68Ga-RM2 PET-MRI versus MRI alone for evaluation of patients with biochemical recurrence of prostate cancer: a single-centre, single-arm, phase 2/3 imaging trial.

BACKGROUND: National Comprehensive Cancer Network guidelines include prostate-specific membrane antigen (PSMA)-targeted PET for detection of biochemical recurrence of prostate cancer. However, targeting a single tumour characteristic might not be sufficient to reflect the full extent of disease. Gastrin releasing peptide receptors (GRPR) have been shown to be overexpressed in prostate cancer. In this study, we aimed to evaluate the diagnostic performance of the GRPR-targeting radiopharmaceutical 68Ga-RM2 in patients with biochemical recurrence of prostate cancer. METHODS: This single-centre, single-arm, phase 2/3 trial was done at Stanford University (USA). Adult patients (aged ≥18 years) with biochemical recurrence of prostate cancer, a Karnofsky performance status of 50 or higher, increasing prostate-specific antigen concentration 0·2 ng/mL or more after prostatectomy or 2 ng/mL or more above nadir after radiotherapy, and non-contributory conventional imaging (negative CT or MRI, and bone scan) were eligible. All participants underwent 68Ga-RM2 PET-MRI. The primary outcome was the proportion of patients with PET-positive findings on 68Ga-RM2 PET-MRI compared with MRI alone after initial therapy, at a per-patient and per-lesion level. The primary outcome would be considered met if at least 30% of patients had one or more lesions detected by 68Ga-RM2 PET-MRI and the detection by 68Ga-RM2 PET-MRI was significantly greater than for MRI. Each PET scan was interpreted by three independent masked readers using a standardised evaluation criteria. This study is registered with ClinicalTrials.gov, NCT02624518, and is complete. FINDINGS: Between Dec 12, 2015, and July 27, 2021, 209 men were screened for eligibility, of whom 100 were included in analyses. Median follow-up was 49·3 months (IQR 36·7-59·2). The primary endpoint was met; 68Ga-RM2 PET-MRI was positive in 69 (69%) patients and MRI alone was positive in 40 (40%) patients (p<0·0001). In the per-lesion analysis 68Ga-RM2 PET-MRI showed significantly higher detection rates than MRI alone (143 vs 96 lesions; p<0·0001). No grade 1 or worse events were reported. INTERPRETATION: 68Ga-RM2 PET-MRI showed better diagnostic performance than MRI alone in patients with biochemical recurrence of prostate cancer. Further prospective comparative studies with PSMA-targeted PET are needed to gain a better understanding of GRPR and PSMA expression patterns in these patients. FUNDING: The US Department of Defense.

Assessment of T2-weighted Image Quality at Prostate MRI in Patients with and Those without Intramuscular Injection of Glucagon.

Purpose To assess whether administration of intramuscular (IM) glucagon improves T2-weighted image quality at multiparametric MRI (mpMRI) of the prostate. Materials and Methods In this Health Insurance Portability and Accountability Act-compliant single-center study, the authors retrospectively analyzed radiology reports from 3960 mpMRI examinations (2495 after exclusions) performed between September 2013 and September 2019 and performed outcome comparisons and semiquantitative image assessment of axial T2-weighted images from 120 consecutive mpMRI examinations performed between May 2015 and February 2016. Three experienced radiologists blinded to administration of IM glucagon assessed images using a five-point Likert scale (5 = no motion or blur) for overall image quality, anatomic delineation (prostate capsule, rectum, and lymph nodes), and identification of benign prostatic hyperplasia nodules. Wilcoxon rank sum and χ2 tests were used to assess quantitative parameters. Results The number of mpMRI radiology reports (599 examinations performed with glucagon; 1896, without glucagon) mentioning blur or motion were similar between groups (P = .82). Regression analysis of semiquantitative image quality assessments of T2-weighted images from mpMRI examinations (60 performed with glucagon; 60, without glucagon) demonstrated that images with glucagon were more likely to receive higher scores (4 or 5 rating) than those without glucagon only when the rectum (P = .001) and lymph nodes (P = .01) were evaluated, not when the prostatic capsule, benign prostatic hyperplasia nodules, or overall image quality was evaluated. No evidence of differences was found in identified Prostate Imaging Reporting and Data System (PI-RADS) lesions or targeted-biopsy Gleason scores. Conclusion Administration of IM glucagon did not improve T2-weighted image quality in prostate MRI examinations and showed similar PI-RADS scores and biopsy yields compared with examinations without glucagon. Keywords: MRI, Genital/Reproductive, Urinary, Prostate, Oncology, Observer Performance © RSNA, 2023 Online supplemental material is available for this article. See also commentary by Eberhardt in this issue.

MRI of Benign Prostatic Hyperplasia: Important Pre- and Posttherapeutic Considerations.

