MRI-Ultrasound Fused Approach for Prostate Biopsy-How It Is Performed.

The use of MRI-ultrasound image fusion targeted biopsy of the prostate in the face of an elevated serum PSA is now recommended by multiple societies, and results in improved detection of clinically significant cancer and, potentially, decreased detection of indolent disease. This combines the excellent sensitivity of MRI for clinically significant prostate cancer and the real-time biopsy guidance and confirmation of ultrasound. Both transperineal and transrectal approaches can be implemented using cognitive fusion, mechanical fusion with an articulated arm and electromagnetic registration, or pure software registration. The performance has been shown comparable to in-bore MRI biopsy performance. However, a number of factors influence the performance of this technique, including the quality and interpretation of the MRI, the approach used for biopsy, and experience of the practitioner, with most studies showing comparable performance of MRI-ultrasound fusion to in-bore targeted biopsy. Future improvements including artificial intelligence promise to refine the performance of all approaches.

Management Strategy for Prostate Imaging Reporting and Data System Category 3 Lesions.

PURPOSE OF REVIEW: Prostate Imaging Reporting and Data System (PI-RADS) category 3 lesions present a clinical dilemma due to their uncertain nature, which complicates the development of a definitive management strategy. These lesions have an incidence rate of approximately 22-32%, with clinically significant prostate cancer (csPCa) accounting for about 10-30%. Therefore, a thorough evaluation is warranted. RECENT FINDINGS: This review highlights the need for radiology peer review, including the confirmation of dynamic contrast-enhanced (DCE) compliance, as the initial step. Additional MRI models such as VERDICT or Tofts need to be verified. Current evidence shows that imaging and clinical indicators can be used for risk stratification of PI-RADS 3 lesions. For low-risk lesions, a safety net monitoring approach involving annual repeat MRI can be employed. In contrast, lesions deemed potentially risky based on prostate-specific antigen density (PSAD), 68 Ga-PSMA PET/CT, MPS, Proclarix, or AI/machine learning models should undergo biopsy. It is recommended to establish a multidisciplinary team that takes into account factors such as age, PSAD, prostate, and lesion size, as well as previous biopsy pathological findings. Combining expert opinions, clinical-imaging indicators, and emerging methods will contribute to the development of management strategies for PI-RADS 3 lesions.

Management of Patients With a Negative Multiparametric Prostate MRI Examination: AJR Expert Panel Narrative Review.

Multiparametric prostate MRI (mpMRI) aids risk stratification of patients with elevated PSA levels. While most clinically significant prostate cancers are detected by mpMRI, insignificant cancers are less evident. Thus, multiple international prostate cancer guidelines now endorse routine use of prostate MRI as a secondary screening test before prostate biopsy. Nonetheless, management of patients with negative mpMRI results (defined as PI-RADS category 1 or 2) remains unclear. This AJR Expert Panel Narrative Review summarizes the available literature on patients with an elevated screening PSA level and a negative prostate mpMRI, and provides guidance for these patients' management. Systematic biopsy should not be routinely performed after a negative mpMRI in patients at average risk but should be considered in patients at high risk. In patients who undergo PSA screening rather than systematic biopsy after negative mpMRI, clear triggers should be established for when to perform a repeat MRI. Patients with negative MRI followed by negative biopsy should follow their healthcare practitioners' preferred guidelines concerning subsequent PSA screening for the patient's risk level. Insufficient high-level data exist to support routine use of adjunctive serum or urine biomarkers, artificial intelligence, or PSMA PET to determine the need for prostate biopsy after negative mpMRI.

Partial-gland Cryoablation Outcomes for Localized Prostate Cancer in Patients with Magnetic Resonance Imaging (MRI)-visible and MRI-invisible Lesions.

