Interreader variability in prostate MRI reporting using Prostate Imaging Reporting and Data System version 2.1.

OBJECTIVES: To evaluate the agreement among readers with different expertise in detecting suspicious lesions at prostate multiparametric MRI using Prostate Imaging Reporting and Data System (PI-RADS) version 2.1. METHODS: We evaluated 200 consecutive biopsy-naïve or previously negative biopsy men who underwent MRI for clinically suspected prostate cancer (PCa) between May and September 2017. Of them, 132 patients underwent prostate biopsy. Seven radiologists (four dedicated uro-radiologists and three non-dedicated abdominal radiologists) reviewed and scored all MRI examinations according to PI-RADS v2.1. Agreement on index lesion detection was evaluated with Conger's k coefficient, agreement coefficient 1 (AC1), percentage of agreement (PA), and indexes of specific positive and negative agreement. Clinical and radiological features that may influence variability were evaluated. RESULTS: Agreement in index lesion detection among all readers was substantial (AC1 0.738; 95% CI 0.695-0.782); dedicated radiologists showed higher agreement compared with non-dedicated readers. Clinical and radiological parameters that positively influenced agreement were PSA density ≥ 0.15 ng/mL/cc, pre-MRI high risk for PCa, positivity threshold of PI-RADS score 4 + 5, PZ lesions, homogeneous signal intensity of the PZ, and subjectively easy interpretation of MRI. Positive specific agreement was significantly higher among dedicated readers, up to 93.4% (95% CI 90.7-95.4) in patients harboring csPCa. Agreement on absence of lesions was excellent for both dedicated and non-dedicated readers (respectively 85.1% [95% CI 78.4-92.3] and 82.0% [95% CI 77.2-90.1]). CONCLUSIONS: Agreement on index lesion detection among radiologists of various experiences is substantial to excellent using PI-RADS v2.1. Concordance on absence of lesions is excellent across readers' experience. KEY POINTS: • Agreement on index lesion detection among radiologists of various experiences is substantial to excellent using PI-RADS v2.1. • Concordance between experienced readers is higher than between less-experienced readers. • Concordance on absence of lesions is excellent across readers' experience.

Dynamic contrast-enhanced MRI in oncology: how we do it.

Magnetic resonance imaging (MRI) is particularly attractive for clinical application in perfusion imaging thanks to the absence of ionizing radiation and limited volumes of contrast agent (CA) necessary. Dynamic contrast-enhanced MRI (DCE-MRI) involves sequentially acquiring T1-weighted images through an organ of interest during the passage of a bolus administration of CA. It is a particularly flexible approach to perfusion imaging as the signal intensity time course allows not only rapid qualitative assessment, but also quantitative measures of intrinsic perfusion and permeability parameters. We examine aspects of the T1-weighted image series acquisition, CA administration, post-processing that constitute a DCE-MRI study in clinical practice, before considering some heuristics that may aid in interpreting the resulting contrast enhancement time series. While qualitative DCE-MRI has a well-established role in the diagnostic assessment of a range of tumours, and a central role in MR mammography, clinical use of quantitative DCE-MRI remains limited outside of clinical trials. The recent publication of proposals for standardized acquisition and analysis protocols for DCE-MRI by the Quantitative Imaging Biomarker Alliance may be an opportunity to consolidate and advance clinical practice.

Impact of Sarcopenic Obesity on Failure to Rescue from Major Complications Following Pancreaticoduodenectomy for Cancer: Results from a Multicenter Study.