New minimally invasive techniques that reduce morbidity while improving lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) have become attractive alternatives for patients, in comparison to traditional techniques such as transurethral resection of the prostate (TURP) and simple prostatectomy. Pre- and postprocedural MRI is not routinely performed for LUTS due to BPH treatments. However, because of the combination of rapidly evolving treatments available for LUTS due to BPH and increasing demand for prebiopsy prostate MRI for detection of clinically significant prostate cancer (PCa), an understanding of procedural techniques and expected changes are important for accurate interpretation of prostate MRI performed after treatment of BPH. The authors discuss the imaging evaluation of LUTS due to BPH and emerging predictors of treatment success. The posttreatment appearance and underlying anatomic changes in the prostate after medical, surgical, and minimally invasive treatments including TURP, simple prostatectomy, laser enucleations and ablations, prostatic urethral lift, water vapor thermal therapy, and prostate artery embolization are detailed. Most procedures reduce prostate volume, notably in the periurethral prostatic tissue. Ablations create areas of necrosis and can distort the normal zonal anatomy between the transition zone and the peripheral zone, and prostate artery embolization creates infarcts in the transition zone. Mechanical prostatic urethral lift devices open the anterior channel at the bladder base but create susceptibility artifacts that can obscure and prevent detection of a lesion in the transition zone. Also discussed are the detection of clinically significant prostate cancer in the postprocedural prostate and imaging of BPH procedure complications such as urethral strictures, abscesses, and hematuria. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Purysko in this issue.

Correlation of 68Ga-RM2 PET with Postsurgery Histopathology Findings in Patients with Newly Diagnosed Intermediate- or High-Risk Prostate Cancer.

68Ga-RM2 targets gastrin-releasing peptide receptors (GRPRs), which are overexpressed in prostate cancer (PC). Here, we compared preoperative 68Ga-RM2 PET to postsurgery histopathology in patients with newly diagnosed intermediate- or high-risk PC. Methods: Forty-one men, 64.0 ± 6.7 y old, were prospectively enrolled. PET images were acquired 42-72 min (median ± SD, 52.5 ± 6.5 min) after injection of 118.4-247.9 MBq (median ± SD, 138.0 ± 22.2 MBq) of 68Ga-RM2. PET findings were compared with preoperative multiparametric MRI (mpMRI) (n = 36) and 68Ga-PSMA11 PET (n = 17) and correlated to postprostatectomy whole-mount histopathology (n = 32) and time to biochemical recurrence. Nine participants decided to undergo radiation therapy after study enrollment. Results: All participants had intermediate- (n = 17) or high-risk (n = 24) PC and were scheduled for prostatectomy. Prostate-specific antigen was 8.8 ± 77.4 (range, 2.5-504) and 7.6 ± 5.3 ng/mL (range, 2.5-28.0 ng/mL) when participants who ultimately underwent radiation treatment were excluded. Preoperative 68Ga-RM2 PET identified 70 intraprostatic foci of uptake in 40 of 41 patients. Postprostatectomy histopathology was available in 32 patients in which 68Ga-RM2 PET identified 50 of 54 intraprostatic lesions (detection rate = 93%). 68Ga-RM2 uptake was recorded in 19 nonenlarged pelvic lymph nodes in 6 patients. Pathology confirmed lymph node metastases in 16 lesions, and follow-up imaging confirmed nodal metastases in 2 lesions. 68Ga-PSMA11 and 68Ga-RM2 PET identified 27 and 26 intraprostatic lesions, respectively, and 5 pelvic lymph nodes each in 17 patients. Concordance between 68Ga-RM2 and 68Ga-PSMA11 PET was found in 18 prostatic lesions in 11 patients and 4 lymph nodes in 2 patients. Noncongruent findings were observed in 6 patients (intraprostatic lesions in 4 patients and nodal lesions in 2 patients). Sensitivity and accuracy rates for 68Ga-RM2 and 68Ga-PSMA11 (98% and 89% for 68Ga-RM2 and 95% and 89% for 68Ga-PSMA11) were higher than those for mpMRI (77% and 77%, respectively). Specificity was highest for mpMRI with 75% followed by 68Ga-PSMA11 (67%) and 68Ga-RM2 (65%). Conclusion: 68Ga-RM2 PET accurately detects intermediate- and high-risk primary PC, with a detection rate of 93%. In addition, 68Ga-RM2 PET showed significantly higher specificity and accuracy than mpMRI and a performance similar to 68Ga-PSMA11 PET. These findings need to be confirmed in larger studies to identify which patients will benefit from one or the other or both radiopharmaceuticals.

68Ga-PSMA-11 PET/MRI in Patients with Newly Diagnosed Intermediate- or High-Risk Prostate Adenocarcinoma: PET Findings Correlate with Outcomes After Definitive Treatment.

