1) low muscle attenuation (MA)-an established factor for muscle depletion-and (2) moderate risk for malnutrition to be independently associated with shorter overall survival (p = 0.006 and p = 0.008, respectively). MA was significantly lower in overweight and obese patients (p = 0.04). Muscle body composite measurements were not predictive for post-operative morbidity. CONCLUSION: The study suggests that pre-operative low MA and moderate risk for malnutrition are associated with shorter survival in patients with recurrent gynaecological malignancies treated with pelvic exenteration. Further studies are needed to validate these findings in larger cohorts.

Psychosocial effects of whole-body MRI screening in adult high-risk pathogenic TP53 mutation carriers: a case-controlled study (SIGNIFY).

BACKGROUND: Germline TP53 gene pathogenic variants (pv) cause a very high lifetime risk of developing cancer, almost 100% for women and 75% for men. In the UK, annual MRI breast screening is recommended for female TP53 pv carriers. The SIGNIFY study (Magnetic Resonance Imaging screening in Li Fraumeni syndrome: An exploratory whole body MRI) study reported outcomes of whole-body MRI (WB-MRI) in a cohort of 44 TP53 pv carriers and 44 matched population controls. The results supported the use of a baseline WB-MRI screen in all adult TP53 pv carriers. Here we report the acceptability of WB-MRI screening and effects on psychosocial functioning and health-related quality of life in the short and medium terms. METHODS: Psychosocial and other assessments were carried out at study enrolment, immediately before MRI, before and after MRI results, and at 12, 26 and 52 weeks' follow-up. RESULTS: WB-MRI was found to be acceptable with high levels of satisfaction and low levels of psychological morbidity throughout. Although their mean levels of cancer worry were not high, carriers had significantly more cancer worry at most time-points than controls. They also reported significantly more clinically significant intrusive and avoidant thoughts about cancer than controls at all time-points. There were no clinically significant adverse psychosocial outcomes in either carriers with a history of cancer or in those requiring further investigations. CONCLUSION: WB-MRI screening can be implemented in TP53 pv carriers without adverse psychosocial outcomes in the short and medium terms. A previous cancer diagnosis may predict a better psychosocial outcome. Some carriers seriously underestimate their risk of cancer. Carriers of pv should have access to a clinician to help them develop adaptive strategies to cope with cancer-related concerns and respond to clinically significant depression and/or anxiety.

Multiparametric MR imaging for detection of clinically significant prostate cancer: a validation cohort study with transperineal template prostate mapping as the reference standard.

PURPOSE: To evaluate the diagnostic performance of multiparametric (MP) magnetic resonance (MR) imaging for prostate cancer detection by using transperineal template prostate mapping (TTPM) biopsies as the reference standard and to determine the potential ability of MP MR imaging to identify clinically significant prostate cancer. MATERIALS AND METHODS: Institutional review board exemption was granted by the local research ethics committee for this retrospective study. Included were 64 men (mean age, 62 years [range, 40-76]; mean prostate-specific antigen, 8.2 ng/mL [8.2 µg/L] [range, 2.1-43 ng/mL]), 51 with biopsy-proved cancer and 13 suspected of having clinically significant cancer that was biopsy negative or without prior biopsy. MP MR imaging included T2-weighted, dynamic contrast-enhanced and diffusion-weighted imaging (1.5 T, pelvic phased-array coil). Three radiologists independently reviewed images and were blinded to results of biopsy. Two-by-two tables were derived by using sectors of analysis of four quadrants, two lobes, and one whole prostate. Primary target definition for clinically significant disease necessary to be present within a sector of analysis on TTPM for that sector to be deemed positive was set at Gleason score of 3+4 or more and/or cancer core length involvement of 4 mm or more. Sensitivity, negative predictive value, and negative likelihood ratio were calculated to determine ability of MP MR imaging to rule out cancer. Specificity, positive predictive value, positive likelihood ratio, accuracy (overall fraction correct), and area under receiver operating characteristic curves were also calculated. RESULTS: Twenty-eight percent (71 of 256) of sectors had clinically significant cancer by primary endpoint definition. For primary endpoint definition (≥ 4 mm and/or Gleason score ≥ 3+4), sensitivity, negative predictive value, and negative likelihood ratios were 58%-73%, 84%-89%, and 0.3-0.5, respectively. Specificity, positive predictive value, and positive likelihood ratios were 71%-84%, 49%-63%, and 2.-3.44, respectively. Area under the curve values were 0.73-0.84. CONCLUSION: Results of this study indicate that MP MR imaging has a high negative predictive value to rule out clinically significant prostate cancer and may potentially have clinical use in diagnostic pathways of men at risk.