BACKGROUND: Failure to rescue (FTR) is a quality-of-care indicator in pancreatic surgery, but may also identify patients who may not tolerate major postoperative complications despite being treated with best available care. Previous studies found that high visceral adipose tissue-to-skeletal muscle ratio is associated with poor outcomes following pancreaticoduodenectomy (PD). The aim of the study is to assess the impact of sarcopenic obesity on occurrence of FTR from major complications in cancer patients undergoing PD. METHODS: Prospectively collected data from three high-volume hospitals were reviewed. Total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed at preoperative staging computed tomography scan. Sarcopenic obesity was defined as high VFA/TAMA ratio. FTR was defined as postoperative mortality following major complication. RESULTS: 120 patients with major complications were included. FTR occurred in 23 (19.2%) patients. The "seminal" complications leading to FTR were pancreatic or biliary fistula-related sepsis (n = 14), postoperative pancreatic fistula (POPF)-related hemorrhage (n = 5), and duodenojejunal anastomosis leak-related sepsis (n = 1). On univariate analysis, older age [odds ratio (OR) 3.5, p = 0.034], American Society of Anesthesiologists (ASA) score 3+ (OR 4.2, p = 0.005), cardiovascular disease (OR 3.3, p = 0.013), low serum albumin (OR 2.6, p = 0.042), sarcopenic obesity (OR 4.2, p = 0.009), POPF (OR 3.1, p = 0.027), and cardiorespiratory complications (OR 3.7, p = 0.011) were significantly associated with FTR. On multivariate analysis, sarcopenic obesity [OR 5.7, 95% confidence interval (CI) 1.6-20.7, p = 0.008], ASA score 3+ (OR 4.1, 95% CI 1.2-14.3, p = 0.025), and pancreatic fistula (OR 3.2, 95% CI 1.0-10.2, p = 0.045) were independently associated with FTR. CONCLUSION: Sarcopenic obesity, low preoperative physical status, and occurrence of pancreatic fistula are associated with significantly higher risk of FTR from major complications after PD.

Preoperative multiparametric MRI of the prostate for the prediction of lymph node metastases in prostate cancer patients treated with extended pelvic lymph node dissection.

OBJECTIVES: To assess the role of preoperative multiparametric MRI (mpMRI) of the prostate in the prediction of nodal metastases in patients treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND). METHODS: We retrospectively analyzed 101 patients who underwent both preoperative mpMRI of the prostate and RP with ePLND at our institution. For each patient, complete preoperative clinical data and tumour characteristics at mpMRI were recorded. Final histopathologic stage was considered the standard of reference. Univariate and multivariate logistic regression analyses were performed. RESULTS: Nodal metastases were found in 23/101 (22.8%) patients. At univariate analyses, all clinical and radiological parameters were significantly associated to nodal invasion (all p<0.03); tumour volume at MRI (mrV), tumour ADC and tumour T-stage at MRI (mrT) were the most accurate predictors (AUC = 0.93, 0.86 and 0.84, respectively). A multivariate model including PSA levels, primary Gleason grade, mrT and mrV showed high predictive accuracy (AUC = 0.956). Observed prevalence of nodal metastases was very low among tumours with mrT2 stage and mrV<1cc (1.8%). CONCLUSION: Preoperative mpMRI of the prostate can predict nodal metastases in prostate cancer patients, potentially allowing a better selection of candidates to ePLND. KEY POINTS: • Multiparametric-MRI of the prostate can predict nodal metastases in prostate cancer • Tumour volume and stage at MRI are the most accurate predictors • Prevalence of nodal metastases is low for T2-stage and <1cc tumours • Preoperative mpMRI may allow a better selection of candidates to lymphadenectomy.

Orbital color Doppler ultrasound as noninvasive tool in the diagnosis of anterior-draining carotid-cavernous fistula.

