Moderate hypofractionated radiotherapy for prostate cancer: 3-year toxicity results of a multicentre randomized phase 3, non-inferiority trial.

BACKGROUND AND PURPOSE: Moderate hypofractionated radiotherapy (HFRT) is a standard treatment for prostate cancer patients. We compared 2 moderate HFRT regimens, with a biologically equivalent dose of 80 Gy in 2 Gy fractions, with a modest simultaneous integrated boost to the dominant intraprostatic lesion. MATERIAL AND METHODS: This is a multicenter, non-inferiority, randomized phase 3 trial with acute toxicity as the primary endpoint, comparing: 56 Gy in 4 weeks (16x3.5 Gy, 4 days/week, Arm A) with 67 Gy in 5 weeks (25x2.68 Gy, 5 days/week, Arm B). The H0 hypothesis is that both regimens are equivalent in terms of acute grade ≥ 2 gastro-intestinal toxicity, defined as a difference in acute grade ≥ 2 gastro-intestinal toxicity of ≤ 10 %. Here we report on acute and late toxicity. RESULTS: We included 170 patients in Arm A and 172 patients in Arm B. The median follow-up time for all patients was 42 months. Acute grade ≥ 2 gastrointestinal toxicity was reported by 24 % of patients in both groups. Acute grade 2 and 3 urinary toxicity was observed in 52 % and 9 % of patients in Arm A and 53 % and 7 % in Arm B. Late grade 2 and grade ≥ 3 gastrointestinal toxicity occurred in 19 % and 4 % of patients in Arm A compared with 15 % and 4 % in Arm B. Late grade 2 and grade ≥ 3 urinary toxicity was observed in 37 % and 10 % of patients in Arm A and 36 % and 6 % in Arm B. CONCLUSION: This analysis confirms that both HFRT regimens are safe and equivalent in terms of acute grade ≥ 2 gastrointestinal toxicity.

Adjuvant Radiotherapy After Radical Cystectomy for Patients with High-risk Muscle-invasive Bladder Cancer: Results of a Multicentric Phase II Trial.

BACKGROUND: High-risk muscle-invasive bladder cancer (MIBC) has a poor prognosis. Old trials showed that external beam radiotherapy (EBRT) after radical cystectomy (RC) decreases the incidence of local recurrences but induces severe toxicity. OBJECTIVE: To evaluate the toxicity and local control rate after adjuvant EBRT after RC delivered with volumetric arc radiotherapy. DESIGN, SETTING, AND PARTICIPANTS: This is a multicentric phase 2 trial. From August 2014 till October 2020, we treated 72 high-risk MIBC patients with adjuvant EBRT after RC. High-risk MIBC is defined as ≥pT3-MIBC ± lymphovascular invasion, fewer than ten lymph nodes removed, pathological positive lymph nodes, or positive surgical margins. INTERVENTION: Patients received 50 Gy in 25 fractions with intensity-modulated radiotherapy to the pelvic lymph nodes ± cystectomy bed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome is acute toxicity. We report on local relapse-free rate (LRFR), clinical relapse-free survival (CRFS), overall survival (OS), and bladder cancer-specific survival (BCSS). RESULTS AND LIMITATIONS: The median follow-up is 18 mo. Forty-two patients (61%) developed acute grade 2 gastrointestinal (GI) toxicity. Four patients (6%) had acute grade 3 GI toxicity. One patient had grade 5 diarrhea and vomiting due to obstruction at 1 mo. Two-year probabilities of developing grade ≥3 and ≥2 GI toxicity were 17% and 76%, respectively. Urinary toxicity, assessed in 17 patients with a neobladder, was acceptable with acute grade 2 and 3 urinary toxicity reported in 53% (N = 9) and 18% (N = 3) of the patients, respectively. The 2-yr LRFR is 83% ± 5% and the 2-yr CRFS rate is 43% with a median CRFS time of 12 mo (95% confidence interval: 3-21 mo). Two-year OS and BCSS are 52% ± 7% and 62% ± 7%, respectively. Shortcomings are the nonrandomized study design and limited follow-up. CONCLUSIONS: Adjuvant EBRT after RC can be administered without excessive severe toxicity. PATIENT SUMMARY: In this report, we looked at the incidence of toxicity and local control after adjuvant external beam radiotherapy (EBRT) following radical cystectomy (RC) in high-risk muscle-invasive bladder cancer patients. We found that adjuvant EBRT was feasible and resulted in good local control. We conclude that these data support further enrollment of patients in ongoing trials to evaluate the place of adjuvant EBRT after RC.

