Enhancing the Kaiser score for lesion characterization in unenhanced breast MRI.

PURPOSE: To adapt the methodology of the Kaiser score, a clinical decision rule for lesion characterization in breast MRI, for unenhanced protocols. METHOD: In this retrospective IRB-approved cross-sectional study, we included 93 consecutive patients who underwent breast MRI between 2021 and 2023 for further work-up of BI-RADS 0, 3-5 in conventional imaging or for staging purposes (BI-RADS 6). All patients underwent biopsy for histologic verification or were followed for a minimum of 12 months. MRI scans were conducted using 1.5 T or 3 T scanners using dedicated breast coils and a protocol in line with international recommendations including DWI and ADC. Lesion characterization relied solely on T2w and DWI/ADC-derived features (such as lesion type, margins, shape, internal signal, surrounding tissue findings, ADC value). Statistical analysis was done using decision tree analysis aiming to distinguish benign (histology/follow-up) from malignant outcomes. RESULTS: We analyzed a total of 161 lesions (81 of them non-mass) with a malignancy rate of 40%. Lesion margins (spiculated, irregular, or circumscribed) were identified as the most important criterion within the decision tree, followed by the ADC value as second most important criterion. The resulting score demonstrated a strong diagnostic performance with an AUC of 0.840, providing both rule-in and rule-out criteria. In an independent test set of 65 lesions the diagnostic performance was verified by two readers (AUC 0.77 and 0.87, kappa: 0.62). CONCLUSIONS: We developed a clinical decision rule for unenhanced breast MRI including lesion margins and ADC value as the most important criteria, achieving high diagnostic accuracy.

Using the Kaiser Score as a clinical decision rule for breast lesion classification: Does computer-assisted curve type analysis improve diagnosis?

PURPOSE: We aimed to investigate the effect of using visual or automatic enhancement curve type assessment on the diagnostic performance of the Kaiser Score (KS), a clinical decision rule for breast MRI. METHOD: This IRB-approved retrospective study analyzed consecutive conventional BI-RADS 0, 4 or 5 patients who underwent biopsy after 1.5T breast MRI according to EUSOBI recommendations between 2013 and 2015. The KS includes five criteria (spiculations; signal intensity (SI)-time curve type; margins of the lesion; internal enhancement; and presence of edema) resulting in scores from 1 (=lowest) to 11 (=highest risk of breast cancer). Enhancement curve types (Persistent, Plateau or Wash-out) were assessed by two radiologists independently visually and using a pixel-wise color-coded computed parametric map of curve types. KS diagnostic performance differences between readings were compared by ROC analysis. RESULTS: In total 220 lesions (147 benign, 73 malignant) including mass (n = 148) and non-mass lesions (n = 72) were analyzed. KS reading performance in distinguishing benign from malignant lesions did not differ between visual analysis and parametric map (P = 0.119; visual: AUC 0.875, sensitivity 95 %, specificity 63 %; and map: AUC 0.901, sensitivity 97 %, specificity 65 %). Additionally, analyzing mass and non-mass lesions separately, showed no difference between parametric map based and visual curve type-based KS analysis as well (P = 0.130 and P = 0.787). CONCLUSIONS: The performance of the Kaiser Score is largely independent of the curve type assessment methodology, confirming its robustness as a clinical decision rule for breast MRI in any type of breast lesion in clinical routine.

External validation of nomograms including MRI features for the prediction of side-specific extraprostatic extension.

BACKGROUND: Prediction of side-specific extraprostatic extension (EPE) is crucial in selecting patients for nerve-sparing radical prostatectomy (RP). Multiple nomograms, which include magnetic resonance imaging (MRI) information, are available predict side-specific EPE. It is crucial that the accuracy of these nomograms is assessed with external validation to ensure they can be used in clinical practice to support medical decision-making. METHODS: Data of prostate cancer (PCa) patients that underwent robot-assisted RP (RARP) from 2017 to 2021 at four European tertiary referral centers were collected retrospectively. Four previously developed nomograms for the prediction of side-specific EPE were identified and externally validated. Discrimination (area under the curve [AUC]), calibration and net benefit of four nomograms were assessed. To assess the strongest predictor among the MRI features included in all nomograms, we evaluated their association with side-specific EPE using multivariate regression analysis and Akaike Information Criterion (AIC). RESULTS: This study involved 773 patients with a total of 1546 prostate lobes. EPE was found in 338 (22%) lobes. The AUCs of the models predicting EPE ranged from 72.2% (95% CI 69.1-72.3%) (Wibmer) to 75.5% (95% CI 72.5-78.5%) (Nyarangi-Dix). The nomogram with the highest AUC varied across the cohorts. The Soeterik, Nyarangi-Dix, and Martini nomograms demonstrated fair to good calibration for clinically most relevant thresholds between 5 and 30%. In contrast, the Wibmer nomogram showed substantial overestimation of EPE risk for thresholds above 25%. The Nyarangi-Dix nomogram demonstrated a higher net benefit for risk thresholds between 20 and 30% when compared to the other three nomograms. Of all MRI features, the European Society of Urogenital Radiology score and tumor capsule contact length showed the highest AUCs and lowest AIC. CONCLUSION: The Nyarangi-Dix, Martini and Soeterik nomograms resulted in accurate EPE prediction and are therefore suitable to support medical decision-making.

