Clinically Significant Prostate Cancer Detection After a Negative Prebiopsy MRI Examination: Comparison of Biparametric Versus Multiparametric MRI.

BACKGROUND. The frequency of clinically significant prostate cancer (csPCa) following negative biparametric MRI (bpMRI) and multiparametric MRI (mpMRI) has not been well investigated in direct comparative studies. OBJECTIVE. The purposes of this study were to compare the frequency of csPCa after negative prebiopsy bpMRI and mpMRI and to evaluate factors predictive of csPCa in the two cohorts. METHODS. This retrospective study included 232 men (mean age, 64.5 years) with negative bpMRI from August 2017 to March 2020 and 193 men (mean age, 69.0 years) with negative mpMRI from January 2018 to December 2018. PI-RADS category 1 or 2 was defined as negative. The study institution offered bpMRI as a low-cost self-pay option for patients without insurer coverage of prebiospy mpMRI. Patient characteristics and subsequent biopsy results were recorded. CsPCa was defined as Gleason score of 3 + 4 or greater. Multivariable regression analyses were performed to identify independent predictors of csPCa. The AUC of PSA density (PSAD) for csPCA was computed, and the diagnostic performance of PSAD was assessed at a clinically established threshold of 0.15 ng/mL2. RESULTS. Systematic biopsy was performed after negative bpMRI for 41.4% (96/232) of patients and after negative mpMRI for 30.5% (59/193) (p = .02). Among those undergoing biopsy, csPCa was present in 15.6% (15/96) in the bpMRI cohort versus 13.6% (8/59) in the mpMRI cohort (p = .69). The NPV for csPCa was 84% (81/96) for bpMRI and 86% (51/59) for mpMRI. In multivariable analyses, independent predictors of csPCa included smaller prostate volume (OR, 0.27; p < .001) and greater PSAD (OR, 3.09; p < .001). In multivariable models, bpMRI (compared with mpMRI) was not independently predictive of csPCa (p > .05). PSAD had an AUC for csPCa of 0.71 (95% CI, 0.56-0.87) in the bpMRI cohort versus 0.68 (95% CI, 0.42-0.93) in the mpMRI cohort. For detecting csPCa, a PSAD threshold of 0.15 ng/mL2 had NPV of 90% and PPV of 28%, in the bpMRI cohort versus NPV of 92% and PPV of 44% in the mpMRI cohort. CONCLUSION. The frequencies of csPCa were not significantly different at systematic biopsy performed after negative bpMRI and mpMRI examinations. PSAD had similar diagnostic utility for csPCa in the two cohorts. CLINICAL IMPACT. Either bpMRI or mpMRI, in combination with PSAD measurement, can help avoid negative prostate biopsies.

Mesenchymal Neoplasms of the Prostate and Seminal Vesicles: Spectrum of Disease with Radiologic-Pathologic Correlation.

There is a wide spectrum of benign and malignant mesenchymal neoplasms of the prostate, which account for less than 1% of all prostatic tumors. These include distinctive tumors that arise from the specialized prostatic stroma and site-agnostic neoplasms such as smooth muscle tumors, fibrous or myofibroblastic neoplasms, neurogenic tumors, vascular tumors, and a plethora of sarcomas. Select tumors show classic sites of origin within the prostate. While stromal tumors of uncertain malignant potential (STUMPs) commonly involve the peripheral zone at the prostate base, leiomyomas typically originate from the central prostate toward the apex. Some "prostatic" neoplasms such as gastrointestinal stromal tumors, solitary fibrous tumor (SFT), paragangliomas, and neurogenic tumors arise primarily from periprostatic soft tissues. Most mesenchymal tumors of the prostate and seminal vesicles manifest as large tumors that cause nonspecific symptoms; prostate-specific antigen level is not typically elevated. Diverse mesenchymal neoplasms demonstrate characteristic histopathologic and immunocytochemical features and variable cross-sectional imaging findings. While leiomyoma and SFT typically display low signal intensity on T2-weighted images, synovial sarcomas commonly show hemorrhage. Diagnosis is difficult because of the rarity and lack of awareness of the tumors and the significant overlap in histopathologic features. Select tumors show characteristic genetic abnormalities that allow the diagnosis to be established. For example, more than 90% of SFTs are characterized by a unique NAB2-STAT6 gene fusion, and more than 95% of synovial sarcomas are associated with a distinctive SYT-SSX chimeric transcript. Accurate diagnosis is imperative for optimal management owing to markedly different tumor biology as well as attendant therapeutic and prognostic implications. While STUMPs commonly recur, sarcomas typically charter an aggressive course with poor prognosis. Online supplemental material is available for this article. ©RSNA, 2022.

Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

Diagnosis of Anastomotic Leak.

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

Sarcopenia is associated with worse overall survival in patients with anal squamous cell cancer.

BACKGROUND AND OBJECTIVES: Sarcopenia is associated with poor long-term outcomes in many gastrointestinal cancers, but its role in anal squamous cell carcinoma (ASCC) is not defined. We hypothesized that patients with sarcopenic ASCC experience worse long-term outcomes. METHODS: A retrospective review of patients with ASCC treated at an academic medical center from 2006 to 2017 was performed. Of 104 patients with ASCC, 64 underwent PET/computed tomography before chemoradiation and were included in the analysis. The skeletal muscle index was calculated as total L3 skeletal muscle divided by height squared. Sarcopenia thresholds were 52.4 cm2 /m2 for men and 38.5 cm2 /m2 for women. Cox regression analysis was performed to assess overall and progression-free survival. RESULTS: Twenty-five percent of the patients were sarcopenic (n = 16). Demographics were similar between groups. There was no difference in the clinical stage or comorbidities between groups. On multivariate analysis, factors associated with worse overall survival were male gender (hazard ratio [HR] 3.7, P = .022) and sarcopenia (HR 3.6, P = .019). Male gender was associated with worse progression-free survival (HR 2.6, P = .016). CONCLUSIONS: Sarcopenia is associated with worse overall survival in patients with anal cancer. Further studies are indicated to determine if survival can be improved with increased attention to nutritional status in sarcopenic patients.

Characterization of long-term prognosis in acute pancreatitis: An explorative analysis.

BACKGROUND/OBJECTIVES: Severity classification systems of acute pancreatitis (AP) assess inpatient morbidity and mortality without predicting outpatient course of AP. To provide appropriate outpatient care, determinants of long-term prognosis must also be identified. The aim of this study was to define clinical groups that carry long-term prognostic significance in AP. METHODS: A retrospective study that included patients admitted with AP was conducted. Determinants of long-term prognosis were extracted: These included Revised Atlanta and Determinant Based Classification (RAC), Charlson Comorbidity Index (CCI), Modified CT Severity Index (MCTSI), etiology, and local complications (LCs). Seven surrogates of morbidity up to 1 year after discharge were also collected and subsequently imputed into a clustering algorithm. The algorithm was set to produce three categories and multinomial regression analysis was performed. RESULTS: 281 patients were included. The incidences of morbidity endpoints were similar among the 3 RAC categories. Three clusters were identified that carried long-term prognostic significance. Each cluster was given a name to reflect prognosis. The limited AP had the best prognosis and included patients without LCs with a low co-morbidity burden. The brittle AP had a low co-morbidity burden and high MCTSI (LCs 94%). It ran a very morbid course but had excellent survival. The high-risk AP had the worst prognosis with the highest mortality rate (28%). They had a high co-morbidity burden without local complications. CONCLUSION: Categories that carry long-term prognostic significance in AP have been developed. This study could help formulate appropriate follow-up and ultimately improve AP outcomes.

MRI Evaluation of the Response of Rectal Cancer to Neoadjuvant Chemoradiation Therapy.

MRI plays a critical role in the staging and restaging of rectal cancer. Although newly diagnosed early-stage rectal cancers may immediately be amenable to surgical resection, patients with advanced disease first undergo neoadjuvant therapy that consists of a combination of chemotherapy and radiation therapy. Evaluation of rectal cancer after neoadjuvant therapy is best performed with MRI, given its superior soft-tissue contrast and its ability to allow multiplanar imaging and functional evaluation. In this setting, MRI allows accurate evaluation of primary tumor staging, which is determined on the basis of the depth of invasion within and through the rectal wall and the involvement of adjacent organs. MRI can also be used to evaluate posttreatment morphologic components within the tumors, including fibrosis and mucinous changes that have been shown to correlate with the response to treatment. Additional features such as the circumferential resection margin and extramural vascular invasion-factors shown to affect prognosis and local recurrence-are also assessed before and after therapy. Functional assessment with diffusion-weighted MRI and perfusion MRI plays a role in predicting tumor aggressiveness and the likelihood of response to treatment, as well as the extent of residual tumor after therapy. Lymph node staging is also performed at MRI, with assessment of not only lymph node size but also the internal architecture and signal intensity characteristics. ©RSNA, 2019 See discussion on this article by Wasnik and Al-Hawary .

Magnetic resonance enterography/enteroclysis in acquired small bowel diverticulitis and small bowel diverticulosis.

