New Prostate MRI Scoring Systems (PI-QUAL, PRECISE, PI-RR, and PI-FAB): AJR Expert Panel Narrative Review.

Multiparametric MRI (mpMRI), interpreted using PI-RADS, improves the initial detection of clinically significant prostate cancer (PCa). Prostate MR image quality has increasingly recognized relevance to the use of mpMRI for PCa diagnosis. Additionally, mpMRI is increasingly used in scenarios beyond initial detection, including active surveillance and assessment for local recurrence after prostatectomy, radiation therapy, or focal therapy. Acknowledging these evolving demands, specialized prostate MRI scoring systems beyond PI-RADS have emerged, to address distinct scenarios and unmet needs. Examples include Prostate Imaging Quality (PI-QUAL) for assessment of image quality of mpMRI, Prostate Cancer Radiologic Estimation of Change in Sequential Evaluation (PRECISE) recommendations for evaluation of serial mpMRI examinations during active surveillance, Prostate Imaging for Recurrence Reporting System (PI-RR) for assessment for local recurrence after prostatectomy or radiation therapy, and Prostate Imaging after Focal Ablation (PI-FAB) for assessment for local recurrence after focal therapy. These systems' development and early uptake signal a compelling shift towards prostate MRI standardization in different scenarios, and ongoing research will help refine their roles in practice. This AJR Expert Panel Narrative Review critically examines these new prostate MRI scoring systems (PI-QUAL, PRECISE, PI-RR, and PI-FAB), analyzing the available evidence, delineating current limitations, and proposing solutions for improvement.

Prostate MRI Qualification: AJR Expert Panel Narrative Review.

Prostate MRI is now established as a first-line investigation for individuals presenting with suspected localized or locally advanced prostate cancer. Successful delivery of the MRI-directed pathway for prostate cancer diagnosis relies on high-quality imaging as well as the interpreting radiologist's experience and expertise. Radiologist certification in prostate MRI may help limit interreader variability, optimize outcomes, and provide individual radiologists with documentation of meeting predefined standards. This AJR Expert Panel Narrative Review summarizes existing certification proposals, recognizing variable progress across regions in establishing prostate MRI certification programs. To our knowledge, Germany is the only country with a prostate MRI certification process that is currently available for radiologists. However, prostate MRI certification programs have also recently been proposed in the United States and United Kingdom and by European professional society consensus panels. Recommended qualification processes entail a multifaceted approach, incorporating components such as minimum case numbers, peer learning, course participation, continuing medical education credits, and feedback from pathology results. Given the diversity in health care systems, including in the provision and availability of MRI services, national organizations will likely need to take independent approaches to certification and accreditation. The relevant professional organizations should begin developing these programs or continue existing plans for implementation.

Mesenchymal chondrosarcoma: imaging features and clinical findings.

OBJECTIVE: To describe imaging and clinical features of primary mesenchymal chondrosarcoma (MCS) and evaluate for presence of a distinct biphasic pattern on imaging. MATERIAL AND METHODS: Patients with a pathologic diagnosis of MCS were identified along with imaging of their primary tumor. Size, location, appearance (lytic, sclerotic, or mixed), presence, extent and distribution of calcifications, cortical destruction, soft tissue extension, periosteal reaction, contrast enhancement, and radiotracer uptake were recorded. The presence of T2-hyperintense tumor lobules on MRI and a biphasic morphology (distinct calcified and non-calcified components) on CT were assessed. Presence and location of metastases were documented. RESULTS: Twenty-three patients (mean age 28.0 ± 13.8 years) were reviewed (13 skeletal, 10 extraskeletal). Overall mean tumor size was 10.2 ± 7.2 cm, 7.1 ± 7.3 cm in non-metastatic and 13.2 ± 5.9 cm (p = 0.004) in metastatic cases. Locations were extremities (n = 11), head/neck (n = 4), chest wall (n = 4), pelvis (n = 3), and retroperitoneum (n = 1). Skeletal MCS were aggressive mixed lytic and sclerotic (n = 8), purely lytic (n = 4), or juxtacortical (n = 1) lesions with cortical destruction and soft tissue extension. Chondroid calcifications were common (80%). On MRI, the presence of T2-hyperintense lobules was seen in 35%. A biphasic morphology on imaging was seen in 30%. Metastases were common (52%) with the most common site being the lungs (75%). All tumors were hypermetabolic with a mean SUVmax of 14.3 (5.6-34) on PET/CT. CONCLUSION: Skeletal MCS commonly present as aggressive lytic bone lesions with chondroid calcifications. A biphasic morphology was seen in one-third of cases. Metastases were common at initial presentation and more commonly seen with larger tumors.