Clinical utility of diffusion-weighted magnetic resonance imaging in prostate cancer.

UNLABELLED: What's known on the subject? and What does the study add? This article reviews what is currently known about diffusion weighted MRI (DW-MRI) in prostate cancer. This mini-review concisely summarises, for clinical managing patients with prostate cancer, the clinical utility of diffusion weighted MRI. OBJECTIVE: • To review the clinical utility of diffusion-weighted magnetic resonance imaging (DW-MRI) in patients with prostate cancer. MATERIAL AND METHODS: • The current literature on prostate cancer and DW-MRI was reviewed. RESULTS: • DW-MRI can be readily acquired on a modern scanner with a short image acquisition time and no need for i.v. contrast medium. • The image contrast is based on the diffusion of water molecules and thus reflects tissue cellularity. • There is increasing evidence that DW- MRI improves the sensitivity and specificity of prostate cancer detection as well as the identification of tumour aggressiveness. • DW-MRI is also showing substantial promise as a response biomarker for both local and metastatic disease CONCLUSIONS: • DW-MRI is proving to be a useful adjunct to conventional T2-weighted MRI sequences. • The eventual role of DW-MRI in combination with other MRI techniques for multiparametric assessment of prostate cancer needs to be defined further.

Detection and staging of radio-recurrent prostate cancer using multiparametric MRI.

OBJECTIVE: We determined the sensitivity and specificity of multiparametric magnetic resonance imaging (MP-MRI) in detection of locally recurrent prostate cancer and extra prostatic extension in the post-radical radiotherapy setting. Histopathological reference standard was whole-mount prostatectomy specimens. We also assessed for any added value of the dynamic contrast enhancement (DCE) sequence in detection and staging of local recurrence. METHODS: This was a single centre retrospective study. Participants were selected from a database of males treated with salvage prostatectomy for locally recurrent prostate cancer following radiotherapy. All underwent pre-operative prostate-specific antigen assay, positron emission tomography CT, MP-MRI and transperineal template prostate mapping biopsy prior to salvage prostatectomy. MP-MRI performance was assessed using both Prostate Imaging-Reporting and Data System v. 2 and a modified scoring system for the post-treatment setting. RESULTS: 24 patients were enrolled. Using Prostate Imaging-Reporting and Data System v. 2, sensitivity, specificity, positive predictive value and negative predictive value was 64%, 94%, 98% and 36%. MP-MRI under staged recurrent cancer in 63%. A modified scoring system in which DCE was used as a co-dominant sequence resulted in improved diagnostic sensitivity (61%-76%) following subgroup analysis. CONCLUSION: Our results show MP-MRI has moderate sensitivity (64%) and high specificity (94%) in detecting radio-recurrent intraprostatic disease, though disease tends to be under quantified and under staged. Greater emphasis on dynamic contrast images in overall scoring can improve diagnostic sensitivity. ADVANCES IN KNOWLEDGE: MP-MRI tends to under quantify and under stage radio-recurrent prostate cancer. DCE has a potentially augmented role in detecting recurrent tumour compared with the de novo setting. This has relevance in the event of any future modified MP-MRI scoring system for the irradiated gland.

Computed tomography in metastatic renal cell carcinoma.

Recent developments in chemotherapy have resulted in several new drug treatments for metastatic renal cell carcinoma (RCC). These therapies have shown improved progression-free survival and are applicable to many more patients than the conventional cytokine-based treatments for metastatic RCC. Consequently imaging is playing a greater part in the management of such patients. Computed tomography (CT) remains the primary imaging modality with other imaging modalities playing a supplementary role. CT is used in the diagnosis and staging of metastatic RCC. It is used in the follow-up of patients after nephrectomy, in assessing the extent of metastatic disease, and in evaluating response to treatment. This review looks at the role of CT in patients with metastatic RCC and describes the appearances of metastatic RCC before and following systemic therapy.

The role of imaging in the diagnosis, staging, and management of testicular cancer.

OBJECTIVE: The objective of this article is to describe recent developments in imaging patients with testicular germ cell tumors (GCTs). CONCLUSION: Most patients with testicular GCTs can now be expected to be cured, so the focus on management moves toward identifying patients who need more aggressive treatment and avoiding long-term complications. CT remains central in the selection of a management strategy, although the roles of MRI and PET continue to evolve.

MR imaging features of vaginal malignancies.