PURPOSE: Small bowel (SB) diverticulosis is a rare disorder that may entail serious complications, including SB diverticulitis. Both are often missed in imaging. Magnetic resonance enterography/enteroclysis (MRE) is increasingly used to assess SB disease; awareness of the appearance of SB diverticulitis is essential to ensure appropriate management. Our aim was to systematically describe imaging characteristics of SB diverticulosis and diverticulitis in MRE. METHODS: This retrospective, HIPAA-compliant study identified 186 patients with suspected SB diverticulosis/diverticulitis in medical databases of two tertiary medical centres between 2005 and 2011. Patients with surgically confirmed diagnoses of SB diverticulosis/diverticulitis were included. Two observers analyzed MR images for the presence, location, number, and size of diverticula, wall thickness, and mural and extramural patterns of inflammation. RESULTS: Seven patients were recruited. MRI analysis showed multiple diverticula in all (100 %). Diverticular size ranged from 0.5 to 6 cm. Prevalence of diverticula was higher in the proximal than the distal SB (jejunum 86 %, ileum 57 %, distal ileum43%). Diverticulitis occurred in 3/7 patients (43 %) showing asymmetric bowel wall thickening and focal mesenteric inflammation. CONCLUSION: SB diverticulitis demonstrates characteristic MRE imaging features to distinguish this rare disorder from more common diseases. Asymmetric, focal mesenteric and mural inflammation and presence of multiple diverticula are keys to diagnosis. KEY POINTS: • Small bowel diverticulosis and diverticulitis is rare and often missed in imaging • Acquired small bowel diverticula are variable in size and number • Small bowel diverticulitis demonstrates characteristic features on MR enterography/enteroclysis • A focal or segmental asymmetric small bowel inflammation should prompt the search for diverticula.

Computed Tomography Morphometrics and Pulmonary Intolerance in Endometrial Cancer Robotic Surgery.

STUDY OBJECTIVES: To identify morphometric characteristics of obese patients that best predict pulmonary intolerance to robotic pelvic surgery using a novel method for quantifying adipose distribution. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Fifty-nine patients with endometrial cancer who underwent robotic hysterectomy and lymphadenectomy between April 2008 and May 2014 and also underwent perioperative computed tomography (CT) imaging within 1 year. INTERVENTION: Visceral fat volume (VFV) and subcutaneous fat volume (SFV) were quantified through waist circumference measurements along with average volume estimation of slices taken at 3 levels: mid-waist, L2-L3, and L4-L5. Mean and maximum values were obtained for intraoperative physiological data. MEASUREMENTS AND MAIN RESULTS: The patients' mean body mass index (BMI) was 34 (range, 20-59). Along with waist circumference, VFV and SFV quantified by CT at the mid-waist, L2-L3, and L4-L5 levels were all significant independent predictors for peak airway pressure (PAP; average and maximum) and plateau airway pressure (Pplat; average and maximum) on multivariate regression analysis after adjustment for age, ethnicity, diabetes, hypertension, pulmonary disease, smoking, obstructive sleep apnea, American Society of Anesthesiologists classification, and duration of anesthesia. Compared with the other CT parameters, L2-L3 VFV was the best predictor of average PAP (ß = 0.398; p = .002), maximum PAP (ß = 0.493; p < .001), average Pplat (ß = 0.536; p < .001), and maximum Pplat (ß = 0.573; p < .001). CONCLUSION: These novel CT morphometric measurements represent valid predictors of pulmonary intolerance to robotic surgery in obese patients. Of the measures analyzed, VFV at L2-L3 best predicts pulmonary tolerance in obese patients.

Multidisciplinary approach for management of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome and rectal prolapse.

INTRODUCTION AND HYPOTHESIS: Müllerian duct anomalies are frequently associated with congenital anomalies of other organ systems, and in particular, the urinary system. A multidisciplinary approach is often required for successful diagnosis and surgical management of complex pelvic anomalies. The objective of this video is to provide a guide for diagnosis of complex female pelvic anomalies and robotic-assisted approach to surgical management with a multidisciplinary team of surgeons. METHODS: The patient presented is a 24-year-old nulligravida with obstructed hemivagina and ipsilateral renal dysplasia, ipsilateral ectopic ureter, and rectal prolapse. This video outlines the methods used to obtain the correct diagnosis and steps for successful treatment using a robotically assisted surgical approach. RESULTS: Complex Müllerian anomalies involving multiple organ systems may require the use of advanced three-dimensional imaging to achieve the correct diagnosis, and a minimally invasive surgical approach with robotic assistance is an effective strategy for management. CONCLUSIONS: A multidisciplinary approach is often required to successfully diagnose and treat women with complex Müllerian anomalies.