Prostate-specific membrane antigen (PSMA) PET offers an accuracy superior to other imaging modalities in initial staging of prostate cancer and is more likely to affect management. We examined the prognostic value of 68Ga-PSMA-11 uptake in the primary lesion and presence of metastatic disease on PET in newly diagnosed prostate cancer patients before initial therapy. Methods: In a prospective study from April 2016 to December 2020, 68Ga-PSMA-11 PET/MRI was performed in men with a new diagnosis of intermediate- or high-grade prostate cancer who were candidates for prostatectomy. Patients were followed up after initial therapy for up to 5 y. We examined the Kendall correlation between PET (intense uptake in the primary lesion and presence of metastatic disease) and clinical and pathologic findings (grade group, extraprostatic extension, nodal involvement) relevant for risk stratification, and examined the relationship between PET findings and outcome using Kaplan-Meier analysis. Results: Seventy-three men (age, 64.0 ± 6.3 y) were imaged. Seventy-two had focal uptake in the prostate, and in 20 (27%) PSMA-avid metastatic disease was identified. Uptake correlated with grade group and prostate-specific antigen (PSA). Presence of PSMA metastasis correlated with grade group and pathologic nodal stage. PSMA PET had higher per-patient positivity than nodal dissection in patients with only 5-15 nodes removed (8/41 vs. 3/41) but lower positivity if more than 15 nodes were removed (13/21 vs. 10/21). High uptake in the primary lesion (SUVmax > 12.5, P = 0.008) and presence of PSMA metastasis (P = 0.013) were associated with biochemical failure, and corresponding hazard ratios for recurrence within 2 y (4.93 and 3.95, respectively) were similar to or higher than other clinicopathologic prognostic factors. Conclusion: 68Ga-PSMA-11 PET can risk-stratify patients with intermediate- or high-grade prostate cancer before prostatectomy based on degree of uptake in the prostate and presence of metastatic disease.

Renal Artery Variations in Patients With Mild-to-Moderate Hypertension From the RADIANCE-HTN SOLO Trial.

PURPOSE: To assess the variability of renal artery (RA) anatomy and presence of RA-pathology in patients with mild-to-moderate hypertension enrolled in the RADIANCE-HTN SOLO trial. BACKGROUND: RADIANCE-HTN SOLO was a multicenter, international, blinded, randomized, sham-controlled trial evaluating ultrasound-based endovascular renal denervation (RDN) in patients with mild-to-moderate hypertension while off antihypertensive medications. METHODS: Eligible subjects had pre-randomization renal CT- or MR- angiography (CTA, MRA) to confirm anatomic suitability and to define RA ablation sites. All images were sent for independent review for evaluation of RA anatomy and other vascular pathology. RESULTS: A total of 324 patients underwent RA imaging (282 CTA and 42 MRA). Of those, 178 had simple anatomy with a single left and single right RA with mean diameters of 5.4 ± 0.9 and 5.1 ± 0.8 mm and mean lengths of 40.0 ± 12.9 and 52.0 ± 13.1 mm, respectively. Twenty-seven patients (8.3%) had unilateral or bilateral dual RAs with mean diameters of 4.0 ± 0.9 mm on the left and 3.9 ± 0.9 mm on the right. Forty percent (129/324) of patients had at least 1 accessory RA, with mean accessory diameters of 2.4 ± 0.8 mm on the left and 2.3 ± 0.8 mm on the right. Twenty-eight patients (8.6%) had at least 1 short (<25 mm) main RA. Incidental findings included: 9 patients (2.8%) with atherosclerotic RA stenosis ≥30%, 9 patients (2.8%) with fibromuscular dysplasia of RA and 2 patients (0.6%) with kidney and adrenal gland tumors. CONCLUSIONS: Pre-procedure CTA or MRA imaging is a valuable aid in assessing RA anatomy prior to RDN because of variable RA anatomy. CTA or MRA may detect RA lesions, and renal or adrenal tumors which may need additional workup prior to consideration of RDN. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT02649426.

