Additional Value of Dynamic Contrast-enhanced Sequences in Multiparametric Prostate Magnetic Resonance Imaging: Data from the PROMIS Study.

BACKGROUND: Multiparametric magnetic resonance imaging (MP-MRI) is established in the diagnosis of prostate cancer, but the need for enhanced sequences has recently been questioned. OBJECTIVE: To assess whether dynamic contrast-enhanced imaging (DCE) improves accuracy over T2 and diffusion sequences. DESIGN, SETTING, AND PARTICIPANTS: PROMIS was a multicentre, multireader trial, with, in this part, 497 biopsy-naïve men undergoing standardised 1.5T MP-MRI using T2, diffusion, and DCE, followed by a detailed transperineal prostate mapping (TPM) biopsy at 5 mm intervals. Likert scores of 1-5 for the presence of a significant tumour were assigned in strict sequence, for (1) T2 + diffusion and then (2) T2 + diffusion + dynamic contrast-enhanced images. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: For the primary analysis, the primary PROMIS outcome measure (Gleason score ≥4 + 3 or ≥6 mm maximum cancer length) on TPM was used, and an MRI score of ≥3 was considered positive. RESULTS AND LIMITATIONS: Sensitivity without and with DCE was 94% and 95%, specificity 37% and 38%, positive predictive value 51% and 51%, and negative predictive value 90% and 91%, respectively (p > 0.05 in each case). The number of patients avoiding biopsy (scoring 1-2) was similar (123/497 vs 121/497, p = 0.8). The number of equivocal scores (3/5) was slightly higher without DCE (32% vs 28% p = 0.031). The proportion of MRI equivocal (3/5) and positive (4-5) cases showing significant tumours were similar (23% and 71% vs 20% and 69%). No cases of dominant Gleason 4 or higher were missed with DCE, compared with a single case with T2 + diffusion-weighted imaging. No attempt was made to correlate lesion location on MRI and histology, which may be considered a limitation. Radiologists were aware of the patient's prostate-specific antigen. CONCLUSIONS: Contrast adds little when MP-MRI is used to exclude significant prostate cancer. PATIENT SUMMARY: An intravenous injection of contrast may not be necessary when magnetic resonance imaging is used as a test to rule out significant tumours in the prostate.

A Study on Trunk Muscle Activation of 2 Deep Water Running Styles (High-Knee and Cross-Country Style) and Land Walking.

CONTEXT: Deep water running (DWR) is an aquatic aerobic exercise which involves running in water without the feet touching the bottom of the pool, and it may involve different activation of trunk muscles compared with running or walking on land. This form of exercise is gradually being adopted as a form of therapeutic exercise for people with low back pain. It is proposed that different types of running or walking in water may be a more comfortable form of training for the trunk and abdominal muscles compared with exercising on dry land. OBJECTIVES: This study aimed to examine the trunk muscle activation in DWR in 2 different styles-high knee style and cross-country style, and these were compared with walking on land. PARTICIPANTS: Eleven healthy individuals (2 females and 9 males, mean age = 24 [4.6]) were recruited for this study. OUTCOME MEASURES: Surface electromyography was used to examine the activities of the right transversus abdominis, rectus abdominis, lumbar multifidus, and lumbar erector spinae muscles in 5 conditions: static standing on land and in water, running in deep water with high knee and cross-country styles, and finally walking on a treadmill. RESULTS: The percentage of maximal voluntary contraction of the transversus abdominis was significantly higher for both running styles in DWR, compared with that of static standing in water. Comparing directly the 2 styles, muscle activity was higher with a high knee action compared to without. The activation of transversus abdominis during high-knee DWR was comparable with that during treadmill walking and this may have clinical implications. CONCLUSION: The results of this study confirmed that running in deep water with a high knee action activated trunk muscles differently compared with standing or walking on land.

The evolving role of image-guided biopsy and specimen fixation-update from an oncology setting.

Image-guided biopsy is well established in clinical practice, however a recent shift towards "personalized medicine" and genomic research, particularly in the oncology setting, has resulted in a greater demand for tissue, not only at preliminary diagnosis but at multiple time points in the patient's journey. Research into the molecular pathobiology underpinning cancer development and progression continues to identify diagnostic, predictive and prognostic biomarkers that help determine and guide treatment both at the outset, and as patient's progress or recur. This extensive tissue analysis however, necessitates larger tissue cores and a greater number of biopsies with correct fixation of the specimens obtained. We discuss the impact that this shift towards genomic medicine has taken on both radiologists and histopathologists and stress the importance of correct specimen preparation as well as biopsy technique to maximize diagnostic yield, by reviewing different methods of specimen fixation that are now required in clinical practice dependent on the clinical question posed.

