Prostate MRI: who, when, and how? Report from a UK consensus meeting.

The current pathway for men suspected of having prostate cancer [transrectal biopsy, followed in some cases by magnetic resonance imaging (MRI) for staging] results in over-diagnosis of insignificant tumours, and systematically misses disease in the anterior prostate. Multiparametric MRI has the potential to change this pathway, and if performed before biopsy, might enable the exclusion of significant disease in some men without biopsy, targeted biopsy in others, and improvements in the performance of active surveillance. For the potential benefits to be realized, the setting of standards is vital. This article summarizes the outcome of a meeting of UK radiologists, at which a consensus was achieved on (1) the indications for MRI, (2) the conduct of the scan, (3) a method and template for reporting, and (4) minimum standards for radiologists.

Recto-urethral fistula following brachytherapy for localized prostate cancer.

OBJECTIVE: The use of prostate brachytherapy (BT) in the management of prostate cancer is increasing. BT is often chosen because of its perceived lower toxicity when compared with other radical therapy options. Rarely however serious complications can occur. One such complication is recto-urethral fistula (RUF). We report the incidence of RUF following BT at our centre and review the potential factors in fistula development. METHOD: A prospectively collected database was used to identify cases of RUF among 1455 patients treated with prostate BT at a single UK centre with at least 2 years of follow up. This included patients treated with BT monotherapy, as well as those treated with BT combined with external beam radiotherapy and BT used as salvage as all these groups have a higher incidence of RUF. Implant dose and volume characteristics for those patients, their co-morbidities and history of endoscopic procedures were recorded. RESULTS: Recto-urethral fistula was identified in three (0.2%) patients, occurring at 19-27 months following BT. All these patients had BT monotherapy. All three patients had rectal symptoms after their BT and had been investigated with endoscopy and low rectal biopsy. Subsequent surgical management with faecal and/or urinary diversion was required. On review of patients' BT details, radiation dose and volume parameters were higher on the postprocedure CT calculations than had been suggested by the preimplant plan. No other predisposing risk factors for RUF were identified. CONCLUSION: The incidence of RUF in our population is low. RUF following BT has been associated with rectal biopsy in previous series and this is confirmed in our report. Gastrointestinal specialists should not perform biopsy of the anterior rectum in patients who have had BT unless there is a very high clinical suspicion of malignancy.

Imaging for prostate cancer.

The increased incidence and awareness of prostate cancer, together with developments in treatment, has generated a significant need for appropriate imaging to detect and stage the tumour initially, guide radiotherapy delivery and monitor disease on follow-up. Transrectal ultrasound is usually the first imaging investigation, and its role is primarily to guide prostate needle biopsy. It also has an established role in imaging-guided treatments, such as brachytherapy. Magnetic resonance imaging has developed considerably in recent years, and is now the principal staging investigation before treatment. Innovations in functional and biological imaging of the prostate will, in the future, contribute valuable information to support parallel developments in radiotherapy techniques for prostate cancer. The ultimate goal is a coordinated diagnostic and therapeutic approach to individualise and optimise the treatment plan for patients with prostate cancer.

Short-term morbidity and acceptability of 125iodine implantation for localized carcinoma of the prostate.

OBJECTIVE: To report the short-term morbidity and acceptability of the first 50 patients treated with the percutaneous implantation of radioactive iodine seeds for localized carcinoma of the prostate at the Cookridge Hospital. PATIENTS AND METHODS: Fifty patients were treated with transrectal ultrasonography-guided percutaneous implants with radioactive (125I) iodine seeds for localized carcinoma of the prostate. The mean hospital stay was 36 h and most patients were able to return to work or normal activity within one week of implantation. RESULTS: All patients developed urethritis which was most marked within the first 3 months of treatment; 8% of patients developed acute retention which resolved after temporary catheterization. At 3 months, 36% of patients still had moderate frequency and 18% moderate dysuria, but by 12 months these had resolved and only 5% of patients still complained of moderate nocturia. There were no cases of incontinence. The incidence of proctitis was very low, with only 2% still complaining of moderate symptoms at one year. Of those potent before implantation, 72% retained potency at one year. CONCLUSIONS: Although it is too early to comment either on late morbidity or on outcome, the results of this study show a side-effect profile similar to that reported by other centres using the same technique.