Diagnostic Performance of 9 Quantitative Ultrasound Parameters for Detection and Classification of Hepatic Steatosis in Nonalcoholic Fatty Liver Disease.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease worldwide. Quantitative ultrasound (QUS) parameters based on radiofrequency raw data show promise in quantifying liver fat. PURPOSE: The aim of this study was to evaluate the diagnostic performance of 9 QUS parameters compared with magnetic resonance imaging (MRI)-estimated proton density fat fraction (PDFF) in detecting and staging hepatic steatosis in patients with or suspected of NAFLD. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act-compliant institutional review board-approved prospective study, 31 participants with or suspected of NAFLD, without other underlying chronic liver diseases (13 men, 18 women; average age, 52 years [range, 26-90 years]), were examined. The following parameters were obtained: acoustic attenuation coefficient (AC); hepatorenal index (HRI); Nakagami parameter; shear wave elastography measures such as shear wave elasticity, viscosity, and dispersion; and spectroscopy-derived parameters including spectral intercept (SI), spectral slope (SS), and midband fit (MBF). The diagnostic ability (area under the receiver operating characteristic curves and accuracy) of QUS parameters was assessed against different MRI-PDFF cutoffs (the reference standard): 6.4%, 17.4%, and 22.1%. Linearity with MRI-PDFF was evaluated with Spearman correlation coefficients (p). RESULTS: The AC, SI, Nakagami, SS, HRI, and MBF strongly correlated with MRI-PDFF (P = 0.89, 0.89, 0.88, -0.87, 0.81, and 0.71, respectively [P < 0.01]), with highest area under the receiver operating characteristic curves (ranging from 0.85 to 1) for identifying hepatic steatosis using 6.4%, 17.4%, and 22.1% MRI-PDFF cutoffs. In contrast, shear wave elasticity, shear wave viscosity, and shear wave dispersion did not strongly correlate to MRI-PDFF (P = 0.45, 0.38, and 0.07, respectively) and had poor diagnostic performance. CONCLUSION: The AC, Nakagami, SI, SS, MBF, and HRI best correlate with MRI-PDFF and show high diagnostic performance for detecting and classifying hepatic steatosis in our study population. SUMMARY STATEMENT: Quantitative ultrasound is an accurate alternative to MRI-based techniques for evaluating hepatic steatosis in patients with or at risk of NAFLD. KEY FINDINGS: Our preliminary results show that specific quantitative ultrasound parameters accurately detect different degrees of hepatic steatosis in NAFLD.

Upstream Machine Learning in Radiology.

Machine learning (ML) and Artificial intelligence (AI) has the potential to dramatically improve radiology practice at multiple stages of the imaging pipeline. Most of the attention has been garnered by applications focused on improving the end of the pipeline: image interpretation. However, this article reviews how AI/ML can be applied to improve upstream components of the imaging pipeline, including exam modality selection, hardware design, exam protocol selection, data acquisition, image reconstruction, and image processing. A breadth of applications and their potential for impact is shown across multiple imaging modalities, including ultrasound, computed tomography, and MRI.

How Often is the Dynamic Contrast Enhanced Score Needed in PI-RADS Version 2?

BACKGROUND: Prostate imaging reporting and data system version 2 (PI-RADS v2) relegates dynamic contrast enhanced (DCE) imaging to a minor role. We sought to determine how often DCE is used in PI-RADS v2 scoring. MATERIALS AND METHODS: We retrospectively reviewed data from 388 patients who underwent prostate magnetic resonance imaging and subsequent biopsy from January 2016 through December 2017. In accordance with PI-RADS v2, DCE was deemed necessary if a peripheral-zone lesion had a diffusion-weighted imaging score of 3, or if a transition-zone lesion had a T2 score of 3 and diffusion-weighted imaging experienced technical failure. Receiver operating characteristic curve analysis assessed the accuracy of prostate-specific antigen density (PSAD) at different threshold values for differentiating lesions that would be equivocal with noncontrast technique. Accuracy of PSAD was compared to DCE using McNemar's test. RESULTS: Sixty-nine lesions in 62 patients (16%) required DCE for PI-RADS scoring. Biopsy of 10 (14%) of these lesions showed clinically significant cancer (Gleason score ≥7). In the subgroup of patients with equivocal lesions, those with clinically significant cancer had significantly higher PSADs than those with clinically insignificant lesions (means of 0.18 and 0.13 ng/mL/mL, respectively; P= 0.038). In this subgroup, there was no statistical difference in accuracy in determining clinically significant cancer between a PSAD threshold value of 0.13 and DCE (P= 0.25). CONCLUSIONS: Only 16% of our patients needed DCE to generate the PI-RADS version 2 score, raising the possibility of limiting the initial screening prostate MRI to a noncontrast exam. PSAD may also be used to further decrease the need for or to replace DCE altogether.

Simultaneous PET/MRI in the Evaluation of Breast and Prostate Cancer Using Combined Na[18F] F and [18F]FDG: a Focus on Skeletal Lesions.

PURPOSE: The purpose of this study is to prospectively evaluate the performance of sodium 18F]fluoride (Na[18F]F)/2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) simultaneous time-of-flight enabled positron emission tomography (PET)/magnetic resonance imaging (MRI) for the detection of skeletal metastases in selected patients with advanced breast and prostate cancers. PROCEDURE: The institutional review board approved this HIPAA-compliant protocol. Written informed consent was obtained from each patient. A total of 74 patients (23 women and 51 men with breast and prostate cancer, respectively) referred for standard-of-care whole-body bone scintigraphy (WBBS) were enrolled in this prospective study. All patients underwent a [99mTc]methyldiphosphonate ([99mTc]MDP) WBBS followed by Na[18F]F/[18F]FDG PET/MRI. Lesions detected by each imaging modality were tabulated and a lesion-based and patient-based analysis was conducted. RESULTS: On a patient-based analysis, [99mTc]MDP WBBS identified skeletal lesions in 37 patients and PET/MRI in 45 patients. On a lesion-based analysis, WBBS identified a total of 81 skeletal lesions, whereas PET/MRI identified 140 lesions. Additionally, PET/MRI showed extra-skeletal lesions in 19 patients, including lymph nodes (16), prostate (4) lung (3), and liver (2) lesions. CONCLUSIONS: The ability of Na[18F]F/[18F]FDG PET/MRI to identify more skeletal lesions than 99mTc-MDP WBBS and to additionally identify extra-skeletal disease may be beneficial for patient care and represent an alternative to the single modalities performed separately. Na[18F]F/[18F]FDG PET/MRI is a promising approach for evaluation of skeletal and extra-skeletal lesions in a selected population of breast and prostate cancer patients.