Background: Expert consensus recommends treatment of magnetic resonance imaging (MRI)-visible prostate cancer (PCa). Outcomes of partial-gland ablation (PGA) for MRI-invisible PCa remain unknown. Objective: To compare recurrence-free survival, adverse events, and health-related quality of life (HRQoL) outcomes following cryoablation of MRI-visible vs invisible PCa. Design setting and participants: We analyzed data for 75 men who underwent cryoablation therapy between January 2017 and January 2022. PCa identified on MRI-targeted and/or adjacent systematic biopsy cores was defined as MRI-visible, whereas PCa identified on systematic biopsy beyond the targeted zone was defined as MRI-invisible. Outcome measurements and statistical analysis: The primary outcome was recurrence at 12 mo after PGA, defined as the presence of clinically significant PCa (grade group [GG] ≥2) on surveillance biopsy. Adverse events were captured using the Clavien-Dindo classification and HRQoL was captured using the Expanded Prostate Cancer Index-Clinical Practice (EPIC-CP) tool. Results and limitations: Of the 58 men treated for MRI-visible and 17 treated for MRI-invisible lesions, 51 (88%) and 16 (94%), respectively, had at least one surveillance biopsy performed. There were no statistically significant differences in age, race, body mass index, biopsy GG, prostate-specific antigen, prostate volume, or treatment extent between the MRI-visible and MRI-invisible groups. Median follow-up was 44 mo (interquartile range 17-54) and did not significantly differ between the groups. The recurrence rate at 12 mo did not significantly differ between the groups (MRI-visible 39%, MRI-invisible 19%; p = 0.2), and log-rank survival analysis demonstrated no significant difference in recurrence-free survival (p = 0.15). Adverse event rates did not significantly differ (MRI-visible 29%, MRI-invisible 53%; p = 0.092); no man in the MRI-visible group had a Clavien-Dindo grade ≥III complication, while one subject in the MRI-invisible group had a Clavien-Dindo grade III complication. Median EPIC-CP urinary and sexual function scores were similar for the two groups at baseline and at 12 mo after PGA. Study limitations include the retrospective design and small sample size. Conclusions: We observed similar cancer control, adverse event, and HRQoL outcomes for MRI-visible versus MRI-invisible PCa in the first comparison of partial-gland cryoablation. Longer follow-up and external validation of our findings are needed to inform patient selection for PGA for MRI-invisible PCa. Patient summary: Patients with prostate cancer lesions that are not visible on magnetic resonance imaging (MRI) scans who undergo partial gland ablation may have similar treatment outcomes compared to patients with cancer lesions that are visible on MRI.

The role of AI in prostate MRI quality and interpretation: Opportunities and challenges.

Prostate MRI plays an important role in imaging the prostate gland and surrounding tissues, particularly in the diagnosis and management of prostate cancer. With the widespread adoption of multiparametric magnetic resonance imaging in recent years, the concerns surrounding the variability of imaging quality have garnered increased attention. Several factors contribute to the inconsistency of image quality, such as acquisition parameters, scanner differences and interobserver variabilities. While efforts have been made to standardize image acquisition and interpretation via the development of systems, such as PI-RADS and PI-QUAL, the scoring systems still depend on the subjective experience and acumen of humans. Artificial intelligence (AI) has been increasingly used in many applications, including medical imaging, due to its ability to automate tasks and lower human error rates. These advantages have the potential to standardize the tasks of image interpretation and quality control of prostate MRI. Despite its potential, thorough validation is required before the implementation of AI in clinical practice. In this article, we explore the opportunities and challenges of AI, with a focus on the interpretation and quality of prostate MRI.

Test-retest repeatability of ADC in prostate using the multi b-Value VERDICT acquisition.

PURPOSE: VERDICT (Vascular, Extracellular, Restricted Diffusion for Cytometry in Tumours) MRI is a multi b-value, variable diffusion time DWI sequence that allows generation of ADC maps from different b-value and diffusion time combinations. The aim was to assess precision of prostate ADC measurements from varying b-value combinations using VERDICT and determine which protocol provides the most repeatable ADC. MATERIALS AND METHODS: Forty-one men (median age: 67.7 years) from a prior prospective VERDICT study (April 2016-October 2017) were analysed retrospectively. Men who were suspected of prostate cancer and scanned twice using VERDICT were included. ADC maps were formed using 5b-value combinations and the within-subject standard deviations (wSD) were calculated per ADC map. Three anatomical locations were analysed per subject: normal TZ (transition zone), normal PZ (peripheral zone), and index lesions. Repeated measures ANOVAs showed which b-value range had the lowest wSD, Spearman correlation and generalized linear model regression analysis determined whether wSD was related to ADC magnitude and ROI size. RESULTS: The mean lesion ADC for b0b1500 had the lowest wSD in most zones (0.18-0.58x10-4 mm2/s). The wSD was unaffected by ADC magnitude (Lesion: p = 0.064, TZ: p = 0.368, PZ: p = 0.072) and lesion Likert score (p = 0.95). wSD showed a decrease with ROI size pooled over zones (p = 0.019, adjusted regression coefficient = -1.6x10-3, larger ROIs for TZ versus PZ versus lesions). ADC maps formed with a maximum b-value of 500 s/mm2 had the largest wSDs (1.90-10.24x10-4 mm2/s). CONCLUSION: ADC maps generated from b0b1500 have better repeatability in normal TZ, normal PZ, and index lesions.

Pulse Sequence Dependence of a Simple and Interpretable Deep Learning Method for Detection of Clinically Significant Prostate Cancer Using Multiparametric MRI.