Dynamic contrast-enhanced imaging has limited added value over T2-weighted imaging and diffusion-weighted imaging when using PI-RADSv2 for diagnosis of clinically significant prostate cancer in patients with elevated PSA.

AIM: To determine the added value of dynamic contrast-enhanced imaging (DCE) over T2-weighted imaging (T2-WI) and diffusion-weighted imaging (DWI) for detection of clinically significant prostate cancer (csPC) in patients with elevated prostate-specific antigen (PSA). METHODS AND MATERIALS: Two hundred and forty-five patients with elevated PSA underwent multiparametric (mp) magnetic resonance imaging (MRI) of the prostate before biopsy. mpMRI was performed using a 3 T MRI system without an endorectal coil. Patients underwent transrectal ultrasound-guided systematic 12 core biopsy followed by radical prostatectomy (n=68), radiation therapy (n=91), or clinical follow-up for at least 2 years (n=86). csPC was defined as Gleason score ≥3+4 and/or tumour volume of ≥0.5 ml, and/or tumour stage ≥T3a. The MRI findings were scored according to the Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) and an alternative overall assessment category (PI-RADSv2Alt) based on only T2-WI and DWI. RESULTS: In 144 patients (58.8%), csPC was found within 2 years after MRI. With scoring according to the PI-RADSv2 guidelines, DCE was not needed for determination of the overall assessment category in 80.8% (198/245) of patients. Receiver operating characteristic (ROC) analysis showed an area under the curve of 0.79 (95% confidence interval [CI]: 0.74-0.85) for PI-RADSv2 and 0.79 (95% CI: 0.73-0.85) for PI-RADSv2Alt. CONCLUSION: The added value of DCE over T2-WI and DWI is limited when using PI-RADSv2 for diagnosis of csPC in patients with elevated PSA before biopsy. An alternative overall assessment score using only T2-WI and DWI yielded similar performance to PI-RADSv2.

Pitfalls in Interpreting mp-MRI of the Prostate: A Pictorial Review with Pathologic Correlation.

OBJECTIVES: The purpose of this pictorial review is to present a wide spectrum of prostate multiparametric MRI (mp-MRI) pitfalls that may occur in clinical practice, with radiological and pathological correlation. METHODS: All examinations were performed according to ESUR Guidelines protocols. RESULTS AND CONCLUSION: mp-MRI imaging of the prostate often leads to interpreting doubts and misdiagnosis due to the many interpretative pitfalls that a tissue, whether healthy or treated, may cause. These "false-positive" findings may occur in each stage of the disease history, from the primary diagnosis and staging, to the post-treatment stage, and whether they are caused by the tissue itself or are iatrogenic, their recognition is critical for proper treatment and management. Knowledge of these known pitfalls and their interpretation in the anatomical-radiological context can help radiologists avoid misdiagnosis and consequently mistreatment. MAIN MESSAGES: • Some physiological changes in the peripheral and central zone may simulate prostate cancer. • Technical errors, such as mispositioned endorectal coils, can affect the mp-MRI interpretation. • Physiological changes post-treatment can simulate recurrence.

Leiomyomatosis peritonealis disseminata associated with ascites and endometriosis: a case report and review of the literature.

We present a case of leiomyomatosis peritonealis disseminata (LPD) and review the literature. LPD is a rare, benign disorder that is characterized by multiple subperitoneal or peritoneal nodules of varying sizes on the omentum and peritoneal surfaces, grossly resembling disseminated carcinoma. It should be differentiated from other peritoneal tumors. It is mostly asymptomatic and diagnosis is often incidental during surgery. One should be aware of the iatrogenic component of this entity. LPD is being documented with increasing frequency. We report the case of a 39-year-old woman with chronic abdominal pain and heavy dysmenorrhea due to endometriosis associated with LPD. She underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy. LPD and endometriosis is a known association. LPD with ascites and endometriosis however has not yet been reported.