The transrectal ultrasound and MRI appearances of granulomatous prostatitis and its differentiation from carcinoma.

AIMS AND METHODS: Granulomatous prostatitis is a benign inflammatory condition of the prostate which can be mistaken for prostatic carcinoma both clinically and on ultrasound, but is distinguishable histologically. The transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) appearances of 10 patients with histologically confirmed granulomatous prostatitis were evaluated to try and identify any correlation between the two techniques or any specific features on MRI to help distinguish it from carcinoma. Clinical findings and serum prostatic specific antigen (PSA) levels were also evaluated. RESULTS: In five patients, both TRUS and MRI were concordant, showing only changes of benign prostatic hypertrophy (three patients) or showing no abnormality (two patients). In a further three patients, both TRUS and MRI were abnormal, with appearances suggestive of carcinoma. One of these patients had tuberculous prostatitis and had a past history of tuberculosis. In the remaining two patients, there was a discrepancy between TRUS and MRI findings, carcinoma being suspected on TRUS in one with a normal MRI, and carcinoma suspected on MRI in the other with a normal TRUS. CONCLUSION: There is no pattern of clinical, biochemical, ultrasound or MRI findings that allows a specific diagnosis of granulomatous prostatitis to be made, or differentiation from prostatic carcinoma.

Prostate brachytherapy.

In recent years there has been an increase in the number of centres, especially in the USA, using prostate brachytherapy as a means of treating localised prostate cancer. Several centres now have medium term follow up data of large numbers of patients treated with this technique suggesting that outcome in terms of tumour control may be comparable to patients treated surgically. This review summarises results from different brachytherapy series and outlines some of the possible advantages of this technique compared with current conventional treatments for localised prostate cancer.

Dosimetric considerations in the treatment of inoperable endometrial carcinoma by a high dose rate afterloading packing technique.

A series of 23 patients with early adenocarcinoma of the endometrium who underwent a total of 37 modified Heyman packings treated on a high dose rate Microselectron has been reviewed. Using computed tomography (CT), the uterine wall thickness was measured retrospectively and doses calculated at a number of points on the uterine serosa and related normal tissues. The mean and maximum fundal serosal doses were found to be highest posteriorly and the sigmoid colon was adjacent to the posterior surface of the uterus in all instances. By superimposing the isodose distribution on CT sections of the uterus, it is now possible to prescribe to a serosal dose, or, in patients too heavy for the CT scanner, a dose can be prescribed to a point S, which is a reasonable approximation to the serosal position. Since the initial study, a further ten patients have been treated by the same method and, where relevant, data from all 33 patients have been used.

Case report: gas within a cervical vertebral body.

We describe an unusual case of intraosseous gas within the vertebral body of C5. The differential diagnosis and likely aetiology is discussed.

The role of immediate cytological evaluation in CT-guided biopsy.

A prospective study of 130 fine-needle aspiration biopsies (FNAB) was performed on 110 consecutive patients to assess the contribution of immediate cytological evaluation (ICE). All biopsies were performed under CT guidance using either 20 gauge or 22 gauge aspiration needles. Two distinct patient groups were derived from two hospitals. In one hospital a consultant cytologist was usually present, whereas in the other immediate cytological evaluation was not generally available. Overall, a consultant cytologist was present for 52% of the biopsies. The accuracy of the procedure, the number of needle passes made, the complication rates with and without ICE were assessed for each hospital population group. The overall accuracy, with and without ICE, was 72%. Although slightly fewer specimens were deemed inadequate when ICE was available, this difference did not reach statistical significance.

Physiological effect of endobronchial radiotherapy in patients with major airway occlusion by carcinoma.