Primary vaginal malignancies are rare, accounting for only 1%-2% of all gynecologic malignancies. Squamous cell carcinoma makes up about 85% of primary vaginal malignancies. This tumor characteristically arises from the posterior wall of the upper third of the vagina. The main patterns of disease are an ulcerating or fungating mass or an annular constricting lesion. At magnetic resonance (MR) imaging, squamous cell carcinoma has intermediate signal intensity on T2-weighted images and low signal intensity on T1-weighted images. The tumors that account for the remaining 15% of primary vaginal malignancies are adenocarcinoma, melanoma, and sarcomas. The signal intensity characteristics on MR images correlate with the histologic subtypes and reflect the MR imaging appearances of these histologic subtypes elsewhere in the body. Secondary malignancy of the vagina is far more frequent than primary vaginal malignancy. Most vaginal metastases occur by means of direct local spread from the cervix, uterus, or rectum. The MR imaging appearances of these metastases reflect the MR imaging appearances of the primary tumor.

Assessing intra-fractional bladder motion using cine-MRI as initial methodology for Predictive Organ Localization (POLO) in radiotherapy for bladder cancer.

AIM: To assess the feasibility of using cine-MR to study intra-fractional time-volume and volume-deformity patterns of the bladder during radiotherapy as initial methodology for Predictive Organ Localization (POLO). METHODS: Nine patients receiving radiotherapy for localized muscle invasive bladder cancer were prospectively studied. Each had an MR scan performed on an empty bladder using a T1 weighted cine sequence over a period of 20 min. Scans were taken prior to, and repeated towards the end of, radiotherapy treatment. Time-volume sequences were determined and compared before and during radiotherapy. Absolute bladder volumes were then correlated with changes in bladder wall position. RESULTS: The mean post void residual bladder volume prior to radiotherapy at time 0 was 113 cm(3) [SD 53] and this did not differ significantly during radiotherapy -106 cm [SD 40] (p=0.24, paired t-test analysis). A linear relationship was observed for the rate bladder filling over a 20 min period, which did not significantly change on the cine-MR during radiotherapy (regression coefficient 2.1 vs 1.6, respectively, p=0.51). Significant positive relationships were seen between volume and anterior (p=0.02), superior (p<0.001), and inferior (p=0.03) wall motion. These relationships were complex, though linearity was observed for volumes up to 150 cm(3). The 1.5 cm CTV-PTV margin was sufficient to account for expansion in the majority of cases with the only breach occurring on the anterior wall in one patient. CONCLUSIONS: This study confirms the feasibility of using cine-MR for POLO. The development of such predictive methodology may compensate for the need to use an isotropic CTV-PTV margin to simply cover bladder filling when using image-guided radiotherapy.

Outcome of early detection and radiotherapy for occult spinal cord compression.

Retrospective analysis in 150 patients with metastatic prostate cancer was conducted to determine whether early detection with MRI spine and treatment of clinically occult spinal cord compromise (SCC) facilitate preservation of neurologic function. Our results suggest that prophylactic radiotherapy for patients with back pain or radiological SCC without neurologic deficit may facilitate preservation of neurologic function. Thus MRI surveillance for SCC may be important for prostate cancer patients with bone metastases.

Imaging in metastatic renal cell carcinoma.

OBJECTIVE: Metastatic disease occurs in a significant percentage of patients with renal cell carcinoma. Recent advances in systemic therapies for metastatic renal cell carcinoma are likely to have a significant effect on the way patients with advanced disease are imaged. These new therapies have shown a significant increase in progression-free survival. CONCLUSION: Imaging is likely to play an increasing role in the management, diagnosis, and monitoring of response to treatment of metastatic renal cell carcinoma.

Baseline results from the UK SIGNIFY study: a whole-body MRI screening study in TP53 mutation carriers and matched controls.

In the United Kingdom, current screening guidelines for TP53 germline mutation carriers solely recommends annual breast MRI, despite the wide spectrum of malignancies typically seen in this group. This study sought to investigate the role of one-off non-contrast whole-body MRI (WB MRI) in the screening of asymptomatic TP53 mutation carriers. 44 TP53 mutation carriers and 44 population controls were recruited. Scans were read by radiologists blinded to participant carrier status. The incidence of malignancies diagnosed in TP53 mutation carriers against general population controls was calculated. The incidences of non-malignant relevant disease and irrelevant disease were measured, as well as the number of investigations required to determine relevance of findings. In TP53 mutation carriers, 6 of 44 (13.6, 95% CI 5.2-27.4%) participants were diagnosed with cancer during the study, all of which would be considered life threatening if untreated. Two were found to have two primary cancers. Two participants with cancer had abnormalities on the MRI which were initially thought to be benign (a pericardial cyst and a uterine fibroid) but transpired to be sarcomas. No controls were diagnosed with cancer. Fifteen carriers (34.1, 95% CI 20.5-49.9%) and seven controls (15.9, 95% CI 6.7-30.1%) underwent further investigations following the WB MRI for abnormalities that transpired to be benign (p = 0.049). The cancer detection rate in this group justifies a minimum baseline non-contrast WB MRI in germline TP53 mutation carriers. This should be adopted into national guidelines for management of adult TP53 mutation carriers in addition to the current practice of contrast enhanced breast MRI imaging.

