A Comprehensive Commentary on the Multilocular Cystic Renal Neoplasm of Low Malignant Potential: A Urologist's Perspective.

Multilocular cystic renal neoplasm of low malignant potential (MCRNLMP) is a cystic renal tumor with indolent clinical behavior. In most of cases, it is an incidental finding during the examination of other health issues. The true incidence rate is estimated to be between 1.5% and 4% of all RCCs. These lesions are classified according to the Bosniak classification as Bosniak category III. There is a wide spectrum of diagnostic tools that can be utilized in the identification of this tumor, such as computed tomography (CT), magnetic resonance (MRI) or contrast-enhanced ultrasonography (CEUS). Management choices of these lesions range from conservative approaches, such as clinical follow-up, to surgery. Minimally invasive techniques (i.e., robotic surgery and laparoscopy) are preferred, with an emphasis on nephron sparing surgery, if clinically feasible.

Complications Following Decompressive Craniectomy.

BACKGROUND: Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. METHODS: We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. RESULTS: DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. CONCLUSIONS: The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.

Prediction of treatment response in patients with locally advanced cervical cancer using midtreatment PET/MRI during concurrent chemoradiotherapy.

PURPOSE: We aimed to find metabolic, functional or morphological characteristics of the tumor predicting failure to achieve complete metabolic remission (CMR) by the midtreatment PET/MRI (positron emission tomography/magnetic resonance imaging) in cervical cancer patients. METHODS: We evaluated 66 patients treated between August 2015 and November 2019 who underwent pretreatment staging, subsequent midtreatment evaluation, and definitive restaging 3 months after completing the whole treatment, all using PET/MRI. The pretreatment parameters (pre-SUVmax, pre-SUVmean, pre-MTV, pre-MTV­S, pre-TLG, pre-TLG­S [SUV: standard uptake value, MTV: metabolic tumor volume, TLG: total lesion glycolysis]), and the midtreatment parameters at week 5 during chemoradiotherapy (mid-SUVmax, mid-SUVmean, mid-MTV, mid-MTV­S, mid-TLG and mid-TLG-S) were recorded. The value of ADC (apparent diffusion coefficient) was also measured. Furthermore, we recorded absolute and relative changes in all parameters-∆ and ∆%. We divided the whole group of patients into "responders" (CMR) and "non-responders" (non-CMR), and compared them on the basis of the parameters from pre-PET/MRI and mid-PET/MRI. RESULTS: A statistically significant difference in the evaluated parameters between responders and non-responders was found for the following parameters: mid-MTV, mid-TLG, mid-TLG­S, mid-MTV­S, mid-tumor size, and ∆%SUVmax. According to the ROC (receiver operating characteristic) analysis, mid-MTV­S showed the best albeit moderate discrimination ability for the prediction of non-CMR. Significant mutual correlations of all variables, in particular between mid-MTV­S and mid-TLG­S and between mid-MTV and mid-TLG, were found (all p < 0.05). CONCLUSION: Our study confirmed that when using the midtreatment PET/MRI we are able to identify metabolic parameters having the discrimination ability for the prediction of non-CMR. In particular mid-MTV­S, mid-MTV, mid-tumor size, mid-TLG­S, mid-TLG and ∆%SUVmax.

Hybrid imaging PET/MR in prostatic carcinoma.

Imaging of the own prostatic tissue is being not easy using standard tumour imaging approaches, contrast enhanced computed tomography and the hybrid imaging using PET/CT with the application of the 18F-fluorodeoxyglucose. Magnetic resonance imaging is useful in detection of the patients with the elevated prostatic specific antigen (PSA) and/or with the increased index of the health prostate index (PHI). The novel imaging possibilities of the imaging is hybrid positron emission tomography - magnetic resonance imaging (PET/MR) with the application of 18F-fluorocholine (FCH), 18F-natriumfluoride (18F-NaF) or 68Ga-PSMA-11 (ligand of prostatic specific membrane antigen) in detection, staging or restaging of the prostatic carcinoma. PET/MR represents current optimal method of the staging, restaging and therapy response evaluation of prostatic carcinoma.> Keywords: prostatic carcinoma, PET/MR, 18F-fluorocholine, 18F-natriumfluoride, 68Ga-PSMA-11.

Tumor-related Perfusion Changes in White Matter Adjacent to Brain Tumors: Pharmacodynamic Analysis of Dynamic 3T Magnetic Resonance Imaging.