PURPOSE: To investigate the role of orbital color Doppler ultrasound (OCDUS) in the diagnosis of carotid-cavernous fistula (CCF) with anterior drainage and particularly whether a negative OCDUS could avoid an invasive diagnostic cerebral angiography (DSA). MATERIALS AND METHODS: Twenty-two consecutive patients with ophthalmic signs suspecting CCF were submitted to ophthalmologic examination, OCDUS and DSA. CCF diagnosis with OCDUS was based on the finding of a reversed, arterialized and low-resistive-index (RI <0.5) blood flow in the superior ophthalmic vein (SOV). Sensibility, specificity, PPV, NPV, and accuracy of OCDUS were calculated considering both patients and eyes, using DSA as gold standard. RESULTS: DSA demonstrated 20 CCFs in 18 patients. Considering the patients, in 18/22 CCF diagnosis was positive at OCDUS and DSA while 4/22 were negative at both. Considering the eyes, in 24/43 CCF diagnosis was positive at both DSA and OCDUS (total eyes = 43, due to one case of SOV thrombosis). In 19/43 eyes diagnosis was negative at both OCDUS and DSA. So sensitivity, specificity, PPV, NPV, and accuracy of OCDUS in the patients and eyes analysis were all 100 %. CONCLUSIONS: OCDUS is a reliable, noninvasive tool in the diagnosis of CCF; a negative OCDUS could avoid an invasive DSA in patients suspected for anterior-draining CCF.

Monitoring of central retinal artery and vein with color Doppler ultrasound during heart surgery as an alternative to transcranial Doppler ultrasonography: a case report.

Cardiac surgery can have severe neurologic complications. The noninvasive monitoring of intracranial circulation during heart surgery is usually performed with transcranial Doppler ultrasonography. We present the case of a 66-year-old man who underwent elective cardiac surgery for aortic valve replacement and coronary artery bypass graft, in whom monitoring was performed by simultaneously assessing blood flow velocity in the central retinal artery and vein.

Tailored breast cancer screening program with microdose mammography, US, and MR Imaging: short-term results of a pilot study in 40-49-year-old women.

PURPOSE: To evaluate the feasibility, performance, and cost of a breast cancer screening program aimed at 40-49-year-old women and tailored to their risk profile with supplemental ultrasonography (US) and magnetic resonance (MR) imaging. MATERIALS AND METHODS: The institutional review board approved this study, and informed written consent was obtained. A total of 3017 40-49-year-old women were invited to participate. The screening program was tailored to lifetime risk (Gail test) and mammographic density (according to Breast Imaging Reporting and Data Systems [BI-RADS] criteria) with supplemental US or MR imaging and bilateral two-view microdose mammography. The indicators suggested by European guidelines, US incremental cancer detection rate (CDR), and estimated costs were evaluated. RESULTS: A total of 1666 women (67.5% participation rate) were recruited. The average lifetime risk of breast cancer was 11.6%, and nine women had a high risk of breast cancer; 917 women (55.0%) had a high density score (BI-RADS density category 3 or 4). The average glandular dose for screening examinations was 1.49 mGy. Screening US was performed in 835 study participants (50.1%), mostly due to high breast density (800 of 1666 women [48.0%]). Screening MR imaging was performed in nine women (0.5%) at high risk for breast cancer. Breast cancer was diagnosed in 14 women (8.4 cases per 1000 women). Twelve diagnoses were made with microdose mammography, and two were made with supplemental US in dense breasts (2.4 cases per 1000 women). All patients were submitted for surgery, and 10 underwent breast-conserving surgery. The sentinel lymph node was evaluated in 11 patients, resulting in negative findings in six. Pathologic analysis resulted in the diagnosis of four ductal carcinomas in situ and 10 invasive carcinomas (five at stage I). CONCLUSION: A tailored breast cancer screening program in 40-49-year-old women yielded a greater-than-expected number of cancers, most of which were low-stage disease.

Influence of reduced muscle mass and quality on ventilator weaning and complications during intensive care unit stay in COVID-19 patients.