A New Multimodel Machine Learning Framework to Improve Hepatic Fibrosis Grading Using Ultrasound Elastography Systems from Different Vendors.

The purpose of the work described here was to determine if the diagnostic performance of point and 2-D shear wave elastography (pSWE; 2-DSWE) using shear wave velocity (SWV) with a new machine learning (ML) technique applied to systems from different vendors is comparable to that of magnetic resonance elastography (MRE) in distinguishing non-significant (

Prostate Magnetic Resonance Imaging Interpretation Varies Substantially Across Radiologists.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) interpreted by experts is a powerful tool for diagnosing prostate cancer. However, the generalizability of published results across radiologists of varying expertise has not been verified. OBJECTIVE: To assess variability in mpMRI reporting and diagnostic accuracy across radiologists of varying experience in routine clinical care. DESIGN, SETTING, AND PARTICIPANTS: Men who underwent mpMRI and MR-fusion biopsy between 2014-2016. Each MRI scan was read by one of nine radiologists using the Prostate Imaging Reporting and Data System (PIRADS) and was not re-read before biopsy. Biopsy histopathology was the reference standard. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes were the PIRADS score distribution and diagnostic accuracy across nine radiologists. We evaluated the association between age, prostate-specific antigen, PIRADS score, and radiologist in predicting clinically significant cancer (Gleason ≥7) using multivariable logistic regression. We conducted sensitivity analyses for case volume and changes in accuracy over time. RESULTS AND LIMITATIONS: We analyzed data for 409 subjects with 503 MRI lesions. While the number of lesions (mean 1.2 lesions/patient) did not differ across radiologists, substantial variation existed in PIRADS distribution and cancer yield. The significant cancer detection rate was 3-27% for PIRADS 3 lesions, 23-65% for PIRADS 4, and 40-80% for PIRADS 5 across radiologists. Some 13-60% of men with a PIRADS score of <3 on MRI harbored clinically significant cancer. The area under the receiver operating characteristic curve varied from 0.69 to 0.81 for detection of clinically significant cancer. PIRADS score (p<0.0001) and radiologist (p=0.042) were independently associated with cancer in multivariable analysis. Neither individual radiologist volume nor study period impacted the results. MRI scans were not retrospectively re-read by all radiologists, precluding measurement of inter-observer agreement. CONCLUSIONS: We observed considerable variability in PIRADS score assignment and significant cancer yield across radiologists. We advise internal evaluation of mpMRI accuracy before widespread adoption. PATIENT SUMMARY: We evaluated the interpretation of multiparametric magnetic resonance imaging of the prostate in routine clinical care. Diagnostic accuracy depends on the Prostate Imaging Reporting and Data System score and the radiologist.

View-Sharing Artifact Reduction With Retrospective Compressed Sensing Reconstruction in the Context of Contrast-Enhanced Liver MRI for Hepatocellular Carcinoma (HCC) Screening.

BACKGROUND: View-sharing (VS) increases spatiotemporal resolution in dynamic contrast-enhanced (DCE) MRI by sharing high-frequency k-space data across temporal phases. This temporal sharing results in respiratory motion within any phase to propagate artifacts across all shared phases. Compressed sensing (CS) eliminates the need for VS by recovering missing k-space data from pseudorandom undersampling, reducing temporal blurring while maintaining spatial resolution. PURPOSE: To evaluate a CS reconstruction algorithm on undersampled DCE-MRI data for image quality and hepatocellular carcinoma (HCC) detection. STUDY TYPE: Retrospective. SUBJECTS: Fifty consecutive patients undergoing MRI for HCC screening (29 males, 21 females, 52-72 years). FIELD STRENGTH/SEQUENCE: 3.0T MRI. Multiphase 3D-SPGR T1 -weighted sequence undersampled in arterial phases with a complementary Poisson disc sampling pattern reconstructed with VS and CS algorithms. ASSESSMENT: VS and CS reconstructions evaluated by blinded assessments of image quality and anatomic delineation on Likert scales (1-4 and 1-5, respectively), and HCC detection by OPTN/UNOS criteria including a diagnostic confidence score (1-5). Blinded side-by-side reconstruction comparisons for lesion depiction and overall series preference (-3-3). STATISTICAL ANALYSIS: Two-tailed Wilcoxon signed rank tests for paired nonparametric analyses with Bonferroni-Holm multiple-comparison corrections. McNemar's test for differences in lesion detection frequency and transplantation eligibility. RESULTS: CS compared with VS demonstrated significantly improved contrast (mean 3.6 vs. 2.9, P < 0.0001) and less motion artifact (mean 3.6 vs. 3.2, P = 0.006). CS compared with VS demonstrated significantly improved delineations of liver margin (mean 4.5 vs. 3.8, P = 0.0002), portal veins (mean 4.5 vs. 3.7, P < 0.0001), and hepatic veins (mean 4.6 vs. 3.5, P < 0.0001), but significantly decreased delineation of hepatic arteries (mean 3.2 vs. 3.7, P = 0.004). No significant differences were seen in the other assessments. DATA CONCLUSION: Applying a CS reconstruction to data acquired for a VS reconstruction significantly reduces motion artifacts in a clinical DCE protocol for HCC screening. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:984-993.