PNET/Ewing's sarcoma of the kidney: imaging findings in two cases.

The CT-imaging findings of primary renal PNET/Ewing's sarcoma in two patients were retrospectively assessed. A large renal mass with heterogenous contrast enhancement and necrotic and hemorrhagic areas were the predominant characteristics. In adolescents or young adults presenting with a large renal mass, PNET/Ewing's sarcoma may be included in the differential diagnosis.

Imaging treated prostate cancer.

In patients with a clinical suspicion of recurrence after treatment for prostate cancer, imaging can be used to distinguish between local recurrence and metastatic disease. Multiparametric magnetic resonance imaging (mpMRI) of the prostate may be a valuable imaging modality for the detection and localization of local recurrence in patients treated for prostate cancer. In mpMRI, morphological T2-weighted images are combined with functional MRI techniques including diffusion-weighted imaging, dynamic contrast-enhanced imaging, and magnetic resonance spectroscopic imaging to improve accuracy. In this paper, the current status of imaging techniques used to detect and to localize tumor recurrence in patients treated for prostate cancer will be reviewed, with emphasis on mpMRI for local prostate cancer recurrence.

Screening and early diagnosis of prostate cancer: an update.

Screening for prostate cancer has become a main controversial topic. First the currently used screening tools, PSA (Prostate Specific Antigen) and DRE (Digital Rectal Examination) have a low accuracy in the prediction of prostate cancer. Second, the benefit of screening in reducing the prostate cancer related mortality was not uniformly shown in older screening studies and there was concern about the risk of overdiagnosis and over-treatment of insignificant prostate cancers. Very recently, 3 major prospective, randomized screening studies have been published. This paper aims to provide an overview how the performance of the current screening tools can be ameliorated and evaluates the recently published screening studies with practical considerations for future screening protocols.

Clinical and imaging tools in the early diagnosis of prostate cancer, a review.

Measurement of serum Prostate Specific Antigen (PSA) level is useful to detect early prostate cancer. PSA-screening may reduce the mortality rate from prostate cancer, but this is associated with a high rate of overdiagnosis and overtreatment. To improve the detection of clinically significant cancers, several auxiliary clinical and imaging tools can be used. The absolute PSA value can be complemented with parameters such as PSA velocity, PSA density and free/total PSA. Transrectal Ultrasound (TRUS) has only moderate accuracy in the detection of prostate carcinoma, but is very useful in the estimation of prostate volume and thus calculation of PSA-density. The role of Magnetic Resonance Imaging (MRI) in diagnosis and staging of prostate carcinoma is rapidly increasing. Morphologic T2-weighted MR images (T2-WI), preferably with an endorectal coil, depict the prostatic anatomy with high resolution and can detect tumoral areas within the peripheral zone of the prostate. Addition of MR spectroscopic imaging (MRSI), dynamic contrast enhanced MRI (DCE-MRI) and/or diffusion weighted imaging (DWI) further increase the diagnostic performance of MRI. The gold standard for diagnosis of prostate carcinoma is histological assessment obtained by transrectal ultrasound-guided systematic core needle biopsy. In the future, imaging-based targeted biopsies may improve the biopsy yield and decrease the number of biopsy cores. Computed Tomography (CT) and positron emission tomography (PET) have no value in early prostate cancer detection and the indications are limited to lymph node staging and detection of distant metastases.

Magnetic resonance imaging in diagnosis, staging and radiotherapy planning for prostate cancer.

T2-weighted magnetic resonance imaging (MRI), preferably using an endorectal coil, is able to clearly depict the normal prostatic anatomy and to identify prostate cancer with fair diagnostic accuracy. The latter can be further increased by using functional techniques such as spectroscopy (assessment of prostatic metabolism), dynamic contrast-enhanced MRI (assessment of angiogenesis) and diffusion-weighted imaging (assessment of cellular density). T2-weighted MRI is an important tool for local staging of prostate cancer in patients clinically staged as cT1 or cT2, because of its high specificity for macroscopic capsular extension or seminal vesicle invasion. Compared to CT-imaging, MRI depicts the internal prostatic anatomy, prostatic margins and the extent of prostatic tumours much more clearly. This benefit can be exploited to improve the accuracy of target delineations in radiotherapy planning.