Interactive, Up-to-date Meta-Analysis of MRI in the Management of Men with Suspected Prostate Cancer.

The aim of this study was to test an interactive up-to-date meta-analysis (iu-ma) of studies on MRI in the management of men with suspected prostate cancer. Based on the findings of recently published systematic reviews and meta-analyses, two freely accessible dynamic meta-analyses (https://iu-ma.org) were designed using the programming language R in combination with the package "shiny." The first iu-ma compares the performance of the MRI-stratified pathway and the systematic transrectal ultrasound-guided biopsy pathway for the detection of clinically significant prostate cancer, while the second iu-ma focuses on the use of biparametric versus multiparametric MRI for the diagnosis of prostate cancer. Our iu-mas allow for the effortless addition of new studies and data, thereby enabling physicians to keep track of the most recent scientific developments without having to resort to classical static meta-analyses that may become outdated in a short period of time. Furthermore, the iu-mas enable in-depth subgroup analyses by a wide variety of selectable parameters. Such an analysis is not only tailored to the needs of the reader but is also far more comprehensive than a classical meta-analysis. In that respect, following multiple subgroup analyses, we found that even for various subgroups, detection rates of prostate cancer are not different between biparametric and multiparametric MRI. Secondly, we could confirm the favorable influence of MRI biopsy stratification for multiple clinical scenarios. For the future, we envisage the use of this technology in addressing further clinical questions of other organ systems.

Assessment of pelvic organ prolapse with the Pelvic Inclination Correction System: defining the normal range and threshold to pathology.

PURPOSE: To define the normal range and threshold values for pathologic prolapse on MRI using the PICS line and assess its correlation with the pubococcygeal line (PCL). METHODS: This prospective, IRB-approved study included 20 nulliparous volunteers and 18 prolapse patients (POP-Q Stage ≥ 2). Organ positions (bladder, cervix, anorectal junction) relative to PICS and PCL were measured on dynamic MRI. Differences in organ position were compared. Receiver-operating characteristic (ROC) analysis was performed to identify cutoff values for prolapse using the PICS line. The correlation between PICS and PCL measurements was tested with Spearman's rank correlation. RESULTS: In volunteers, median bladder and cervix positions measured to the PICS at rest were - 2.7 cm and - 5.3 cm compared to - 1.9 cm and - 2.7 cm in patients (p < 0.001). During straining, bladder and cervix were at - 0.9 cm and - 3.2 cm in volunteers versus + 2.5 cm and + 2.5 cm in patients (p < 0.001). Correlation was strong for PICS and PCL measurements for all three compartments (δ = 0.883-0.970, p ≤ 0.001). AUCs of PICS for the anterior and middle compartment were 0.98 (95% confidence interval [CI] 0.96-1.00, p < 0.001) and 0.96 (95% CI 0.89-1.00, p < 0.001) for differentiating patients from healthy volunteers. AUC for the posterior compartment was 0.76 (95% CI 0.57-0.96, p = 0.034). CONCLUSION: PICS measurements reliably differentiate patients from volunteers in the anterior and middle compartment. Future studies need to identify a reliable threshold for the posterior compartment. PICS and PCL measurements are strongly correlated.

Risk factors for prostate cancer in men with false-negative mpMRI: A retrospective single center cohort study of image quality scores and clinical parameters.