BACKGROUND & AIMS: Sarcopenia, a loss of muscle mass, quality and function, which is particularly evident in respiratory muscles, has been associated with many clinical adverse outcomes. In this study, we aimed at evaluating the role of reduced muscle mass and quality in predicting ventilation weaning, complications, length of intensive care unit (ICU) and of hospital stay and mortality in patients admitted to ICU for SARS-CoV-2-related pneumonia. METHODS: This was an observational study based on a review of medical records of all adult patients admitted to the ICU of a tertiary hospital in Milan and intubated for SARS-CoV-2-related pneumonia during the first wave of the COVID-19 pandemic. Muscle mass and quality measurement were retrieved from routine thoracic CT scans, when sections passing through the first, second or third lumbar vertebra were available. RESULTS: A total of 81 patients were enrolled. Muscle mass was associated with successful extubation (OR 1.02, 95% C.I. 1.00-1.03, p = 0.017), shorter ICU stay (OR 0.97, 95% C.I. 0.95-0.99, p = 0.03) and decreased hospital mortality (HR 0.98, 95% C.I. 0.96-0.99, p = 0.02). Muscle density was associated with successful extubation (OR 1.07, 95% C.I. 1.01-1.14; p = 0.02) and had an inverse association with the number of complications in ICU (Β -0.07, 95% C.I. -0.13 - -0.002, p = 0.03), length of hospitalization (Β -1.36, 95% C.I. -2.21 - -0.51, p = 0.002) and in-hospital mortality (HR 0.88, 95% C.I. 0.78-0.99, p = 0.046). CONCLUSIONS: Leveraging routine CT imaging to measure muscle mass and quality might constitute a simple, inexpensive and powerful tool to predict survival and disease course in patients with COVID-19. Preserving muscle mass during hospitalisation might have an adjuvant role in facilitating remission from COVID-19.

Transcutaneous electrical stimulation therapy and genetic analysis in Dercum's disease: A pilot study.

ABSTRACT: Dercum's disease (DD), or adiposis dolorosa, is a rare condition of unknown etiology characterized by growth of painful subcutaneous adipose tissue. No specific treatment exists. Pain is often invalidating and resistant to analgesic drugs. We tested the efficacy of Frequency Rhythmic Electrical Modulation System (FREMS) therapy on pain relief. Subcutaneous biopsies were performed for genetic analysis.Nine DD patients were enrolled. Five cycles of FREMS at 3-month intervals during 1 year were administered. Visual analogue scale (VAS), Bartel Index Questionnaire and Short Form 36 questionnaire were used to measure pain and general health status at baseline, 6 and 12 months. Dual-energy X-ray absorptiometry (DEXA) quantified fat mass. Next-Generation Sequencing (NGS) was performed on adipose tissue biopsies and peripheral blood sample to search for somatic variants and specific protein pathway mutation.Seven patients were included in the final analysis. FREMS induced a reduction in VAS score (from 92 to 52.5, P = .0597) and a significant improvement in SF-36 domains (Physical functioning, Role limitation due to physical health, Body pain, Vitality, Social functioning, P < .05). No modification in anthropometrics and DEXA values was observed. The analysis of the mitochondrial Displacement loop (D-loop) region confirmed the clonality of all lipomatous lesions. The presence of the mitochondrially encoded tRNA-Lysine (MT-TK) m.8344A>G variant, occasionally identified in patients with multiple symmetric lipomatosis, was excluded in all subjects. On the other hand, we observed variants in genes belonging to signaling pathways involved in cell cycle and proliferation (Phosphoinositide 3-kinase/AKT/mTOR, MAPK/ERK, and Hippo).FREMS can be a useful tool to alleviate pain and improve overall quality of life in patients with DD. Genetic analysis highlighted the molecular heterogeneity of lipomas.

Advanced Imaging Analysis in Prostate MRI: Building a Radiomic Signature to Predict Tumor Aggressiveness.