RATIONALE AND OBJECTIVES: Multiparametric magnetic resonance imaging (mpMRI) is increasingly used for risk stratification and localization of prostate cancer (PCa). Thanks to the great success of deep learning models in computer vision, the potential application for early detection of PCa using mpMRI is imminent. MATERIALS AND METHODS: Deep learning analysis of the PROSTATEx dataset. RESULTS: In this study, we show a simple convolutional neural network (CNN) with mpMRI can achieve high performance for detection of clinically significant PCa (csPCa), depending on the pulse sequences used. The mpMRI model with T2-ADC-DWI achieved 0.90 AUC score in the held-out test set, not significantly better than the model using Ktrans instead of DWI (AUC 0.89). Interestingly, the model incorporating T2-ADC- Ktrans better estimates grade. We also describe a saliency "heat" map. Our results show that csPCa detection models with mpMRI may be leveraged to guide clinical management strategies. CONCLUSION: Convolutional neural networks incorporating multiple pulse sequences show high performance for detection of clinically-significant prostate cancer, and the model including dynamic contrast-enhanced information correlates best with grade.

Variability of Prostate MRI Charges Among U.S. Hospital-Based Facilities.

The Premier Healthcare Database was used to assess charge variation for prostate MRI examinations in U.S. hospitals from January 2010 to March 2020. In 552 facilities performing 37,073 examinations, the median charge per examination was $4419 with 26-fold variation between the lowest ($593) and highest ($15,150) median facility charges. In multilevel linear regression analysis, interfacility variation explained 63.9% of charge variation. Patients may be charged vastly different prices for prostate MRI depending on the facility.

Major hemorrhage and mortality in COVID-19 patients on therapeutic anticoagulation for venous thromboembolism.

We observed multiple fatal intracranial hemorrhages shortly after initiating therapeutic anticoagulation for treatment of venous thromboembolism (VTE) in COVID-19 patients suggesting increased anticoagulation risk associated with COVID-19. The objective of this study is to quantify risk of major hemorrhage in hospitalized COVID-19 patients on therapeutic anticoagulation for deep venous thrombosis (DVT) or pulmonary embolism (PE). Hospitalized patients with COVID-19 receiving therapeutic anticoagulation for DVT, PE or both at four New York City hospitals were evaluated for hemorrhagic complications. These were categorized as major (including fatal) or clinically relevant non-major according to the criteria of the International Society of Thrombosis and Haemostasis. Hemorrhagic complications were correlated with clinical and laboratory data, ICD-10 code diagnoses and type of anticoagulation treatment. Minor hemorrhages were excluded. Major/clinically relevant hemorrhages occurred in 36 of 170 (21%) hospitalized COVID-19 patients being treated with therapeutic anticoagulation for VTE including 4 (2.4%) fatal hemorrhages. Hemorrhage was 3.4 times more likely with unfractionated heparin 27/76 (36%) compared to 8/81 (10%) with low molecular weight heparin (p = 0.002). Multivariate analysis showed that major hemorrhage was associated with intubation (p = 0.04) and elevated serum LDH (p < 0.001) and low fibrinogen (p = 0.05). Increased risk of hemorrhagic complications in treating VTE in hospitalized COVID-19 patients should be considered especially when using unfractionated heparin, in intubated patients, with low fibrinogen and/or elevated LDH. Checking serum fibrinogen and LDH before initiating therapeutic anticoagulation and monitoring coagulation parameters frequently may reduce bleeding complications.

Predictors of biliary intervention in patients hospitalized for COVID-19.