Combined chemotherapy and pembrolizumab salvages multi-chemotherapy agent and avelumab resistant choriocarcinoma: A case report.

Introduction: Gestational trophoblastic neoplasia (GTN) including choriocarcinoma (CC) frequently requires multi-agent chemotherapy to achieve cure. In chemotherapy-resistant GTN, immunotherapy with the checkpoint inhibitors pembrolizumab, avelumab and camrelizumab are potential new treatment options previously described in small case series, phase 2 trials and case reports. Case description: A 32-year-old woman was diagnosed with gestational choriocarcinoma (FIGO score 5). Prior administered therapy regimes included methotrexate, actinomycin-D followed by open hysterectomy with bilateral salpingectomy (histology without GTN) as well as multi-agent chemotherapy and avelumab single-agent. After detection of a suspicious pulmonary mass video- assisted thoracoscopic left lung segmentectomy was performed confirming CC. The patient experienced an intracerebral haemorrhage and was treated with an emergency decompressive craniotomy. The cerebrospinal fluid showed an increased ratio of hCG compared to serum. Therapy with combined escalated etoposide and cisplatin with pembrolizumab was commenced followed by maintenance pembrolizumab achieving a complete hCG response and negative PET CT. Discussion: In the management of multi drug- resistant GTN, application of checkpoint inhibitor pembrolizumab is a new therapeutic strategy. In this heavily pre-treated patient incorporation of pembrolizumab resulted in complete long-term response in a patient who had also failed avelumab therapy.

Impact of PI-QUAL on PI-RADS and cancer yield in an MRI-TRUS fusion biopsy population.

PURPOSE: To test the inter-reader agreement of the Prostate Imaging Quality (PI-QUAL) score for multiparametric prostate MRI and its impact on diagnostic performance in an MRI-ultrasound fusion biopsy population. PATIENTS AND METHODS: Pre-biopsy multiparametric (T2-weighted, DWI, and DCE) prostate MRIs (mpMRI) of 50 patients undergoing transrectal ultrasound-guided MRI-fusion (MRI-TRUS) biopsy were included. Two radiologists independently assigned a PI-QUAL score to each patient and assessed the diagnostic quality of individual sequences. PI-RADS categories were assigned to six regions per prostate (left and right: base/mid-glandular/apex). Inter-reader agreement was calculated using Cohen's kappa and diagnostic performance was compared by the area under the receiver operating characteristics curve (AUC). RESULTS: In 274 diagnostic areas, the malignancy rate was 62.7% (22.5% clinically significant prostate cancer, ISUP ≥ 2). Inter-reader agreement for the diagnostic quality was poor for T2w (kappa 0.19), fair for DWI and DCE (kappa 0.23 and 0.29) and moderate for PI-QUAL (kappa 0.51). For PI-RADS category assignments, inter-reader agreement was very good (kappa 0.86). Overall diagnostic performance did not differ between studies with a PI-QUAL score > 3 compared to a score ≤ 3 (p = 0.552; AUC 0.805 and 0.839). However, the prevalence of prostate cancer was significantly lower when the PI-QUAL score was ≤ 3 (16.7% vs. 30.2%, p = 0.008). CONCLUSION: PI-QUAL has only a limited impact on PI-RADS diagnostic performance in patients scheduled for MRI-TRUS fusion biopsy. However, the lower cancer prevalence in the lower PI-QUAL categories points out a risk of false-positive referrals and unnecessary biopsies if prostate imaging quality is low.