Radiomics allows the extraction quantitative features from imaging, as imaging biomarkers of disease. The objective of this exploratory study is to implement a reproducible radiomic-pipeline for the extraction of a magnetic resonance imaging (MRI) signature for prostate cancer (PCa) aggressiveness. One hundred and two consecutive patients performing preoperative prostate multiparametric magnetic resonance imaging (mpMRI) and radical prostatectomy were enrolled. Multiparametric images, including T2-weighted (T2w), diffusion-weighted and dynamic contrast-enhanced images, were acquired at 1.5 T. Ninety-three imaging features (Ifs) were extracted from segmentation of index lesion. Ifs were ranked based on a stability rank and redundant Ifs were excluded. Using unsupervised hierarchical clustering, patients were grouped on the basis of similar radiomic patterns, whose association with Gleason Grade Group (GGG), extracapsular extension (ECE), and nodal involvement (pN) was tested. Signatures composed by IFs from T2w-images and Apparent Diffusion Coefficient (ADC) maps were tested for the prediction of GGG, ECE, and pN. T2w radiomic pattern was associated with pN, ECE, and GGG (p = 0.027, 0.05, 0.03) and ADC radiomic pattern was associated with GGG (p = 0.004). The best performance was reached by the signature combing IFs from multiparametric images (0.88, 0.89, and 0.84 accuracy for GGG, pN, and ECE). A reliable multiparametric MRI radiomic signature was extracted, potentially able to predict PCa aggressiveness, to be further validated on an independent sample.

MRI for Rectal Cancer Primary Staging and Restaging After Neoadjuvant Chemoradiation Therapy: How to Do It During Daily Clinical Practice.

PURPOSE: To provide a practical overview regarding the state-of-the-art of the magnetic resonance imaging (MRI) protocol for rectal cancer imaging and interpretation during primary staging and restaging after neoadjuvant chemoradiation therapy (CRT), pointing out technical skills and findings that radiologists should consider for their reports during everyday clinical activity. METHOD: Both 1.5T and 3.0T scanners can be used for rectal cancer evaluation, using pelvic phased array external coils. The standard MR protocol includes T2-weighted imaging of the pelvis, high-resolution T2-weighted sequences focused on the tumor and diffusion-weighted imaging (DWI). The mnemonic DISTANCE is helpful for the interpretation of MR images: DIS, for distance from the inferior part of the tumor to the anorectal-junction; T, for T staging; A, for anal sphincter complex status; N, for nodal staging; C, for circumferential resection margin status; and E, for extramural venous invasion. RESULTS: Primary staging with MRI is a cornerstone in the preoperative workup of patients with rectal cancer, because it provides clue information for decisions on the administration of CRT and surgical treatment. Restaging after CRT is crucial for treatment planning, and findings on post-CRT MRI correlate with the patient's prognosis and survival. It may be useful to remember the mnemonic word "DISTANCE" to check and describe all the relevant MRI findings necessary for an accurate radiological definition of tumor stage and response to CRT. CONCLUSIONS: "DISTANCE" assessment for rectal cancer staging and treatment response estimation after CRT may be helpful as a checklist for a structured reporting.

Changes in body composition during neoadjuvant therapy can affect prognosis in rectal cancer patients: An exploratory study.

AIM: To establish the correlation between changes in body composition after neoadjuvant chemoradiotherapy (nCRT) and postoperative outcomes, in patients with advanced low rectal cancer. METHODS: Patients with clinical stage T≥3 or N+ rectal cancer who underwent nCRT and surgical resection were studied. Skeletal muscle, visceral, and subcutaneous fat cross-sectional area were measured by computed tomography before and after nCRT. Postoperative morbidity, pathologic response to nCRT, overall and disease-free survival was assessed. RESULTS: Fifty-two patients, median age 62 (range 32-79) were studied. A skeletal muscle loss >2% significantly correlated with a shorter disease-free survival both in the overall population (P = 0.048) and in the subgroup of N0 patients (P = 0.048). A subcutaneous fat loss >5% was also associated with a shorter disease-free survival (P = 0.012) in the whole population. CONCLUSIONS: Skeletal muscle loss, after neoadjuvant chemoradiotherapy, negatively impacts on disease-free survival in surgically treated rectal cancer patients.

Can DCE-MRI reduce the number of PI-RADS v.2 false positive findings? Role of quantitative pharmacokinetic parameters in prostate lesions characterization.