PURPOSE: To identify predictors of prostate cancer (PCa) and clinically significant prostate cancer (csPCa) in men with prior false-negative multiparametric MRI (mpMRI), focusing on image quality scoring systems and clinical parameters. METHODS: In this IRB-approved retrospective single-center study, patients with a negative mpMRI (PI-RADS score ≤2) and subsequent prostate biopsies were included. Histopathological results served as reference standard. Welch's t-Test was conducted to identify significant differences in image quality scores (PI-QUAL and PSHS) between patients with and without PCa/csPCA. In addition, clinical parameters (age, BMI, PSA density) and image quality scores (PI-QUAL and PSHS) were examined as potential predictors of PCa/csPCa detection after a false-negative mpMRI in uni- and multivariate analyses. RESULTS: Among 96 patients with negative mpMRI results, 44.8 % had PCa and 16.7 % had csPCa upon biopsy with histopathological confirmation. PI-QUAL scores were significantly lower in patients with PCa (p = 0.03) and csPCa (p = 0.005). PSHS scores were lower in patients with csPCa, but the difference was not statistically significant (p = 0.1). Higher age (p = 0.035) and a lower PI-QUAL score (p < 0.004) were predictors of subsequent csPCa detection upon biopsy, however, a lower PI-QUAL score was the only independent predictor of missed csPCa in false-negative mpMRIs. CONCLUSIONS: Lower image quality scores were associated with missed PCa/csPCa in patients with false-negative mpMRIs, with PI-QUAL being an independent predictor of failed csPCa detection. This highlights the importance of image quality for prostate MRI and advocats the inclusion of its measurement into the standardized report.

Inguinal lymph node metastases from prostate cancer: clinical, pathology, and multimodality imaging considerations.

Objective: To investigate clinical, pathology, and imaging findings associated with inguinal lymph node (LN) metastases in patients with prostate cancer (PCa). Materials and Methods: This was a retrospective single-center study of patients with PCa who underwent imaging and inguinal LN biopsy between 2000 and 2023. We assessed the following aspects on multimodality imaging: inguinal LN morphology; extrainguinal lymphadenopathy; the extent of primary and recurrent tumors; and non-nodal metastases. Imaging, clinical, and pathology features were compared between patients with and without metastatic inguinal LNs. Results: We evaluated 79 patients, of whom 38 (48.1%) had pathology-proven inguinal LN metastasis. Certain imaging aspects- short-axis diameter, prostate-specific membrane antigen uptake on positron-emission tomography, membranous urethra involvement by the tumor, extra-inguinal lymphadenopathy, and distant metastases-were associated with pathology-proven inguinal LN metastases (p < 0.01 for all). Associations with long-axis diameter, fatty hilum, laterality, and uptake of other tracers on positronemission tomography were not significant (p = 0.09-1.00). The patients with metastatic inguinal LNs had higher prostate-specific antigen levels and more commonly had castration-resistant PCa (p < 0.01), whereas age, histological grade, and treatment type were not significant factors (p = 0.07-0.37). None of the patients had inguinal LN metastasis in the absence of locally advanced disease with membranous urethra involvement or distant metastasis. Conclusion: Several imaging, clinical, and pathology features are associated with inguinal LN metastases in patients with PCa. Isolated metastasis to inguinal LNs is extremely rare and unlikely to occur in the absence of high-risk imaging, clinical, or pathology features.