Comparison of hybrid FDG PET/MRI compared with PET/CT in colorectal cancer staging and restaging: a pilot study.

PURPOSE: We report our initial clinical experience from a pilot study to compare the diagnostic accuracy of hybrid PET/MRI with PET/CT in colorectal cancer and discuss potential PET/MRI workflow solutions for colorectal cancer. METHODS: Patients underwent both FDG PET/CT and PET/MRI (Ingenuity TF PET/MRI, Philips Healthcare) for rectal cancer staging or colorectal cancer restaging. The PET acquisition of PET/MRI was similar to that of PET/CT whereas the MRI protocol was selected individually based on the patient's medical history. One nuclear medicine physician reviewed the PET/CT studies and one radiologist reviewed the PET/MRI studies independently. The diagnostic accuracy of each modality was determined in consensus, using available medical records as a reference. RESULTS: Of the 12 patients enrolled, two were for initial staging and ten for restaging. The median scan delay between the two modalities was 60 min. The initial imaging was PET/CT in nine patients and PET/MRI in three patients. When PET/CT was performed first, the SUV values of the 16 FDG avid lesions were greater at PET/MRI than at PET/CT. In contrast, when PET/MRI was performed first, the SUV values of the seven FDG avid lesions were greater at PET/CT than at PET/MRI. PET/MRI provided more detailed T staging than PET/CT. On a per-patient basis, with both patient groups combined for the evaluation of N and M staging/restaging, the true positive rate was 5/7 (71%) for PET/CT and 6/7 (86%) for PET/MRI, and true negative rate was 5/5 (100%) for both modalities. On a per-lesion basis, PET/CT identified 26 of 29 (90%) tumor lesions that were correctly detected by PET/MRI. Our proposed workflow allows for comprehensive cancer staging including integrated local and whole-body assessment. CONCLUSIONS: Our initial experience shows a high diagnostic accuracy of PET/MRI in T staging of rectal cancer compared with PET/CT. In addition, PET/MRI shows at least comparable accuracy in N and M staging as well as restaging to PET/CT. However, the small sample size limits the generalizability of the results. It is expected that PET/MRI would yield higher diagnostic accuracy than PET/CT considering the high soft tissue contrast provided by MRI compared with CT, but larger studies are necessary to fully assess the benefit of PET/MRI in colorectal cancer.

Initial experience of MR/PET in a clinical cancer center.

Magentic Resonance/positron emission tomography (PET) has been introduced recently for imaging of clinical patients. This hybrid imaging technology combines the inherent strengths of MRI with its high soft-tissue contrast and biological sequences with the inherent strengths of PET, enabling imaging of metabolism with a high sensitivity. In this article, we describe the initial experience of MR/PET in a clinical cancer center along with a review of the literature. For establishing MR/PET in a clinical setting, technical challenges, such as attenuation correction and organizational challenges, such as workflow and reimbursement, have to be overcome. The most promising initial results of MR/PET have been achieved in anatomical areas where high soft-tissue and contrast resolution is of benefit. Head and neck cancer and pelvic imaging are potential applications of this hybrid imaging technology. In the pediatric population, MR/PET can decrease the lifetime radiation dose. MR/PET protocols tailored to different types of malignancies need to be developed. After the initial exploration phase, large multicenter trials are warranted to determine clinical indications for this exciting hybrid imaging technology and thereby opening new horizons in molecular imaging.

3.0-T MR-guided transgluteal in-bore-targeted prostate biopsy under local anesthesia in patients without rectal access: a single-institute experience and review of literature.