PURPOSE: To test the potential impact of pharmacokinetic parameters, derived from DCE-MRI analysis, on the diagnostic performance of PI-RADSv.2 classification in prostate lesions characterization. METHOD: Among patients who underwent multiparametric prostate MRI (mpMRI) (January 2016-March 2018) followed by histological evaluation (targeted biopsies/prostatectomy), 103 men were retrospectively selected. For each patient the index lesion was identified and pharmacokinetic parameters (Ktrans, Kep, Ve, Vp) were assessed. MRI diagnostic performance in the detection of significant tumors [Gleason Score (GS)≥7] was assessed, considering PI-RADS≥3 as positive. RESULTS: GS ≥ 7 (n = 59) showed higher Ktrans (p < 0.01) and Kep (p = 0.01) compared to GS < 7. At ROC curve analysis, a Ktrans cut-off of 191 × 10-3/min was identified to predict the presence of GS ≥ 7 (AUC:0.75; sensitivity:95%; specificity:61%). Sensitivity and PPV of mpMRI using PI-RADSv.2 were 98% and 61%. Reclassifying PI-RADS≥3 lesions according to Ktrans cut-off, 22 false positives were shifted to true negatives with 3 false negative findings; PPV raised to 79%. Appling Ktrans cut-off to PI-RADS 3 lesions of peripheral zone (n = 18), 12 true negatives, 4 true positives, 2 false positives were identified. CONCLUSIONS: Despite its high sensitivity prostate mpMRI generates many false positive cases: Ktrans in addition to PIRADS v.2 seems to improve MRI-PPV and may help in avoiding redundant biopsies.

Association Between Prostate Imaging Reporting and Data System (PI-RADS) Score for the Index Lesion and Multifocal, Clinically Significant Prostate Cancer.

BACKGROUND: The ability to identify clinically significant prostate cancer (csPCa) has dramatically improved with the introduction of multiparametric magnetic resonance imaging (mpMRI). Given the growing interest in targeted biopsy and focal therapy, improving our knowledge on the relationship between mpMRI parameters and the ability to predict csPCa multifocality is mandatory. OBJECTIVE: To assess whether the Prostate Imaging Reporting and Data System (PI-RADS) score for the index lesion (IL) may predict multifocal csPCa undetected by mpMRI. DESIGN, SETTING, AND PARTICIPANTS: The study included 343 patients who underwent mpMRI of the prostate with subsequent biopsy between 2014 and 2017 at a single tertiary care referral centre. INTERVENTION: Lesions with a PI-RADS v.2 score ≥2 detected at mpMRI (IL) were targeted with a fusion biopsy (Bx) approach (mpMRI-Bx). Moreover, each patient underwent a random extended transrectal ultrasound-guided biopsy (TRUS-Bx) during the same session. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa outside the IL was defined as disease detected at TRUS-Bx with a Gleason score (GS)≥3+4 and equal to or greater than the GS for the IL. The extent of csPCa detected in target and random cores was reported and stratified according to the GS and PI-RADS score for the IL. The probability of diagnosing csPCa outside the IL according to the PI-RADS score was also assessed in multivariable logistic regression analyses (MVA) after accounting for confounders. RESULTS AND LIMITATIONS: The detection rate for csPCa outside the IL was 30%. The detection rate for csPCa at TRUS-Bx was 8% for PI-RADS 2, 15% for PI-RADS 3, 36% for PI-RADS 4, and 58% for PI-RADS 5 lesions (p=0.03). Overall, the median length of csPCa found at TRUS-Bx and thus missed at mpMRI was 2.6mm. However, the length significantly increased with PI-RADS score for the IL, and was 1.8, 2.3, 2.8, and 3.8mm for PI-RADS 2, 3, 4, and 5 lesions, respectively (p=0.03). On MVA, PI-RADS 4 (odds ratio [OR] 7.6; p=0.008) and PI-RADS 5 scores (OR 17.3; p<0.001) were independent predictors of the presence of csPCa outside the IL. The study is limited by its retrospective design. CONCLUSIONS: Overall, the accuracy of mpMRI in identifying multifocal csPCa is poor, missing low-volume csPCa in approximately 30% of patients. Moreover, the rate and the extent of csPCa undetected by mpMRI significantly increased with the PI-RADS score for the IL, which can thus be considered a proxy for tumour multifocality. PATIENT SUMMARY: The accuracy of multiparametric magnetic resonance imaging in identifying prostate cancer multifocality is poor. False negative findings were highly related to the PI-RADS score of the index lesion. These findings raise concerns about the indication for targeting the index lesion only when considering prostate biopsy and focal approaches.