Conical ultrashort echo time (UTE) MRI in the evaluation of pediatric acute appendicitis.

PURPOSE: Magnetic resonance imaging (MRI) sequences with conical k-space trajectories are able to decrease motion artifacts while achieving ultrashort echo times (UTE). We assessed the performance of free-breathing conical UTE MRI in the evaluation of the pediatric pelvis for suspected appendicitis. METHODS: Our retrospective review of 84 pediatric patients who underwent MRI for suspected appendicitis compared three contrast-enhanced sequences: free-breathing conical UTE, breath-hold three-dimensional (3D) spoiled gradient echo (BH-SPGR), and free-breathing high-resolution 3D SPGR (FB-SPGR). Two radiologists performed blinded and independent evaluations of each sequence for image quality (four point scale), anatomic delineation (four point scale), and diagnostic confidence (five point scale). Subsequently, the three sequences were directly compared for overall image quality (- 3 to + 3 scale). Scores were compared using Kruskal-Wallis and Wilcoxon signed-rank tests. RESULTS: UTE demonstrated significantly better perceived signal-to-noise ratio (SNR) and fewer artifacts than BH-SPGR and FB-SPGR (means of 3.6 and 3.4, 3.4 and 3.2, 3.1 and 2.7, respectively; p < 0.0006). BH-SPGR and FB-SPGR demonstrated significantly better contrast than UTE (means of 3.6, 3.4, and 3.2, respectively; p < 0.03). In the remaining categories, UTE performed significantly better than FB-SPGR (p < 0.00001), while there was no statistical difference between UTE and BH-SPGR. Direct paired comparisons of overall image quality demonstrated the readers significantly preferred UTE over both BH-SPGR (mean + 0.5, p < 0.00001) and FB-SPGR (mean + 1.2, p < 0.00001). CONCLUSIONS: In the evaluation of suspected appendicitis, free-breathing conical UTE MRI performed better in the assessed metrics than FB-SPGR. When compared to BH-SPGR, UTE demonstrated superior perceived SNR and fewer artifacts.

Gallium 68 PSMA-11 PET/MR Imaging in Patients with Intermediate- or High-Risk Prostate Cancer.

Purpose To report the results of dual-time-point gallium 68 (68Ga) prostate-specific membrane antigen (PSMA)-11 positron emission tomography (PET)/magnetic resonance (MR) imaging prior to prostatectomy in patients with intermediate- or high-risk cancer. Materials and Methods Thirty-three men who underwent conventional imaging as clinically indicated and who were scheduled for radical prostatectomy with pelvic lymph node dissection were recruited for this study. A mean dose of 4.1 mCi ± 0.7 (151.7 MBq ± 25.9) of 68Ga-PSMA-11 was administered. Whole-body images were acquired starting 41-61 minutes after injection by using a GE SIGNA PET/MR imaging unit, followed by an additional pelvic PET/MR imaging acquisition at 87-125 minutes after injection. PET/MR imaging findings were compared with findings at multiparametric MR imaging (including diffusion-weighted imaging, T2-weighted imaging, and dynamic contrast material-enhanced imaging) and were correlated with results of final whole-mount pathologic examination and pelvic nodal dissection to yield sensitivity and specificity. Dual-time-point metabolic parameters (eg, maximum standardized uptake value [SUVmax]) were compared by using a paired t test and were correlated with clinical and histopathologic variables including prostate-specific antigen level, Gleason score, and tumor volume. Results Prostate cancer was seen at 68Ga-PSMA-11 PET in all 33 patients, whereas multiparametric MR imaging depicted Prostate Imaging Reporting and Data System (PI-RADS) 4 or 5 lesions in 26 patients and PI-RADS 3 lesions in four patients. Focal uptake was seen in the pelvic lymph nodes in five patients. Pathologic examination confirmed prostate cancer in all patients, as well as nodal metastasis in three. All patients with normal pelvic nodes in PET/MR imaging had no metastases at pathologic examination. The accumulation of 68Ga-PSMA-11 increased at later acquisition times, with higher mean SUVmax (15.3 vs 12.3, P < .001). One additional prostate cancer was identified only at delayed imaging. Conclusion This study found that 68Ga-PSMA-11 PET can be used to identify prostate cancer, while MR imaging provides detailed anatomic guidance. Hence, 68Ga-PSMA-11 PET/MR imaging provides valuable diagnostic information and may inform the need for and extent of pelvic node dissection.