BACKGROUND: Endobronchial radiotherapy by a high dose rate remote after-loading technique (high dose rate brachytherapy) has become an established treatment for major airway occlusion by inoperable carcinoma of the bronchus. Only limited objective data on its effect on pulmonary physiology and on radiographic and bronchoscopic appearances are available. The aim of this study was to make a detailed assessment of patients before and after high dose rate brachytherapy to determine which investigations were useful and to generate data for comparing this with other methods of treatment. METHODS: Twenty patients with major airway obstruction by inoperable lung cancer underwent a detailed assessment before receiving endobronchial radiotherapy (15 Gy at 1 cm in a single fraction) and six weeks after treatment. This included chest radiography, computed tomography of the thorax, bronchoscopy including an obstruction index, five minute walking tests, isotope ventilation and perfusion lung scanning, and full lung function tests with maximum inspiratory and expiratory flow-volume loops. RESULTS: Nineteen patients (mean age 69 years) completed the study. Symptomatic improvement occurred in 17 patients. A collapsed lobe or lung, seen on the chest radiograph in 13, reexpanded in nine. Bronchoscopic appearances improved in 18, the mean obstruction index decreasing from 6.2 to 2.8. The isotope scans showed significant increases in the percentage of total lung ventilation (V) and perfusion (Q) measured over the abnormal lung (V 17.7% to 27.7%, Q 15.1 to 21.9%). Five minute walking distance (305 to 329 m), forced expiratory volume in one second (FEV1 1.45 to 1.61 l), forced vital capacity (FVC 2.17 to 2.48 l) and ratio of forced expiratory to forced inspiratory flow rate at 50% vital capacity (FEF50/FIF50 0.58 to 0.88) all increased significantly. CONCLUSIONS: Endobronchial radiotherapy led to subjective benefit in most cases in terms of symptoms and bronchoscopic and radiological appearances. There was objective improvement in spirometric indices and in exercise tolerance with increased pulmonary ventilation and perfusion and evidence of decreased intrathoracic airway obstruction.

Production of autostimulatory growth factors by the human carcinoma line, RPMI 2650.

The human carcinoma line RPMI 2650 produces autocrine factors; they are detected by the ability of RPMI 2650 conditioned medium (CM) to stimulate growth in soft agar of RPMI 2650 cells plated at low density. The autocrine activity in crude CM can be fractionated by ultrafiltration into a lower molecular weight (MW) fraction (R1-30), which concentrates molecules in the 1000-30,000 Da range; and a higher MW fraction (R30) with molecules greater than 30,000 Da in a more concentrated form. R1-30 is labile to acid, base, and heat treatment, whereas R30 is stable to (and sometimes activated by) these treatments. Boiling of R30, however, renders it labile to acid, base, and trypsin treatments. CM can be separated into a weakly heparin-binding fraction (with stability properties similar, but not identical, to R1-30), and a non-heparin binding fraction (with stability properties similar to R30). RPMI 2650 cells secrete transforming growth factor (TGF)alpha- and TGF beta-like molecules, but the R1-30 fraction can be distinguished from these TGFs, and from most other known growth factors, by its unusual combination of acid lability and weak affinity for heparin. Since the R30/non-heparin binding fraction is rendered labile by boiling or acid treatment, it may represent a bound or conformationally stable form of a growth factor.

Changes in target volume during radiotherapy treatment of invasive bladder carcinoma.

Ninety patients with stage T3 Nx Mo carcinoma of the urinary bladder were treated with radical megavoltage external beam radiotherapy. Planning for treatment was undertaken on a treatment planning system utilizing CT scan slices to define the target volume and patient outline. All patients underwent a second CT scan half way through their course of treatment to assess any change in target volume and the continued adequacy of the original treatment plan. Seventy-two patients (80%) had no spatial shift in target volume, but, of the 18 patients with such a shift, treatment plans were changed in seven. The majority of patients had no delay in continuing their treatment after replanning, but one patient had a gap of 5 days before restarting treatment. An analysis of the factors possibly associated with a change in target volume showed that a primary tumour at the bladder base, rather than elsewhere in the bladder, was the single most important criterion for predicting target volume changes. There was no correlation between the size of the initial tumour, or the size of the prostate gland in male patients, and the occurrence of a shift in volume outside the initial target volume. Some method of regularly assessing the continued relevance of the target volume may be needed in this group of patients to improve the precision of treatment and also improve results.

Early detection of relapse after treatment for metastatic germ cell tumour of the testis: an exercise in medical audit.