BACKGROUND/AIM: To verify perfusion differences in white matter adjacent to glioblastomas and metastatic tumors in dynamic contrast-enhanced (DCE) 3T-magnetic resonance imaging (MRI) using gradient echo (GRE) T1 techniques. MATERIALS AND METHODS: A retrospective comparative study was carried out on adults with glioblastoma (n=67) and brain metastases (n=31). In each patient, conventional 3T-MRI and DCE-MRI with 25 acquisitions of GRE-T1 were performed. The initial area under the contrast-uptake curve (iAUC) and transfer constant (Ktrans) in peritumoral regions of the white matter were evaluated using T1 pharmacodynamic modeling software. RESULTS: Statistically significantly higher relative iAUC (p<0.001) and Ktrans (p<0.01) values were recorded for peritumoral white matter near glioblastomas compared to that near metastases: 2.29 (SD=1.11) and 2.12 (SD=1.05) vs. 0.96 (SD=0.31) and 1.18 (SD=0.35), respectively. CONCLUSION: In comparison to Ktrans, the iAUC obtained by DCE-MRI is more suitable for assessing glioblastomas because it better reflects pharmacokinetic peritumoral changes. Increased iAUC in white matter near to tumor generally indicates glioblastoma, however, a low level does not exclude it.

Magnetic resonance imaging as an adjunct diagnostic tool in computed tomography defined Bosniak IIF-III renal cysts: a multicenter study.

INTRODUCTION: CT imaging is the standard examination for renal cystic lesions and defines the Bosniak category, which dictates further management. Given that Bosniak II/IIF/III renal cystic lesions can potentially harbor renal cell carcinoma (RCC), additional diagnostic modalities may be required in management decision making. AIM: To determine the value of additional magnetic resonance imaging in CT-defined Bosniak IIF-III renal cystic lesions. MATERIALS AND METHODS: This a multicenter retrospective study of 46 consecutive patients, diagnosed with cystic renal lesions between 2009 and 2016. The inclusion criteria were: (1) cystic renal lesion classified as Bosniak IIF-III on CT, (2) a subsequent MRI examination, and (3) documented outcome via surgery for cystic renal mass or follow-up. RESULTS: 46 patients (35 males, 11 females) were included. The mean size of the cystic lesion was 3.92 cm (0.7-10 cm). According to the CT findings, Bosniak IIF and III were found in 12 (26.1%) and 34 (73.9%) cases. Reclassification of Bosniak category was done after MRI examination in 31 cases (67.4%). An upgrade rate of 58.7% (27 cases) to a higher category was made, while the downgrade rate to a lower category was achieved in 4 cases (8.7%). As a result, significant therapeutic management change was made in 12/31 patients (38.7%), of whom 8 underwent subsequent surgery. CONCLUSION: MRI study may reduce the use of Bosniak IIF category (in comparison with CT), which has a direct impact on therapeutic management (surgery vs. surveillance) in a significant proportion of patients.

Pre-surgical Multiparametric Assessment of Breast Lesions Using 3-Tesla Magnetic Resonance.

BACKGROUND/AIM: The aim of this study was to evaluate experience with multiparametric breast imaging on 3-Tesla magnetic resonance (3T-MRI) scanner using a dedicated 18-channel coil compared to histological findings in women after surgery. MATERIALS AND METHODS: The study included 100 women with 105 Breast Imaging Reporting and Data System (BI-RADS) 4 to 6 lesions by mammography who were examined using 3T-MRI and subsequently underwent surgery. MRI included non-contrast T1, T2 and T2 short tau inversion recovery (STIR) sequences, diffusion-weighted imaging with apparent diffusion coeficient maps, postcontrast dynamic study and single-voxel MRI spectroscopy. The results were compared to those of histopathological examination. RESULTS: A sensitivity of 98.68% was found for the whole population, with a specificity of 86.20%. The most valuable findings were diffusion restriction with sensitivity of 90.79% and specificity of 89.66%, and increased choline in the spectrum with sensitivity of 68.42% and specificity of 93.10%. Evaluation of the enhancement curve had sensitivity of 45.05% and specificity of 72.41%. In examination of lymph nodes, 3T-MRI had sensitivity of 92.59% and specificity of 93.87%. CONCLUSION: Multiparametric 3T-MRI breast imaging shows excellent results in evaluation of breast cancer compared to histological findings, both for primary tumor and nodal metastases. The greatest contribution to improving diagnostic performance is the evaluation of diffusion.

Assessment of grading in newly-diagnosed glioma using 18F-fluorothymidine PET/CT.