A comparison of CT- and ultrasound-based imaging to localize the prostate for external beam radiotherapy.

PURPOSE: This study assesses the accuracy of NOMOS B-mode acquisition and targeting system (BAT) compared with computed tomography (CT) in localizing the prostate. METHODS AND MATERIALS: Twenty-six patients were CT scanned, and the prostate was localized by 3 observers using the BAT system. The BAT couch shift measurements were compared with the CT localization. Six of the patients had gold markers present in the prostate, and the prostate movement determined by BAT was compared with the movement determined by the gold markers. RESULTS: Using the BAT system, the 3 observers determined the prostate position to be a mean of 1-5 mm over all directions with respect to the CT. The proportion of readings with a difference >3 mm between the observers was in the range of 25% to 44%. The prostate movement based on gold markers was an average of 3-5 mm different from that measured by BAT. The literature assessing the accuracy and reproducibility on BAT is summarized and compared with our findings. CONCLUSIONS: We have found that there are systematic differences between the BAT-defined prostate position compared with that estimated on CT using gold grain marker seeds.

Diffusion-weighted MRI for detecting prostate tumour in men at increased genetic risk.

BACKGROUND: Diffusion-weighted (DW)-MRI is invaluable in detecting prostate cancer. We determined its sensitivity and specificity and established interobserver agreement for detecting tumour in men with a family history of prostate cancer stratified by genetic risk. METHODS: 51 men with a family history of prostate cancer underwent T2-W + DW-endorectal MRI at 3.0 T. Presence of tumour was noted at right and left apex, mid and basal prostate sextants by 2 independent observers, 1 experienced and the other inexperienced in endorectal MRI. Sensitivity and specificity against a 10-core sampling technique (lateral and medial cores at each level considered together) in men with >2× population risk based on 71 SNP analysis versus those with lower genetic risk scores was established. Interobserver agreement was determined at a subject level. RESULTS: Biopsies indicated cancer in 28 sextants in 13/51 men; 32 of 51 men had twice the population risk (>0.25) based on 71 SNP profiling. Sensitivity/specificity per-subject for patients was 90.0%/86.4% (high-risk) vs. 66.7%/100% (low-risk, observer 1) and 60.0%/86.3% (high-risk) vs. 33.3%/93.8% (low-risk, observer 2) with moderate overall inter-observer agreement (kappa = 0.42). Regional sensitivities/specificities for high-risk vs. low-risk for observer 1 apex 72.2%/100% [33.3%/100%], mid 100%/93.1% [100%/97.3%], base 16.7%/98.3% [0%/100%] and for observer 2 apex 36.4%/98.1% [0%/100%], mid 28.6%/96.5% [100%/100%], base 20%/100% [0%/97.3%] were poorer as they failed to detect multiple lesions. CONCLUSION: Endorectal T2W + DW-MRI at 3.0 T yields high sensitivity and specificity for tumour detection by an experienced observer in screening men with a family history of prostate cancer and increased genetic risk.

The normal post-surgical anatomy of the male pelvis following radical prostatectomy as assessed by magnetic resonance imaging.

The magnetic resonance imaging (MRI) appearances of recurrent prostate cancer following radical prostatectomy have been documented in the radiology literature; however little has been written on the range of normal post-operative appearances. Common routes of surgical access for radical prostatectomy include retropubic and transperineal, although newer minimally invasive methods are gaining increasing acceptance. Specifically the range of appearances of the anastomotic site, the prostatic bed, the position of the bladder base, periurethral tissue, levator sling, rectum and residual seminal vesicles (if present) are demonstrated. A non-enhancing low signal nodule is frequently seen at the vesicourethral anastomosis or within the seminal vesicle remnant and usually represents fibrosis. Appearances following different surgical accesses do not differ tremendously, although the retropubic fat pad is reduced or absent following a retropubic approach. Anterior rectal-wall scarring may be present following a transperineal approach. Other post-surgical findings that may mimic disease include a lymphocoele and injected bladder-neck bulking agent. Many patients referred for MRI following radical prostatectomy will have a pathological study showing disease recurrence, although in non-pathological studies the radiological features can differ significantly. It is important for the radiologist to be aware of the spectrum of normal post-surgical appearances so not to confuse these with locally recurrent disease.