Objetivo: Investigar achados clinicopatológicos e de imagem associados a metástases linfonodais inguinais em pacientes com câncer de próstata (CaP). Materiais e Métodos: Estudo retrospectivo de uma única instituição de pacientes com CaP submetidos a exames de imagem e biópsia inguinal de linfonodos em 2000­2023. A imagem multimodalidade foi avaliada para morfologia inguinal do linfonodo, linfadenopatia fora da região inguinal, extensão do CaP primário/recorrente e sítios metastáticos não nodais. Características de imagem e clinicopatológicas foram comparadas entre pacientes com e sem linfonodos inguinais metastáticos pela patologia. Resultados: Entre 79 pacientes estudados, 38 (48,1%) apresentaram metástase inguinal de linfonodo comprovada patologicamente. Certos achados de imagem ­ diâmetro do eixo curto, captação do antígeno de membrana prostático específico na tomografia por emissão de pósitrons, envolvimento da uretra membranosa pelo tumor, linfadenopatia fora da região inguinal e metástases a distância ­ foram associados com metástases inguinais no linfonodo pela patologia (p < 0,01). Diâmetro de eixo longo, hilo gorduroso, lateralidade, captação em outros traçadores de tomografia por emissão de pósitrons não foram significativos (p = 0,09­1,00). Clinicopatologicamente, os pacientes com linfonodos inguinais metastáticos apresentaram maior antígeno prostático específico e foram mais resistentes à castração (p < 0,01); idade, grau histológico e tipo de tratamento não foram estatisticamente significantes (p = 0,07­0,37). Nenhum paciente apresentou metástase inguinal isolada no linfonodo na ausência de doença localmente avançada com envolvimento da uretra membranosa ou metástase a distância. Conclusão: Várias características de imagem e clinicopatológicas foram associadas a metástases em LNs inguinais em pacientes com CaP. A metástase isolada para os LNs inguinais é extremamente rara e é improvável que ocorra na ausência de características de imagem e clinicopatológicas de alto risco.

Pelvic organ movements in asymptomatic nulliparous and symptomatic premenopausal women with pelvic organ prolapse in dynamic MRI: a feasibility study comparing midsagittal single-slice with multi-slice sequences.

PURPOSE: To compare multi-slice (MS) MRI sequences of the pelvis acquired at rest and straining to dynamic midsagittal single-slice (SS) sequences for the assessment of pelvic organ prolapse (POP). METHODS: This IRB-approved prospective single-center feasibility study included 23 premenopausal symptomatic patients with POP and 22 asymptomatic nulliparous volunteers. MRI of the pelvis at rest and straining was performed with midsagittal SS and MS sequences. Straining effort, visibility of organs and POP grade were scored on both. Organ points (bladder, cervix, anorectum) were measured. Differences between SS and MS sequences were compared with Wilcoxon test. RESULTS: Straining effort was good in 84.4% on SS and in 64.4% on MS sequences (p = 0.003). Organ points were always visible on MS sequences, whereas the cervix was not fully visible in 31.1-33.3% on SS sequences. At rest, there were no statistically significant differences of organ point measurements between SS and MS sequences in symptomatic patients. At straining, positions of bladder, cervix, and anorectum were + 1.1 cm (± 1.8 cm), - 0.7 cm (± 2.9 cm), and + 0.7 cm (± 1.3 cm) on SS and + 0.4 mm (± 1.7 cm), - 1.4 cm (± 2.6 cm), and + 0.4 cm (± 1.3 cm) on MS sequences (p < 0.05). Only 2 cases of higher-grade POP were missed on MS sequences (both with poor straining effort). CONCLUSION: MS sequences increase the visibility of organ points compared to SS sequences. Dynamic MS sequences can depict POP if images are acquired with sufficient straining effort. Further work is needed to optimize the depiction of the maximum straining effort with MS sequences.

Index lesion contouring on prostate MRI for targeted MRI/US fusion biopsy - Evaluation of mismatch between radiologists and urologists.

PURPOSE: Mistargeting of focal lesions due to inaccurate segmentations can lead to false-negative findings on MRI-guided targeted biopsies. The purpose of this retrospective study was to examine inter-reader agreement of prostate index lesion segmentations from actual biopsy data between urologists and radiologists. METHOD: Consecutive patients undergoing transperineal MRI-targeted prostate biopsy for PI-RADS 3-5 lesions between January 2020 and December 2021 were included. Agreement between segmentations on T2w-images between urologists and radiologists was assessed with Dice similarity coefficient (DSC) and 95 % Hausdorff distance (95 % HD). Differences in similarity scores were compared using Wilcoxon test. Differences depending on lesion features (size, zonal location, PI-RADS scores, lesion distinctness) were tested with Mann-Whitney U test. Correlation with prostate signal-intensity homogeneity score (PSHS) and lesion size was tested with Spearman's rank correlation. RESULTS: Ninety-three patients (mean age 64.9 ± 7.1y, median serum PSA 6.5 [4.33-10.00]) were included. Mean similarity scores were statistically significantly lower between urologists and radiologists compared to radiologists only (DSC 0.41 ± 0.24 vs. 0.59 ± 0.23, p < 0.01; 95 %HD 6.38 ± 5.45 mm vs. 4.47 ± 4.12 mm, p < 0.01). There was a moderate and strong positive correlation between DSC scores and lesion size for segmentations from urologists and radiologists (ρ = 0.331, p = 0.002) and radiologists only (ρ = 0.501, p < 0.001). Similarity scores were worse in lesions ≤ 10 mm while other lesion features did not significantly influence similarity scores. CONCLUSION: There is significant mismatch of prostate index lesion segmentations between urologists and radiologists. Segmentation agreement positively correlates with lesion size. PI-RADS scores, zonal location, lesion distinctness, and PSHS show no significant impact on segmentation agreement. These findings could underpin benefits of perilesional biopsies.