The impact of computed high b-value images on the diagnostic accuracy of DWI for prostate cancer: A receiver operating characteristics analysis.

To evaluate the performance of computed high b value diffusion-weighted images (DWI) in prostate cancer detection. 97 consecutive patients who had undergone multiparametric MRI of the prostate followed by biopsy were reviewed. Five radiologists independently scored 138 lesions on native high b-value images (b = 1200 s/mm2), apparent diffusion coefficient (ADC) maps, and computed high b-value images (contrast equivalent to b = 2000 s/mm2) to compare their diagnostic accuracy. Receiver operating characteristic (ROC) analysis and McNemar's test were performed to assess the relative performance of computed high b value DWI, native high b-value DWI and ADC maps. No significant difference existed in the area under the curve (AUC) for ROCs comparing B1200 (b = 1200 s/mm2) to computed B2000 (c-B2000) in 5 readers. In 4 of 5 readers c-B2000 had significantly increased sensitivity and/or decreased specificity compared to B1200 (McNemar's p < 0.05), at selected thresholds of interpretation. ADC maps were less accurate than B1200 or c-B2000 for 2 of 5 readers (P < 0.05). This study detected no consistent improvement in overall diagnostic accuracy using c-B2000, compared with B1200 images. Readers detected more cancer with c-B2000 images (increased sensitivity) but also more false positive findings (decreased specificity).

Structured Reporting of Multiphasic CT for Hepatocellular Carcinoma: Effect on Staging and Suitability for Transplant.

OBJECTIVE: The purpose of this study is to evaluate whether use of a standardized radiology report template would improve the ability of liver transplant surgeons to diagnose stage T2 hepatocellular carcinoma (HCC) and determine patient suitability to undergo orthotopic liver transplant (OLT). MATERIALS AND METHODS: In this retrospective study, a standardized template was devised, and its use was mandated for reporting of liver CT findings for patients with cirrhosis and HCC. Two surgeons analyzed 200 reports (100 before and 100 after template implementation) for descriptions of cirrhosis, portal hypertension, lesion enhancement characteristics, tumor thrombus, portal and superior mesenteric vein patency, and Organ Procurement Transplantation Network (OPTN) class. Ability to determine Milan criteria and surgeon satisfaction were also assessed. Data obtained before and after template implementation were statistically analyzed using the Cochran-Mantel-Haenszel test. RESULTS: Template implementation increased the percentage of reports documenting the presence or absence of portal hypertension (74% to 88% for surgeon 1 and 86% to 87% for surgeon 2; p = 0.042); lesion number (76% to 88% for surgeon 2 [no change for surgeon 1]; p = 0.038), size (95% to 96% for surgeon 1 and 82% to 93% for surgeon 2; p = 0.03), and enhancement (93% to 94% for surgeon 1 and 80% to 91% for surgeon 2; p = 0.049); presence of tumor thrombus (10% to 57% for surgeon 1 and 31% to 63% for surgeon 2; p < 0.001); and OPTN class (8% to 82% for surgeon 1 and 2% to 81% for surgeon 2; p < 0.001). The surgeons were significantly more able to determine the presence of T2 disease and qualification for exception points after implementation of the template (increasing from 80% to 94%; p = 0.025). Satisfaction with reports also improved (p < 0.0001). CONCLUSION: The reporting template improved determination of patient suitability to undergo transplant according to the Milan criteria.

Variable refocusing flip angle single-shot fast spin echo imaging of liver lesions: increased speed and lesion contrast.

