Prospective Assessment of Tumour Burden and Bone Disease in Plasma Cell Dyscrasias Using DW-MRI and Exploratory Bone Biomarkers.

Novel biomarkers for tumour burden and bone disease are required to guide clinical management of plasma cell dyscrasias. Recently, bone turnover markers (BTMs) and Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) have been explored, although their role in the prospective assessment of multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS) is unclear. Here, we conducted a pilot observational cohort feasibility study combining serum BTMs and DW-MRI in addition to standard clinical assessment. Fifty-five patients were recruited (14 MGUS, 15 smouldering MM, 14 new MM and 12 relapsed MM) and had DW-MRI and serum biomarkers (P1NP, CTX-1, ALP, DKK1, sclerostin, RANKL:OPG and BCMA) measured at baseline and 6-month follow-up. Serum sclerostin positively correlated with bone mineral density (r = 0.40-0.54). At baseline, serum BCMA correlated with serum paraprotein (r = 0.42) and serum DKK1 correlated with serum free light chains (r = 0.67); the longitudinal change in both biomarkers differed between International Myeloma Working Group (IMWG)-defined responders and non-responders. Myeloma Response Assessment and Diagnosis System (MY-RADS) scoring of serial DW-MRI correlated with conventional IMWG response criteria for measuring longitudinal changes in tumour burden. Overall, our pilot study suggests candidate radiological and serum biomarkers of tumour burden and bone loss in MM/MGUS, which warrant further exploration in larger cohorts to validate the findings and to better understand their clinical utility.

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.

Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee.

Spontaneous osteonecrosis of the knee (SONK) is generally associated with a poor prognosis but the outcome depends on the clinical and radiological stage at which the patients present. The earliest stage of this condition does not necessarily progress in every patient, but discriminatory radiological information is lacking in order to differentiate these patients so that unnecessary surgical intervention can be avoided. We describe 20 sequential cases of early SONK diagnosed by magnetic resonance imaging (MRI) in which non-operative management led to the spontaneous resolution of symptoms and MRI changes. Our data was compared to published series in order to derive more accurate prognostic criteria that may then be used to determine appropriate management. Average age of patients was 52 years (42-64). All patients' symptoms resolved with conservative treatment at an average of 4.8 (3-8) months after symptoms began. All MRIs returned to normal. MRI prognostic criteria that appear to indicate a benign course are the absence of focal epiphyseal contour depression and the absence of lines of low signal intensity deep in the condyles. The presence of high signal T2 rim and a length >14 mm and depth >4 mm of the low signal T2 lesion did not necessarily indicate a bad prognosis. Early SONK in this group of patients resolves without surgical intervention. The group is typically middle aged, present with acute focal pain in the knee, have no secondary cause of osteonecrosis, have minimal or no changes on plain radiographs, and have focal changes on MRI. Recognition of this group using MRI identifies the earliest changes in SONK and gives prognostic information that avoids inappropriate surgical intervention.

Laparoscopic staging in selected patients with colorectal liver metastases as a prelude to liver resection.

BACKGROUND: Careful selection of patients with colorectal liver metastases for liver resection should minimize the risk of unnecessary laparotomy due to unresectable disease. The impact of staging laparoscopy with laparoscopic ultrasonography (LapUS) on clinical decision making in selected patients with potentially resectable colorectal liver metastases was evaluated. PATIENTS AND METHODS: Staging laparoscopy with or without LapUS was performed in 77 of 415 consecutive patients (19%) with colorectal liver metastases deemed potentially resectable following liver-specific CT and/or MRI scanning. Retrospective analysis of prospectively collected data compared clinical outcomes with those in whom laparoscopy had been deferred in favour of laparotomy. RESULTS: Staging laparoscopy was successful in 76 of 77 patients (99%). Adverse events occurred in three patients (4%): bowel injury n=2; late port site metastasis, n=1. Laparoscopic staging identified factors precluding curative resection in 16 patients (21%), thus averting unnecessary laparotomy. Of the 57 patients (74%) staged laparoscopically who underwent surgical exploration, 7 patients (12%) were unresectable and liver resection was achieved in 50 (88%). DISCUSSION: Laparoscopic staging remains useful in detecting occult intra- and extra-hepatic tumour in selected patients with potentially operable colorectal liver metastases.