Multi-reader evaluation of different image quality scoring systems in prostate MRI.

OBJECTIVES: To evaluate different image quality scoring systems in the assessment of factors limiting diagnostic accuracy of prostate MRI. METHODS: This retrospective IRB-approved study included 281 patients undergoing prostate MRI prior to biopsy. Four readers (2 experienced, 2 novice) independently reviewed all MRI examinations (n = 295) and assigned scores for subjective image quality (1-5; 1:poor, 5:excellent), the PI-QUAL and the PSHS scoring system. The original PI-RADS scores were extracted from the report and transperineal template saturation biopsy served as histopathological reference. RESULTS: Inter-reader agreement was found to be good, with PSHS showing highest agreement (kappa: 0.65). The PSHS scoring system performed well assessing the influence of image quality on sensitivity of MR for clinically-significant cancer for the experienced readers using a PI-RADS score cut-off ≥ 3/≥4, as did the PI-QUAL scoring system with a PI-RADS cut-off ≥ 4. For the less experienced radiologist, this was true for PSHS (clinically-significant and all cancers) and PI-QUAL scores (clinically-significant cancers) for a PI-RADS score ≥ 3. PSHS scores were positively associated with the detection of clinically-significant cancer based on a PI-RADS cut-off ≥ 4, OR 1.86 (95 % CI 1.22-2.82), and had the highest Somers' D. CONCLUSIONS: The PSHS scoring system performed well in assessing the effect of image quality on detection rates, as did the PI-QUAL system. Since both systems focus on different aspects of image quality, their incorporation into prostate MRI reports could further enhance standardization and allow for a reliable assessment of image quality as a potential confounder in prostate MRI.

Right-sided ALPPS after preoperative emergency embolization of the right hepatic artery: case report with a favorable anatomy.

In patients with extensive colorectal liver metastases (CRLM) and insufficient future liver remnant (FLR) a faster and more effective FLR augmentation than portal vein embolization is the associating liver partition and portal vein ligation in staged hepatectomy (ALPPS). Before ALPPS, the presence of arterial blood supply to the subsequently resected hemiliver must be ensured. We present a case with neoadjuvant-treated CRLM and insufficient FLR who developed a large intrahepatic hematoma after liver biopsy. For continuous bleeding, the right hepatic artery was embolized. Fortunately, an accessory right hepatic artery arising from the superior mesenteric artery was present, which enabled the ALPPS procedure to be performed. After ALPPS, the patient did not experience liver failure. The case exemplifies that preoperative evaluation of the vascular supply of the liver is of paramount importance in advanced hepatic surgery such as ALPPS.

Prediction of pelvic lymph node metastases and PSMA PET positive pelvic lymph nodes with multiparametric MRI and clinical information in primary staging of prostate cancer.