AIM: To evaluate the proliferation activity in gliomas using 18F-fluorothymidine (18F-FLT)-positron emission tomography/computed tomography (PET/CT). PATIENTS AND METHODS: Samples of 26 tumors were analyzed (mean age=51.6; range=26-72 years; 16 males, 10 females). All examinations were performed using a PET/CT scanner equipped with lutetium oxyorthosilicate (LSO) detectors. All data were acquired with a delay of 15 min, following intravenous application of 18F-FLT (dosed 2 MBq/kg of body weight). The PET/CT contained CT after intravenous application of iodinated contrast agent and high-resolution brain PET acquired during 15 min in one position. PET/CT was performed before confirmation of the histological diagnosis and the level of 18F-FLT accumulation was compared to the grading of the tumor evaluated using immunohistochemistry staining of Ki-67. Samples were obtained by stereotactic biopsy (5×) or surgical resection (21×). RESULTS: Five tumors of grade IV, 7 tumors of grade III and 14 tumors of grade II were found. Pre-bioptical discrimination between high-grade and low-grade tumors reached accuracy 92.3% (24/26), sensitivity 92.3% (12/13) and specificity 92.9 (13/14). The mean maximum standardized uptake value (SUVmax) in high-grade tumors was 2.23, significantly different from low-grade tumors (mean SUVmax 0.61, T=7.803, p<0.0001). CONCLUSION: 18F-FLT-PET/CT enables to estimate the proliferation activity of glioma before biopsy.

Length of occlusion predicts recanalization and outcome after intravenous thrombolysis in middle cerebral artery stroke.

BACKGROUND AND PURPOSE: The length of large vessel occlusion is considered a major factor for therapy in patients with ischemic stroke. We used 4D-CT angiography evaluation of middle cerebral artery occlusion in prediction of recanalization and favorable clinical outcome and after intravenous thrombolysis (IV-tPA). METHODS: In 80 patients treated with IV-tPA for acute complete middle cerebral artery/M1 occlusion determined using CT angiography and temporal maximum intensity projection, calculated from 4D-CT angiography, the length of middle cerebral artery proximal stump, occlusion in M1 or M1 and M2 segment were measured. Univariate and multivariate analyses were performed to define independent predictors of successful recanalization after 24 hours and favorable outcome after 3 months. RESULTS: The length of occlusion was measureable in all patients using temporal maximum intensity projection. Recanalization thrombolysis in myocardial infarction 2 to 3 was achieved in 37 individuals (46%). The extension to M2 segment as a category (odds ratio, 4.58; 95% confidence interval, 1.39-15.05; P=0.012) and the length of M1 segment occlusion (odds ratio, 0.82; 95% confidence interval, 0.73-0.92; P=0.0007) with an optimal cutoff value of 12 mm (sensitivity 0.67; specificity 0.71) were significant independent predictors of recanalization. Favorable outcome (modified Rankin scale 0-2) was achieved in 25 patients (31%), baseline National Institutes of Health Stroke Scale (odds ratio, 0.82; 95% confidence interval, 0.72-0.93; P=0.003) and the length of occlusion M1 in segment (odds ratio, 0.79; 95% confidence interval, 0.69-0.91; P=0.0008) with an optimal cutoff value of 11 mm (sensitivity 0.74; specificity 0.76) were significant independent predictors of favorable outcome. CONCLUSIONS: The length of middle cerebral artery occlusion is an independent predictor of successful IV-tPA treatment.

Automated infarction core delineation using cerebral and perfused blood volume maps.

PURPOSE: Thrombolytic therapy in patients with acute ischemic stroke is contraindicated when the infarction core exceeds a given threshold. To date, there are no standardized guidelines for computed tomography infarction core assessment. Current practice involves use of thresholding methods, where the results are further adjusted by an experienced physician. An automated method for infarction core delineation and volume measurement was developed and tested. MATERIALS AND METHODS: CT postprocessing software was developed for analysis of whole brain perfused blood volume (PBV) and cerebral blood volume (CBV) maps. The program was designed for potential use with mean transit time (MTT) or cerebral blood flow (CBF) maps. The proposed method was tested on a set of 12 patients on both PBV and CBV maps with whole brain coverage by comparison with the results of a simple thresholding method and with manually marked findings provided by two independent physicians. RESULTS: The proposed method produced a marked infarct core volume corresponding to 53 % of the manually delineated volumes. The simple thresholding method with the optimal threshold, using the same dataset, marked 15[Formula: see text] larger volume compared to the volume delineated by physicians. CONCLUSION: An automated infarction core segmentation method based on local neighborhood features was developed and tested, demonstrating its utility in distinguishing between infarcted and non-infarcted areas, as well as reduction in the number of false positives and volume error.