Mammography and breast sonography in transsexual women.

Data on the necessity of performing screening mammographies in transsexual women are lacking. The main objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women. Fifty Dutch-speaking transsexual women were interviewed about the following: attitude towards mammography and breast sonography, importance attributed to and satisfaction with breast appearance, opinion about the necessity of breast check-up, expectations regarding discomfort during the exams and knowledge about the breast surgery. A fasting blood sample, clinical breast exam, mammography and breast sonography were performed. At mammography the following parameters were noted: density, technical quality, location of the prostheses, presence of any abnormalities and painfulness. At sonography the following parameters were recorded: density, presence of cysts, visualisation of retro-areolar ducts or any abnormalities. Twenty-three percent of patients are not aware of the type of breast implants and 79% do not know their position to the pectoral muscles. Patient satisfaction with the appearance of their breasts was rather high (7.94 on a scale of 0-10). Mean expected and experienced pain from mammography was low (4.37 and 2.00 respectively). There was no statistically significant difference in expected pain between those who already had mammography and those who did not. There was a significant positive correlation between the expected and the experienced pain. Mammography and breast sonography were technically feasible and no gross anomalies were detected. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. Since breast cancer risk in transsexual women is largely unknown and breast exams are very well accepted, breast screening habits in this population should not differ from those of biological women.

The role of oncoplastic surgery in breast cancer.

The authors discuss the objectives of oncoplastic surgery in breast cancer management. Indications and advantages are summarised. Some surgical techniques are described. The authors report their own experience with oncoplastic surgery (26 patients who had immediate breast reconstruction after tumorectomy, and 126 patients who had lumpectomy alone. Oncoplastic surgery was characterised by a wider excision, with negative margins in all cases. In isolated breast conservative tumorectomy, 20% of the margins were positive, requiring re-excision or radical mastectomy. Oncoplastic surgery is preferred especially in younger patients with smaller breasts, since it is less cosmetically mutulating and allows complete tumor resection with save margins.

Is there a role for sonography in breast cancer screening?

Sonography can disclose tumors that remain mammographically occult. As a result, many have suggested to perform sonography in addition to screening mammography, especially in women with dense breasts. This approach, however, should be dealt with very cautiously. First of all, the term "mammographically occult" should be used carefully, because lesions that are missed because of suboptimal mammographic image quality or bad positioning or because no attempt has been made to compare with previous mammograms must not automatically be considered as mammographically occult. Secondly, introduction of sonography in mammographic screening is not straightforward because (1) it is extremely difficult to detect small malignant lesions with sonography without concurrently causing an excess of false positive results, (2) it is unclear how sonographic screening should be organized and quality-assured, (3) it is not unreasonable to expect that the excess costs of sonographic screening would favor other prevention strategies with more favorable cost/benefit ratio to decrease overall mortality. But most importantly, no large-scale trials have unequivocally proven the validity of sonography screening so far, neither in the general population, nor in subgroups with dense mammograms and/or at increased risk of breast cancer. Therefore, mammography remains currently the only screening tool that is associated with a decrease of breast cancer specific mortality and that should be used for mass screening.

Ruptured tuboovarian abscess causing peritonitis in a postmenopausal woman. A difficult diagnosis on imaging.

Pelvic inflammatory disease with tuboovarian abscess is rare in postmenopausal women. Clinical and sonographic findings are usually sufficient to recognize pelvic inflammatory disease in premenopausal women, but in the elderly the disease may easily be overlooked, largely by unexpectedness. Computed tomography can be helpful when the clinical and sonographic findings are complex or equivocal. However, when the level of suspicion is low, it can be very difficult to interpret, especially when complicated with peritonitis, as illustrated in the present case report.

[Legal liability of the radiologist in missed breast cancer diagnosis]. / Aansprakelijkheid van de radioloog in geval ven gemiste diagnose bij borstkanker (screening).

There have been few lawsuits alleging missed breast cancer diagnosis in Belgium so far. However, since the introduction of the Flemish organised breast cancer screening program in June 2001, one might expect an increase in the years to come. In the present paper, we focus on risk management pointers that minimize the risk of incurring a malpractice lawsuit.