Purpose: To compare the accuracy of multiparametric MRI (mpMRI), 68Ga-PSMA PET and the Briganti 2019 nomogram in the prediction of metastatic pelvic lymph nodes (PLN) in prostate cancer, to assess the accuracy of mpMRI and the Briganti nomogram in prediction of PET positive PLN and to investigate the added value of quantitative mpMRI parameters to the Briganti nomogram. Method: This retrospective IRB-approved study included 41 patients with prostate cancer undergoing mpMRI and 68Ga-PSMA PET/CT or MR prior to prostatectomy and pelvic lymph node dissection. A board-certified radiologist assessed the index lesion on diffusion-weighted (Apparent Diffusion Coefficient, ADC; mean/volume), T2-weighted (capsular contact length, lesion volume/maximal diameters) and contrast-enhanced (iAUC, kep, Ktrans, ve) sequences. The probability for metastatic pelvic lymph nodes was calculated using the Briganti 2019 nomogram. PET examinations were evaluated by two board-certified nuclear medicine physicians. Results: The Briganti 2019 nomogram performed superiorly (AUC: 0.89) compared to quantitative mpMRI parameters (AUCs: 0.47-0.73) and 68Ga-PSMA-11 PET (AUC: 0.82) in the prediction of PLN metastases and superiorly (AUC: 0.77) in the prediction of PSMA PET positive PLN compared to MRI parameters (AUCs: 0.49-0.73). The addition of mean ADC and ADC volume from mpMRI improved the Briganti model by a fraction of new information of 0.21. Conclusions: The Briganti 2019 nomogram performed superiorly in the prediction of metastatic and PSMA PET positive PLN, but the addition of parameters from mpMRI can further improve its accuracy. The combined model could be used to stratify patients requiring ePLND or PSMA PET.

Sarcomatoid renal cell carcinoma: MRI features and their association with survival.

OBJECTIVE: To evaluate MRI features of sarcomatoid renal cell carcinoma (RCC) and their association with survival. METHODS: This retrospective single-center study included 59 patients with sarcomatoid RCC who underwent MRI before nephrectomy during July 2003-December 2019. Three radiologists reviewed MRI findings of tumor size, non-enhancing areas, lymphadenopathy, and volume (and percentage) of T2 low signal intensity areas (T2LIA). Clinicopathological factors of age, gender, ethnicity, baseline metastatic status, pathological details (subtype and extent of sarcomatoid differentiation), treatment type, and follow-up were extracted. Survival was estimated using Kaplan-Meier method and Cox proportional-hazards regression model was used to identify factors associated with survival. RESULTS: Forty-one males and eighteen females (median age 62 years; interquartile range 51-68) were included. T2LIAs were present in 43 (72.9%) patients. At univariate analysis, clinicopathological factors associated with shorter survival were: greater tumor size (> 10 cm; HR [hazard ratio] = 2.44, 95% CI 1.15-5.21; p = 0.02), metastatic lymph nodes (present; HR = 2.10, 95% CI 1.01-4.37; p = 0.04), extent of sarcomatoid differentiation (non-focal; HR = 3.30, 95% CI 1.55-7.01; p < 0.01), subtypes other than clear cell, papillary, or chromophobe (HR = 3.25, 95% CI 1.28-8.20; p = 0.01), and metastasis at baseline (HR = 5.04, 95% CI 2.40-10.59; p < 0.01). MRI features associated with shorter survival were: lymphadenopathy (HR = 2.24, 95% CI 1.16-4.71; p = 0.01) and volume of T2LIA (> 3.2 mL, HR = 4.22, 95% CI 1.92-9.29); p < 0.01). At multivariate analysis, metastatic disease (HR = 6.89, 95% CI 2.79-16.97; p < 0.01), other subtypes (HR = 9.50, 95% CI 2.81-32.13; p < 0.01), and greater volume of T2LIA (HR = 2.51, 95% CI 1.04-6.05; p = 0.04) remained independently associated with worse survival. CONCLUSION: T2LIAs were present in approximately two thirds of sarcomatoid RCCs. Volume of T2LIA along with clinicopathological factors were associated with survival.

Evaluating residual tumor after neoadjuvant chemotherapy for muscle-invasive urothelial bladder cancer: diagnostic performance and outcomes using biparametric vs. multiparametric MRI.