PURPOSE: To evaluate acquisition time and clinical image quality of a variable refocusing flip angle (vrf) single-shot fast spin echo (SSFSE) sequence in comparison with a conventional SSFSE sequence for imaging of liver lesions in patients undergoing whole-body PET/MRI for oncologic staging. METHODS: A vrfSSFSE sequence was acquired in 43 patients with known pancreatic neuroendocrine tumors undergoing 68Ga-DOTA-TOC PET on a simultaneous time-of-flight 3.0T PET/MRI. Liver lesions ≥1.5 cm with radionucleotide uptake were analyzed. Contrast-to-noise ratios (CNRs) were measured, and four blinded radiologists assessed overall image quality. Differences in repetition time and CNR were assessed using a paired Student's t test with p < 0.05 considered statistically significant. Inter-reader variability was assessed with Fleiss' kappa statistic. RESULTS: 53 eligible lesions in 27 patients were included for analysis. vrfSSFSE demonstrated higher mean lesion CNR compared to SSFSE (9.9 ± 4.1 vs. 6.7 ± 4.1, p < 0.001). Mean repetition time (TR) was 679 ± 97 ms for the vrfSSFSE sequence compared to 1139 ± 106 ms for SSFSE (p < 0.0001), corresponding to a 1.7-fold decrease in acquisition time. Overall quality of liver lesion and common bile duct images with the vrfSSFSE sequence was graded as superior than or equivalent to the SSFSE sequence for 59% and 67% of patients, respectively. CONCLUSIONS: Compared to conventional SSFSE, vrfSSFSE resulted in improved lesion contrast on simultaneous PET/MRI in patients with liver metastases. Due to decreased SAR demands, vrfSSFSE significantly decreased TR, allowing coverage of the entire liver in a single twenty-second breath hold. This may have important clinical implications in the setting of PET/MRI, where scan time is limited by the necessity of whole-body image acquisition in addition to bed specific imaging.

Increased Speed and Image Quality for Pelvic Single-Shot Fast Spin-Echo Imaging with Variable Refocusing Flip Angles and Full-Fourier Acquisition.

Purpose To assess image quality and speed improvements for single-shot fast spin-echo (SSFSE) with variable refocusing flip angles and full-Fourier acquisition (vrfSSFSE) pelvic imaging via a prospective trial performed in the context of uterine leiomyoma evaluation. Materials and Methods Institutional review board approval and informed consent were obtained. vrfSSFSE and conventional SSFSE sagittal and coronal oblique acquisitions were performed in 54 consecutive female patients referred for 3-T magnetic resonance (MR) evaluation of known or suspected uterine leiomyomas. Two radiologists who were blinded to the image acquisition technique semiquantitatively scored images on a scale from -2 to 2 for noise, image contrast, sharpness, artifacts, and perceived ability to evaluate uterine, ovarian, and musculoskeletal structures. The null hypothesis of no significant difference between pulse sequences was assessed with a Wilcoxon signed rank test by using a Holm-Bonferroni correction for multiple comparisons. Results Because of reductions in specific absorption rate, vrfSSFSE imaging demonstrated significantly increased speed (more than twofold, P < .0001), with mean repetition times compared with conventional SSFSE imaging decreasing from 1358 to 613 msec for sagittal acquisitions and from 1494 to 621 msec for coronal oblique acquisitions. Almost all assessed image quality and perceived diagnostic capability parameters were significantly improved with vrfSSFSE imaging. These improvements included noise, sharpness, and ability to evaluate the junctional zone, myometrium, and musculoskeletal structures for both sagittal acquisitions (mean values of 0.56, 0.63, 0.42, 0.56, and 0.80, respectively; all P values < .0001) and coronal oblique acquisitions (mean values of 0.81, 1.09, 0.65, 0.93, and 1.12, respectively; all P values < .0001). For evaluation of artifacts, there was an insufficient number of cases with differences to allow statistical testing. Conclusion Compared with conventional SSFSE acquisition, vrfSSFSE acquisition increases 3-T imaging speed via reduced specific absorption rate and leads to significant improvements in perceived image quality and perceived diagnostic capability when evaluating pelvic structures. © RSNA, 2016 Online supplemental material is available for this article.

High temporal resolution dynamic MRI and arterial input function for assessment of GFR in pediatric subjects.

PURPOSE: To introduce a respiratory-gated high-spatiotemporal-resolution dynamic-contrast-enhanced MRI technique and a high-temporal-resolution aortic input function (HTR-AIF) estimation method for glomerular filtration rate (GFR) assessment in children. METHODS: A high-spatiotemporal-resolution DCE-MRI method with view-shared reconstruction was modified to incorporate respiratory gating, and an AIF estimation method that uses a fraction of the k-space data from each respiratory period was developed (HTR-AIF). The method was validated using realistic digital phantom simulations and demonstrated on clinical subjects. The GFR estimates using HTR-AIF were compared with estimates obtained by using an AIF derived directly from the view-shared images. RESULTS: Digital phantom simulations showed that using the HTR-AIF technique gives more accurate AIF estimates (RMSE = 0.0932) compared with the existing estimation method (RMSE = 0.2059) that used view-sharing (VS). For simulated GFR > 27 mL/min, GFR estimation error was between 32% and 17% using view-shared AIF, whereas estimation error was less than 10% using HTR-AIF. In all clinical subjects, the HTR-AIF method resulted in higher GFR estimations than the view-shared method. CONCLUSION: The HTR-AIF method improves the accuracy of both the AIF and GFR estimates derived from the respiratory-gated acquisitions, and makes GFR estimation feasible in free-breathing pediatric subjects.