Not All Multiparametric Magnetic Resonance Imaging-targeted Biopsies Are Equal: The Impact of the Type of Approach and Operator Expertise on the Detection of Clinically Significant Prostate Cancer.

BACKGROUND: The extensive use of multiparametric magnetic resonance imaging (mpMRI) has led to an even more widespread use of different targeted biopsy techniques and approaches. The best way of performing targeted biopsies and the effect of operator expertise have still to be defined. OBJECTIVE: To compare the rate of detection of clinically significant prostate cancer (csPCa) of different mpMRI targeted approaches and to assess the role of operator expertise in the detection of csPCa. DESIGN, SETTING, AND PARTICIPANTS: We included 244 consecutive patients who underwent both 12-core transrectal ultrasound (TRUS) biopsy and mpMRI targeted biopsy with either a cognitive biopsy (CB) or fusion biopsy (FB) approach during the same session between 2013 and 2016 at a single tertiary referral centre. INTERVENTION: All men underwent 1.5-T mpMRI with an endorectal coil. All biopsies were performed by three operators as their first cases of targeted biopsy. Lesions with a Prostate Imaging Recording and Data System (PI-RADS) v.2 score of ≥3 detected at mpMRI were targeted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa was defined as disease with a Gleason score at biopsy of ≥7. Operator expertise was coded as the progressive number of targeted biopsies performed by each physician. Multivariable logistic regression analyses (MVA) were used to assess the association between the targeted biopsy technique (FB vs CB) and operator expertise for detection of csPCa. Covariates consisted of prostate-specific antigen, prostate volume, PI-RADS v.2 (3 vs >3), number of targeted cores per MRI lesion, and digital rectal examination (negative vs positive). The same analyses were performed for patients undergoing FB only after accounting for the FB approach (transrectal vs transperineal). A lowess smoothing weighted function was used to graphically assess the effect of operator expertise on the probability of detecting csPCa, after accounting for all confounders. RESULTS AND LIMITATIONS: Overall, 157 patients (64%) underwent FB and 87 (36%) underwent CB. The overall csPCa detection rate was 58% for FB and 45% for CB (p=0.07). A significantly higher rate of csPCa detection in targeted samples was observed for FB compared to CB (57% vs 36%; p=0.002). On MVA, FB and operator expertise were significantly associated with a higher probability of csPCa detection in targeted samples (odds ratio [OR] 2.4 and 1.7, respectively; both p≤0.03). When the same analyses were repeated for patients undergoing FB, operator expertise remained an independent predictor of csPCa detection (OR 1.9; p=0.004). An increase in the probability of detecting csPCa with the number of procedures performed was observed after accounting for all confounders. CONCLUSIONS: We demonstrated that FB had higher detection rate than CB for csPCa. Moreover, operator expertise was significantly associated with higher detection rates for csPCa. PATIENT SUMMARY: When different targeted biopsy techniques were compared, fusion biopsy provided a higher detection rate compared to cognitive biopsy for clinically significant prostate cancer (csPCa). Moreover, we found that operator expertise was an important predictor of the detection of csPCa, regardless of the procedure used.

Association Between Changes in Body Composition and Neoadjuvant Treatment for Pancreatic Cancer.