BACKGROUND: Neoadjuvant chemotherapy (NAC) before radical cystectomy is standard of care in patients with muscle-invasive bladder cancer (MIBC). Response assessment after NAC is important but suboptimal using CT. We assessed MRI without vs. with intravenous contrast (biparametric [BP] vs. multiparametric [MP]) for identifying residual disease on cystectomy and explored its prognostic role. METHODS: Consecutive MIBC patients that underwent NAC, MRI, and cystectomy between January 2000-November 2022 were identified. Two radiologists reviewed BP-MRI (T2 + DWI) and MP-MRI (T2 + DWI + DCE) for residual tumor. Diagnostic performances were compared using receiver operating characteristic curve analysis. Kaplan-Meier curves and Cox proportional-hazards models were used to evaluate association with disease-free survival (DFS). RESULTS: 61 patients (36 men and 25 women; median age 65 years, interquartile range 59-72) were included. After NAC, no residual disease was detected on pathology in 19 (31.1%) patients. BP-MRI was more accurate than MP-MRI for detecting residual disease after NAC: area under the curve = 0.75 (95% confidence interval (CI), 0.62-0.85) vs. 0.58 (95% CI, 0.45-0.70; p = 0.043). Sensitivity were identical (65.1%; 95% CI, 49.1-79.0) but specificity was higher in BP-MRI compared with MP-MRI for determining residual disease: 77.8% (95% CI, 52.4-93.6) vs. 38.9% (95% CI, 17.3-64.3), respectively. Positive BP-MRI and residual disease on pathology were both associated with worse DFS: hazard ratio (HR) = 4.01 (95% CI, 1.70-9.46; p = 0.002) and HR = 5.13 (95% CI, 2.66-17.13; p = 0.008), respectively. Concordance between MRI and pathology results was significantly associated with DFS. Concordant positive (MRI+/pathology+) patients showed worse DFS than concordant negative (MRI-/pathology-) patients (HR = 8.75, 95% CI, 2.02-37.82; p = 0.004) and compared to the discordant group (MRI+/pathology- or MRI-/pathology+) with HR = 3.48 (95% CI, 1.39-8.71; p = 0.014). CONCLUSION: BP-MRI was more accurate than MP-MRI for identifying residual disease after NAC. A negative BP-MRI was associated with better outcomes, providing complementary information to pathological assessment of cystectomy specimens.

Management of biliary obstruction in patients with newly diagnosed alveolar echinococcosis: a Swiss retrospective cohort study.

BACKGROUND AND STUDY AIMS: Alveolar echinococcosis, an orphan zoonosis affecting the liver, is of increasing concern worldwide. Most symptomatic cases present at an advanced and inoperable stage, sometimes with biliary obstruction prompting biliary tract interventions. These are, however, associated with a high risk of infectious complications. The aim of this retrospective study was to compare the effectiveness and safety of conservative and interventional treatment approaches in patients with newly diagnosed alveolar echinococcosis and biliary obstruction. PATIENTS AND METHODS: Alveolar echinococcosis patients treated at two referral centres in Switzerland, presenting with hyperbilirubinaemia (total bilirubin >1.5 Upper Limit of Normal) at diagnosis were included, unless another underlying aetiology, i.e. common bile duct stones or decompensated cirrhosis, was identified. Patients were divided into two groups, according to whether they initially received a biliary tract intervention. The primary endpoint was normalisation of bilirubin levels within a 6-month period. Secondary endpoints included, among others, the occurrence of early and late biliary complications, the need for biliary tract interventions during follow-up and overall duration of hospital stays for treatment initiation and for biliary complications. RESULTS: 28 patients were included in this study, of whom 17 received benzimidazole therapy alone and 11 additionally received a biliary tract intervention. Baseline characteristics did not differ between groups. All but one patient in each group achieved the primary endpoint (p=0.747). Biliary tract intervention was associated with faster laboratory improvement (t1/2 1.3 vs 3.0 weeks), but also with more frequent early biliary complications (7/11 vs 1/17, p=0.002) and longer initial hospital stay (18 days vs 7 days, p=0.007). CONCLUSION: Biliary obstruction in patients with newly diagnosed alveolar echinococcosis can be treated effectively with benzimidazole therapy alone. Biliary tract intervention, on the other hand, is associated with a high complication rate and should probably be reserved for patients with insufficient response to benzimidazole therapy.