PURPOSE: To describe the technique and evaluate the performance of MRI-guided transgluteal in-bore-targeted biopsy of the prostate gland under local anesthesia in patients without rectal access. METHODS: Ten men (mean age, 69 (range 57-86) years) without rectal access underwent 13 MRI-guided transgluteal in-bore-targeted biopsy of the prostate gland under local anesthesia. All patients underwent mp-MRI at our institute prior to biopsy. Three patients had prior US-guided transperineal biopsy which was unsuccessful in one, negative in one, and yielded GG1 (GS6) PCa in one. Procedure time, complications, histopathology result, and subsequent management were recorded. RESULTS: Median interval between rectal surgery and presentation with elevated PSA was 12.5 years (interquartile range (IQR) 25-75, 8-36.5 years). Mean PSA was 11.9 (range, 4.8 -59.0) ng/ml and PSA density was 0.49 (0.05 -3.2) ng/ml/ml. Distribution of PI-RADS v2.0/2.1 scores of the targeted lesions were PI-RADS 5-3; PI-RADS 4-6; and PI-RADS 3-1. Mean lesion size was 1.5 cm (range, 1.0-3.6 cm). Median interval between MRI and biopsy was 5.5 months (IQR 25-75, 1.5-9 months). Mean procedure time was 47.4 min (range, 29-80 min) and the number of cores varied between 3 and 5. Of the 13 biopsies, 4 yielded clinically significant prostate cancer (csPca), with a Gleason score ≥ 7, 1 yielded insignificant prostate cancer (Gleason score = 6), 7 yielded benign prostatic tissue, and one was technically unsuccessful. 3/13 biopsies were repeat biopsies which detected csPCa in 2 out of the 3 patients. None of the patients had biopsy-related complication. Biopsy result changed management to radiation therapy with ADT in 2 patients with the rest on active surveillance. CONCLUSION: MRI-guided transgluteal in-bore-targeted biopsy of the prostate gland under local anesthesia is feasible in patients without rectal access.

Acquired ductopenia: an insight into imaging findings.

Hepatic ductopenia is a pathologic diagnosis characterized by a decrease in the number of intrahepatic bile ducts as a consequence of various underlying etiologies. Some etiologies, such as primary sclerosing cholangitis, primary biliary cholangitis, and ischemic cholangitis, often have distinctive imaging findings. In contrast, other causes such as chronic rejection following liver transplantation, drug-induced biliary injury, infection, malignancy such as lymphoma, and graft-versus-host disease may only have ancillary or non-specific imaging findings. Thus, diagnosing ductopenia in conditions with nonspecific imaging findings requires a multidimensional approach, including clinical evaluation, serological testing, imaging, and liver histology to identify the underlying cause. These etiologies lead to impaired bile flow, resulting in cholestasis, liver dysfunction, and, ultimately, cirrhosis and liver failure if the underlying cause remains untreated or undetected. In the majority of instances, individuals diagnosed with ductopenia exhibit a positive response to treatment addressing the root cause or cessation of the causative agent. This article focuses on acquired causes of ductopenia, its clinical manifestation, histopathology, imaging diagnosis, and management.

Chronic Pelvic Pain: Role of Imaging in the Diagnosis and Management.

Chronic pelvic pain (CPP) in women is not uncommon, and it may be difficult to identify the exact cause difficult to manage. It is major health problem for women that affects the quality of their daily lives. The etiology of chronic pelvic pain may be of gynecological or non-gynecological origin and associated with several predisposing and precipitating factors. Psychological and social factors also contribute to the syndrome of CPP and must be evaluated before managing these patients. Due to multifactorial etiology, CPP needs a multidisciplinary approach for diagnosis and management. A detailed history and physical examination supported by appropriate laboratory tests and imaging are the keys to diagnosis. In this paper, the role of imaging in diagnosis and management of CPP is reviewed. Imaging findings should be correlated with detailed clinical examination findings as there are imaging findings that may be unrelated and not the cause of CPP in a particular patient, imaging findings should be correlated with the clinical circumstances.

Secondary sclerosing cholangitis: mimics of primary sclerosing cholangitis.

Sclerosing cholangitis is a chronic cholestatic disease characterized by stricturing, beading, and obliterative fibrosis of the bile ducts. Sclerosing cholangitis is considered primary (PSC) if no underlying etiology is identified or secondary (SSC) if related to another identifiable cause. In this article, we will review the clinical features, pathogenesis, diagnosis, and imaging findings of PSC and SSC, with an emphasis on features that may aid in the distinction of these entities. We will also discuss various etiologies of SSC including recurrent pyogenic cholangitis, other infectious etiologies, ischemic damage, toxic insults, and immunologic, congenital, and miscellaneous causes, highlighting the unique imaging findings and clinical context of each diagnosis.

Magnetic resonance cholangiopancreatography: pitfalls in interpretation.

Magnetic resonance cholangiopancreatography (MRCP) has become a widely accepted noninvasive diagnostic tool in the assessment of pancreatic and biliary disease. MRCP essentially exploits extended T2 relaxation times of slow-moving fluid and delineates the outline of biliary and pancreatic ducts on T2-weighted images. In order to maximize the clinical implication of MRCP, it is of utmost importance for radiologists to optimize the acquisition technique, be aware of patient-related factors and physiologic changes than can affect its performance and interpretation. It is critical to understand the most common artifacts and pitfalls encountered during acquisition and interpretation of MRCP. We provide a general overview of the different pitfalls encountered in MRCP and pearls on how to manage them in real-world practice.