Importance: Sarcopenia and sarcopenic obesity have been associated with poor outcomes in unresectable pancreatic cancer (PC). Neoadjuvant treatment (NT) is used increasingly to improve resectability; however, its effects on fat and muscle body composition have not been characterized. Objectives: To evaluate whether NT affects muscle mass and adipose tissue in patients with borderline resectable PC (BRPC) and locally advanced PC (LAPC) and determine whether there were potential differences between patients who ultimately underwent resection and those who did not. Design, Setting, and Participants: In this retrospective cohort study conducted at 4 academic medical centers, 193 patients with BRPC and LAPC undergoing surgical exploration after NT who had available computed tomographic scans (both at diagnosis and preoperatively) and confirmed pancreatic ductal adenocarcinoma were evaluated. The study was conducted from January 2013 to December 2015. Data analysis was performed from September 2016 to May 2017. Measurement of body compartments was evaluated with volume assessment software before and after NT. A radiologist blinded to the patient outcome assessed the areas of skeletal muscle, total adipose tissue, and visceral adipose tissue through a standardized protocol. Exposures: Receipt of NT. Main Outcomes and Measures: Achievement of pancreatic resection at surgical exploration after the receipt of NT. Results: Of the 193 patients with complete radiologic imaging available after NT, 96 (49.7%) were women; mean (SD) age at diagnosis was 64 (11) years. Most patients received combined therapy with fluorouracil, irinotecan, oxaliplatin, leucovorin, and folic acid (124 [64.2%]) and 86 (44.6%) received chemoradiotherapy as well. The median interval between pre-NT and post-NT imaging was 6 months (interquartile range [IQR], 4-7 months). All body compartments significantly changed. The adipose compound decreased (median total adipose tissue area from 284.0 cm2; IQR, 171.0-414.0 to 250.0 cm2; IQR, 139.0-363.0; P < .001; median visceral adipose tissue area from 115.2 cm2; IQR, 59.9-191.0 to 97.7 cm2; IQR, 48.0-149.0 cm2; P < .001), whereas the lean mass slightly improved (median skeletal muscle from 122.1 cm2; IQR, 99.3-142.0 to 123 cm2; IQR 104.8-152.5 cm2; P = .001). Surgical resection was achievable in 136 (70.5%) patients. Patients who underwent resection had experienced a 5.9% skeletal muscle area increase during NT treatment, whereas those who did not undergo resection had a 1.7% decrease (P < .001). Conclusions and Relevance: Patients with PC experience a significant loss of adipose tissue during neoadjuvant chemotherapy, but no muscle wasting. An increase in muscle tissue during NT is associated with resectability.

Preoperative sarcopenia determinants in pancreatic cancer patients.

BACKGROUND & AIMS: Recent studies report that muscle depletion can impair short and long-term results after abdominal surgery. The aim of the present study is to quantify sarcopenia rate in patients undergoing pancreatic resection for cancer and to identify possible determinants of muscle waste. METHODS: Total abdominal muscle area (TAMA) and visceral fat area (VFA) were measured by preoperative CT scan imaging at the level of the third lumbar vertebra in 273 patients undergoing pancreas resection for cancer. Demographics, preoperative parameters, and cancer stage were prospectively collected in our Institutional electronic database. An adjusted regression model was used to identify independent predictors for low TAMA. RESULTS: 176 (64.5%) patients were sarcopenic, with only 52 of them showing weight loss > 10%. Patients with cancer stage II and III had lower TAMA compared to patients with stage I (p = 0.002). The magnitude of weight loss was inversely correlated with VFA (p = 0.001), while no correlation with TAMA was found. Multivariate analysis showed that cancer stage was an independent predictor of low TAMA. Patients aged over 75 had the highest probability of having both low TAMA (p = 0.031) and high VFA (p < 0.0001). CONCLUSIONS: Most of patients undergoing oncologic pancreatic surgery are sarcopenic. Cancer stage was an independent determinant of sarcopenia while nutritional factors seem less important. An age of over 75 years was significantly correlated with both muscle compartment depletion and visceral fat increase.