Multicenter Phase II Clinical Trial of Gemcitabine and Cisplatin as Neoadjuvant Chemotherapy for Patients With High-Grade Upper Tract Urothelial Carcinoma.

PURPOSE: Neoadjuvant chemotherapy (NAC) has proven survival benefits for patients with invasive urothelial carcinoma of the bladder, yet its role for upper tract urothelial carcinoma (UTUC) remains undefined. We conducted a multicenter, single-arm, phase II trial of NAC with gemcitabine and split-dose cisplatin (GC) for patients with high-risk UTUC before extirpative surgery to evaluate response, survival, and tolerability. METHODS: Eligible patients with defined criteria for high-risk localized UTUC received four cycles of split-dose GC before surgical resection and lymph node dissection. The primary study end point was rate of pathologic response (defined as < ypT2N0). Secondary end points included progression-free survival (PFS), overall survival (OS), and safety and tolerability. RESULTS: Among 57 patients evaluated, 36 (63%) demonstrated pathologic response (95% CI, 49 to 76). A complete pathologic response (ypT0N0) was noted in 11 patients (19%). Fifty-one patients (89%) tolerated at least three complete cycles of split-dose GC, 27 patients (47%) tolerated four complete cycles, and all patients proceeded to surgery. With a median follow up of 3.1 years, 2- and 5-year PFS rates were 89% (95% CI, 81 to 98) and 72% (95% CI, 59 to 87), while 2- and 5-year OS rates were 93% (95% CI, 86 to 100) and 79% (95% CI, 67 to 94), respectively. Pathologic complete and partial responses were associated with improved PFS and OS compared with nonresponders (≥ ypT2N any; 2-year PFS 100% and 95% v 76%, P < .001; 2-year OS 100% and 100% v 80%, P < .001). CONCLUSION: NAC with split-dose GC for high-risk UTUC is a well-tolerated, effective therapy demonstrating evidence of pathologic response that is associated with favorable survival outcomes. Given that these survival outcomes are superior to historical series, these data support the use of NAC as a standard of care for high-risk UTUC, and split-dose GC is a viable option for NAC.

Prognostic Utility of MRI Features in Intradiverticular Bladder Tumor.

BACKGROUND: Intradiverticular bladder tumors (IDBT) are rare but clinically important, as they are difficult to assess endoscopically due to limited anatomic access and risk of perforation. MRI may be helpful in assessing IDBT and providing relevant staging and prognostic information. PURPOSE: To assess MRI findings of IDBT and their relationship with overall survival. METHODS: This retrospective study included 31 consecutive patients with IDBT undergoing MRI from 2008 to 2018 identified through electronic medical records and PACS database search. Two radiologists independently assessed the following MRI features: size (>3 vs ≤3 cm), diverticular neck involvement, Vesical Imaging-Reporting and Data System (VI-RADS) score (>3 vs ≤3), perivesical fat infiltration, additional tumors and suspicious pelvic lymph nodes. Overall survival was estimated using Kaplan-Meier analysis; and the relationship with clinicopathological and MRI features was determined using the Cox proportional-hazards regression model. Inter-reader agreement was assessed using intraclass correlation coefficients (ICC) and Cohen's kappa (K). RESULTS: Median follow-up was 1044 days (interquartile range, 474-1952 days). Twenty-six (83.9%) patients underwent surgical treatment with or without neoadjuvant chemotherapy. On MRI, greater tumor size (>3 cm), diverticular neck involvement, perivesical extension, and suspicious lymph nodes were associated with lower overall survival (HR = 3.6-8.1 and 4.3-6.3 for the 2 radiologists, p ≤ 0.03). Other clinicopathological or MRI findings were not associated with survival (p = 0.27-0.65). Inter-reader agreement was excellent for tumor size (ICC = 0.991; 95% CI 0.982-0.996), fair for VI-RADS (K = 0.52, 95% CI, 0.22-0.82), and moderate for others (K = 0.61-0.79). CONCLUSION: In patients with IDBT, several MRI features were significantly associated with overall survival. Utilizing all available clinicopathological and imaging information may improve estimation of prognosis.