BACKGROUND: Gastrointestinal complications of coronavirus disease-2019 (COVID-19) include abnormal liver function and acalculous cholecystitis. Cholecystostomy performed during the COVID-19 pandemic reflected a shift toward non-surgical treatment of cholecystitis and increased number of critically ill patients suffering from acalculous cholecystitis. PURPOSE: (1) To determine demographic, clinical, laboratory, and ultrasound features associated with cholecystostomy placement during hospitalization for COVID-19. (2) To develop multivariable logistic regression modeling for likelihood of biliary intervention. METHODS: This retrospective review received institutional review board approval. Informed consent was waived. Between March 2020 and June 2020, patients with confirmed SARS-CoV2 infection admitted to New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, NYP/Lower Manhattan Hospital, and NYP/Queens were evaluated for inclusion in this study. Inclusion criteria were (1) patient age ≥ 18, (2) confirmed COVID-19 infection by polymerase chain reaction testing of a nasopharyngeal swab, and (3) abdominal ultrasound performed during hospitalization. Exclusion criteria were (1) history of cholecystectomy and (2) biliary intervention performed prior to abdominal ultrasound. Patients were stratified into two groups based on whether they received cholecystostomy during hospitalization. Differences in demographics, medical history, clinical status, medications, laboratory values, and ultrasound findings between the two groups were evaluated using Chi-square test or Fisher's exact test for categorical variables and t test or Wilcoxon-rank sum test for continuous variables. Multivariable logistic regression was used to model likelihood of biliary intervention. RESULTS: Nine patients underwent cholecystostomy placement and formed the "Intervention Group." 203 patients formed the "No Intervention Group." Liver size and diuretics use during hospitalization were the only variables which were significantly different between the two groups, with p-values of 0.02 and 0.046, respectively. After controlling for diuretics use, the odds of receiving cholecystostomy increased by 30% with every centimeter increase in liver size (p = 0.03). ICU admission approached significance (p = 0.16), as did mechanical ventilation (p = 0.09), septic shock (p = 0.08), serum alkaline phosphatase level (p = 0.16), and portal vein patency (0.14). CONCLUSION: Patients requiring biliary intervention during hospital admission for COVID-19 were likely to harbor liver injury in the form of liver enlargement and require diuretics use.

Quality in MR reporting of the prostate ­ improving acquisition, the role of AI and future perspectives

The high quality of MRI reporting of the prostate is the most critical component of the service provided by a radiologist. Prostate MRI structured reporting with PI-RADS v. 2.1 has been proven to improve consistency, quality, guideline-based care in the management of prostate cancer. There is room for improved accuracy of prostate mpMRI reporting, particularly as PI-RADS core criteria are subjective for radiologists. The application of artificial intelligence may support radiologists in interpreting MRI scans. This review addresses the quality of prostate multiparametric MRI (mpMRI) structured reporting (include improvements in acquisition using artificial intelligence) in terms of size of prostate gland, imaging quality, lesion location, lesion size, TNM staging, sector map, and discusses the future prospects of quality in MR reporting.

Pilot study of the diagnostic utility of 89 Zr-df-IAB2M and 68 Ga-PSMA-11 PET imaging and multiparametric MRI in localized prostate cancer.

BACKGROUND: Accurate diagnosis of localized prostate cancer (PCa) is limited by inadequacy of multiparametric (mp) MRI to fully identify and differentiate localized malignant tissue from benign pathologies. Prostate-specific membrane antigen (PSMA) represents an excellent target for molecular imaging. IAB2M, an 85-kD minibody derived from a de-immunized monoclonal antibody directed at the extracellular domain of human PSMA (huJ591), and PSMA-11, a small molecule ligand have been previously tested as probes for visualization of recurrent/metastatic PCa with PET/CT. This pilot, non-randomized trial studied their diagnostic utility in patients (pts) with localized PCa. METHODS: Pts planned for radical prostatectomy (RP) were enrolled and underwent mpMRI and PET/CT imaging with 89 Zr-df-IAB2M and/or 68 Ga-PSMA-PET/CT. Image results were read by a radiologist blinded to clinical information and pathology results, mapped and compared to corresponding histopathology findings from all lesions, both clinically significant and nonsignificant. The detection rates of all three imaging modalities were measured and correlated. RESULTS: 20 pts with median age of 64.5 (46-79) years and PSA level of 7.5 (1.6-36.56) ng/ml were enrolled. 19 pts underwent RP and were imaged pre-operatively with 89 Zr-Df-IAB2M PET/CT and mpMRI. Nine of those were imaged using 68 Ga-PSMA-11 as well. Out of 48 intraprostatic lesions verified on surgical pathology, IAB2M PET/CT was able to detect 36 (75%). A similar proportion of pathologically confirmed, clinically significant lesions (22/29, 76%) was detected. IAB2M PET/CT was also able to identify 14/19 (74%) extraprostatic lesions. The performance of mpMRI was inferior, with 24/48 detectable lesions (50%) and 18/29 clinically significant intraprostatic lesions (62%). Compared to the current standard (mpMRI), IAB2M PET/CT had a sensitivity of 88%, specificity 38%, positive predictive value 58%, and accuracy 63%. In 9 pts who underwent Ga-PSMA-11 as well, the latter yielded a detection rate of 70% (14/20), which was also seen in clinically significant lesions (10/14, 71%). Ga-PSMA-11 PET/CT also detected 4/6 (67%) extraprostatic lesions. CONCLUSIONS: In this pilot study, the performance of 89 Zr-df-IAB2M was superior to mpMRI and similar to 68 Ga-PSMA-11 PET/CT. The higher detection rate of PSMA-PET supports its use as a diagnostic tool with consequent management change implications in men with localized PCa.