Update for the practicing pathologist: The International Consultation On Urologic Disease-European association of urology consultation on bladder cancer.

The International Consultations on Urological Diseases are international consensus meetings, supported by the World Health Organization and the Union Internationale Contre le Cancer, which have occurred since 1981. Each consultation has the goal of convening experts to review data and provide evidence-based recommendations to improve practice. In 2012, the selected subject was bladder cancer, a disease which remains a major public health problem with little improvement in many years. The proceedings of the 2nd International Consultation on Bladder Cancer, which included a 'Pathology of Bladder Cancer Work Group,' have recently been published; herein, we provide a summary of developments and consensus relevant to the practicing pathologist. Although the published proceedings have tackled a comprehensive set of issues regarding the pathology of bladder cancer, this update summarizes the recommendations regarding selected issues for the practicing pathologist. These include guidelines for classification and grading of urothelial neoplasia, with particular emphasis on the approach to inverted lesions, the handling of incipient papillary lesions frequently seen during surveillance of bladder cancer patients, descriptions of newer variants, and terminology for urine cytology reporting.

Sentinel Lymph Node Mapping of Liver.

BACKGROUND: Although the sentinel lymph node (SLN) hypothesis has been applied to many tissues and organs, liver has remained unstudied. Currently, it is unclear whether hepatic SLNs even exist. If so, they could alter the management of intrahepatic cholangiocarcinoma and other hepatic malignancies by minimizing the extent of surgery while still providing precise nodal staging. This study investigated whether invisible yet tissue-penetrating near-infrared (NIR) fluorescent light can provide simultaneous identification of both the SLN and all other regional lymph nodes (RLNs) in the liver. METHODS: In 25 Yorkshire pigs, this study determined whether SLNs exist in liver and compared the effectiveness of two clinically available NIR fluorophores [methylene blue and indocyanine green (ICG)], and two novel NIR fluorophores previously described by our group (ESNF14 and ZW800-3C) for SLN and RLN mapping. RESULTS: In this study, ESNF14 showed the highest signal-to-background ratio and the longest retention time in SLNs without leakage to second-tier lymph nodes. The findings showed that ICG had apparent leakage to second-tier nodes, and ZW800-3C had poor migration after intraparenchymal injection. However, when injected intravenously, ZW800-3C was able to highlight all RLNs in liver during a 4- to 6-h period. Simultaneous dual-channel imaging of SLN (ESNF14) and RLN (ZW800-3C) permitted unambiguous identification and image-guided resection of SLNs and RLNs in liver. CONCLUSION: The NIR imaging technology enables real-time intraoperative identification of SLNs and RLNs in the liver of swine. If these results are confirmed in patients, new strategies for the surgical management of intrahepatic malignancies should be possible.

Novel PCA-VIP scheme for ranking MRI protocols and identifying computer-extracted MRI measurements associated with central gland and peripheral zone prostate tumors.

PURPOSE: To identify computer-extracted features for central gland and peripheral zone prostate cancer localization on multiparametric magnetic resonance imaging (MRI). MATERIALS AND METHODS: Preoperative T2-weighted (T2w), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) MRI were acquired from 23 men with confirmed prostate cancer. Following radical prostatectomy, the cancer extent was delineated by a pathologist on ex vivo histology and mapped to MRI by nonlinear registration of histology and corresponding MRI slices. In all, 244 computer-extracted features were extracted from MRI, and principal component analysis (PCA) was employed to reduce the data dimensionality so that a generalizable classifier could be constructed. A novel variable importance on projection (VIP) measure for PCA (PCA-VIP) was leveraged to identify computer-extracted MRI features that discriminate between cancer and normal prostate, and these features were used to construct classifiers for cancer localization. RESULTS: Classifiers using features selected by PCA-VIP yielded an area under the curve (AUC) of 0.79 and 0.85 for peripheral zone and central gland tumors, respectively. For tumor localization in the central gland, T2w, DCE, and DWI MRI features contributed 71.6%, 18.1%, and 10.2%, respectively; for peripheral zone tumors T2w, DCE, and DWI MRI contributed 29.6%, 21.7%, and 48.7%, respectively. CONCLUSION: PCA-VIP identified relatively stable subsets of MRI features that performed well in localizing prostate cancer on MRI.

Rapid, high-resolution, non-destructive assessments of metabolic and morphological homogeneity uniquely identify high-grade cervical precancerous lesions.