The relapse patterns of 29 patients who recurred following treatment for metastatic germ cell tumours of the testis (seminoma n = 7, non-seminomatous germ cell tumour n = 22) have been analysed and the relative effectiveness of clinical follow-up and routine investigations in detecting relapse at an early stage have been examined. The analysis shows that routine estimation of the serum tumour markers human chorionic gonadotrophin and alpha-foetoprotein (HCG and AFP) is the single most important follow-up procedure. This is so, even in patients who were previously marker negative; it was the first indicator of relapse in 55% of the patients. Regular clinical examination and chest radiograph in asymptomatic patients was of little value. Chest radiograph gave the first evidence of relapse in only 2 cases (7%). The optimum frequency for follow-up computed tomographic scanning of the chest and abdomen remains debatable. In this series, it was the first abnormal investigation in 7 patients (24%) and proved to be particularly important in patients who had residual radiological abnormalities at the end of initial therapy. Cost analysis shows that intensive follow-up produces a total expenditure on investigations of approximately 4,500 pounds per relapse detected. Regular computed tomographic scanning is especially demanding on resources and costs approximately 12,880 pounds per relapse detected if the recommended protocol is followed.

Primary malignant localized fibrous tumours of the pleura: clinical, radiological and pathological features.

Localized fibrous tumours of the pleura are rare primary pleural tumours that may exhibit malignant behaviour in approximately 20% of cases. The clinical, radiological and pathological features of five patients with malignant localized fibrous tumours of the pleura are presented. Clinical symptoms included chest pain, breathlessness and cough. Hypertrophic pulmonary osteoarthropathy (HPOA) occurred in one patient. Chest radiographs and thoracic computed tomography (CT) demonstrated large necrotic masses, with focal calcification and compressive atelectasis of the underlying lung. Histological features were variable and resulted in designation of these tumours as localized fibrous tumours of the pleura of low or high grade malignancy. The grading of malignancy did not correlate with final outcome, adequacy of surgical excision being the most important factor. These tumours have been referred to as benign pleural fibromas or localized mesotheliomas, but these names are inaccurate and the term localized fibrous tumour of the pleura is to be preferred. This term should also include tumours such as malignant fibrous histiocytoma of the pleura.

Computed tomographic appearances of treated metastatic testicular tumours.

Recent therapeutic advances have considerably improved survival rates in patients with testicular tumours. Computed tomography (CT) permits accurate staging and follow-up monitoring of these patients, and it is important, therefore, to be familiar with the evolution of abnormalities on CT after treatment. This study was undertaken to evaluate these appearances and consider their impact on management. Eighty-three patients with metastatic testicular neoplasms had serial CT scans as part of their management. The average age was 34 years (range 19-66 years) with a mean follow-up period of 30 months (range 3-97 months). Seventy-three patients had nodal disease at some stage: 44% reverted to normal on treatment, with no recurrence, while 30% regressed but did not clear completely. Thirty-six patients had lung lesions: although most responded to treatment persistent abnormality was observed in 39% of cases. Nine patients had extranodal disease. A variable response to treatment is reflected by CT findings that contribute to the development of a follow-up strategy whereby successful therapy may be recognised and residual or recurrent disease confirmed.

Skeletal toxicity with isotretinoin therapy: a clinico-radiological evaluation.

Skeletal toxicity is known to occur with high doses of isotretinoin (greater than 2 mg/kg/day). We have attempted to evaluate the clinical significance and document the extent of musculoskeletal toxicity associated with a relatively low dose of isotretinoin (0.5 mg/kg/day) used in the treatment of severe acne. Radiographs of 120 patients were examined. Twelve per cent showed minor changes (four patients had spinal hyperostoses and 10 had calcaneal hyperostoses). None of the musculoskeletal changes we observed was clinically significant. Comparison with matched control X-rays showed 8% of the controls to have similar non-significant changes. Follow-up of 11 of the patients with abnormal X-rays showed minor deterioration in one patient, no change in four and improvement in six. Thus, doses of 0.5 mg/kg/day isotretinoin in such patients did not produce any significant long-term musculoskeletal changes. With increasing use of this beneficial drug in acne, radiologists and dermatologists should be aware of its skeletal toxicity.

Ultrasound demonstration of pericardial empyema in an infant with pyrexia of undetermined origin.

An infant with pyrexia of unknown origin presented to the Paediatric Unit. The initial infection screen was unhelpful and he was, therefore, referred for abdominal ultrasound to look for occult sepsis. During epigastric scanning, a large loculated fluid collection was demonstrated in the pericardium. A pericardial empyema should not be forgotten as a possible source of infection in the infant with undetermined pyrexia.