Primary systemic amyloidosis: imaging interpretation of this complex multisystemic disease.

This report highlights the diagnostic complexities involved in the case of a 63-year-old female who presented with a non-productive cough and shortness of breath on exertion. Initial chest radiograph demonstrated generalized abnormal interstitial lung markings with thickened peripheral septal lines. Further characterization was sought by CT scan of the chest, and given the possibility of lymphangitic carcinomatosis, a CT scan of the abdomen and pelvis was also performed. The CT scan findings revealed septal line thickening, abnormal omental soft tissue with calcified deposits and wall thickening of the stomach and proximal duodenum. A preliminary differential diagnosis of peritoneal carcinomatosis was made, but cancer markers were equivocal. A CT-guided biopsy of the "omental cake" was non-diagnostic, hence formal biopsy via laparoscopy was undertaken. While awaiting the results, the patient was readmitted with acute haematemesis. Gastric and duodenal biopsies from the endoscopic assessment were positive for Congo red stain and birefringent under polarizsed light, which was consistent with amyloidosis. Histology from the omental biopsies and additional haematological tests concurred. The patient was diagnosed with advanced systemic amyloid light-chain amyloidosis comprising diffuse pulmonary amyloidosis, calcified omental soft tissue deposits, and extensive soft tissue amyloid with cardiac and gastrointestinal involvement. We discuss the spectrum of differential diagnoses posed by the imaging findings and the difficulties faced in interpreting this complex case of systemic amyloidosis.

Ultrasound-guided percutaneous splenic biopsy using an 18-G core biopsy needle: our experience with 52 cases.

OBJECTIVE: The spleen is more commonly affected in multiorgan disease, but alternative sites are selected for biopsy owing to perceived haemorrhage risk. If these sites are inaccessible or, less commonly, the spleen is the only disease site, then splenic biopsy is considered, with most studies using a 20- to 22-G needle. The primary aim of biopsy is to exclude underlying malignancy or to obtain histological analysis in known malignancy, usually lymphoma, when reclassification is required for therapy. We present, to our knowledge, the largest series of 18-G ultrasound-guided splenic core needle biopsy assessing diagnostic and complication rates. METHODS: All ultrasound-guided splenic biopsy cases from May 1990 to May 2015 were identified on the radiology information system. Histological diagnosis and complications were identified from laboratory reports, case notes and discharge summaries to assess diagnostic positive and complication rates. Haemorrhages requiring transfusion, embolization or splenectomy, pneumothorax, other significant intra-abdominal injury or death are classified as major complications, whilst conservative haemorrhage management is considered a minor complication. RESULTS: A total of 52 splenic biopsies were performed in 47 patients. A positive diagnostic yield for all biopsies was 90.4%. The major and minor complication rates were 0% and 1.9% (1/52), respectively. CONCLUSION: Ultrasound-guided 18-G splenic biopsy is a safe and accurate procedure with no added risk of complications when compared with smaller needles or biopsy of other abdominal organs. ADVANCES IN KNOWLEDGE: This is the largest case series of ultrasound-guided splenic biopsy with an 18-G needle, and our experience confirms a high diagnostic yield and a complication rate which compares favourably with the biopsy of other abdominal organs.

Liver metastases in germ cell cancer: defining a role for surgery after chemotherapy.

OBJECTIVE: To review the clinical course and outcome of patients with germ cell cancer and liver metastases treated at one centre, as the presence of hepatic metastases, although rare, is a poor prognostic feature in germ cell cancer. PATIENTS AND METHODS: The case records of all patients with germ cell cancer and liver metastases at presentation, and treated with chemotherapy at a medical oncology unit between 1984 and 2001, were reviewed. The treatment regimens, tumour responses and patient outcome were recorded. RESULTS: Twenty-seven patients with germ cell cancer metastatic to the liver were identified. Complete biochemical and radiological responses were achieved in eight patients after initial chemotherapy and surgery for non-hepatic residual disease. Seven patients had only residual radiological hepatic abnormalities with normal tumour markers at the completion of initial treatment. There were no immediate hepatic resections and no further therapy was given. Serial computed tomography (CT) confirmed a progressive reduction in the size of hepatic lesions in six of seven patients. The persistence of residual hepatic abnormalities was not predictive of relapse, and overall survival of these patients (median survival 49 months, range 15-120) compared well with recent reports of such patients who have undergone hepatic resection. CONCLUSIONS: Conservative management with regular assessment by CT is an acceptable alternative to immediate hepatic resection for patients with isolated residual radiological hepatic abnormalities on completing first-line therapy for metastatic germ cell cancer, and does not adversely affect their survival.