Purpose: Two-photon microscopy (2PM) is an emerging clinical imaging modality with the potential to non-invasively assess tissue metabolism and morphology in high-resolution. This study aimed to assess the translational potential of 2PM for improved detection of high-grade cervical precancerous lesions. Experimental Design: 2P images attributed to reduced nicotinamide adenine dinucleotide (phosphate) (NAD(P)H) and oxidized flavoproteins (FP) were acquired from the full epithelial thickness of freshly excised human cervical tissue biopsies (N = 62). Fifteen biopsies harbored high-grade squamous intraepithelial lesions (HSILs), 14 biopsies harbored low-grade SILs (LSILs), and 33 biopsies were benign. Quadratic discriminant analysis (QDA) leveraged morphological and metabolic functional metrics extracted from these images to predict the presence of HSILs. We performed gene set enrichment analysis (GSEA) using datasets available on the Gene Expression Omnibus (GEO) to validate the presence of metabolic reprogramming in HSILs. Results: Integrating metabolic and morphological 2P-derived metrics from finely sampled, full-thickness epithelia achieved a high 90.8 ± 6.1% sensitivity and 72.3 ± 11.3% specificity of HSIL detection. Notably, sensitivity (91.4 ± 12.0%) and specificity (77.5 ± 12.6%) were maintained when utilizing metrics from only two images at 12- and 72-µm from the tissue surface. Upregulation of glycolysis, fatty acid metabolism, and oxidative phosphorylation in HSIL tissues validated the metabolic reprogramming captured by 2P biomarkers. Conclusion: Label-free 2P images from as few as two epithelial depths enable rapid and robust HSIL detection through the quantitative characterization of metabolic and morphological reprogramming, underscoring the potential of this tool for clinical evaluation of cervical precancers.

Prognostic implications of the magnetic resonance imaging appearance in papillary renal cell carcinoma.

OBJECTIVE: To evaluate the prognostic implications of the MRI appearance and pathological features of papillary renal cell carcinoma (pRCC). METHODS: A total of 128 pRCC in 115 patients who underwent preoperative MRI were characterised in terms of pathological type (type 1 vs. type 2), MRI appearance (focal vs. infiltrative) and additional MRI features. Patients were classified on the basis of the presence or absence of metastatic disease. RESULTS: There were 65 focal type 1, 54 focal type 2 and 9 infiltrative pRCC. All infiltrative pRCC were of histopathological type 2. Renal vein thrombus was present in 89 % of infiltrative pRCC and no cases of focal pRCC. Metastatic disease was observed in 3.7 % of focal type 1, 7.5 % of focal type 2 and 75.0 % of infiltrative type 2 pRCC. Infiltrative MRI appearance was a significant predictor of metastatic disease, independent of pathological type, size and T stage (P ≤ 0.020). Among focal pRCC on MRI, pathological type 2 was not a significant predictor of metastatic disease (P = 0.648). No combination of features achieved significantly greater accuracy for predicting metastatic disease than renal vein thrombus alone (P > 0.5). CONCLUSION: Infiltrative MRI appearance and renal vein thrombus identify a subset of pathological type 2 pRCC at a significantly increased risk of metastatic disease.

Restoration of metabolic functional metrics from label-free, two-photon cervical tissue images using multiscale deep-learning-based denoising algorithms.

Label-free, two-photon imaging captures morphological and functional metabolic tissue changes and enables enhanced understanding of numerous diseases. However, this modality suffers from low signal arising from limitations imposed by the maximum permissible dose of illumination and the need for rapid image acquisition to avoid motion artifacts. Recently, deep learning methods have been developed to facilitate the extraction of quantitative information from such images. Here, we employ deep neural architectures in the synthesis of a multiscale denoising algorithm optimized for restoring metrics of metabolic activity from low-SNR, two-photon images. Two-photon excited fluorescence (TPEF) images of reduced nicotinamide adenine dinucleotide (phosphate) (NAD(P)H) and flavoproteins (FAD) from freshly excised human cervical tissues are used. We assess the impact of the specific denoising model, loss function, data transformation, and training dataset on established metrics of image restoration when comparing denoised single frame images with corresponding six frame averages, considered as the ground truth. We further assess the restoration accuracy of six metrics of metabolic function from the denoised images relative to ground truth images. Using a novel algorithm based on deep denoising in the wavelet transform domain, we demonstrate optimal recovery of metabolic function metrics. Our results highlight the promise of denoising algorithms to recover diagnostically useful information from low SNR label-free two-photon images and their potential importance in the clinical translation of such imaging.

Restoration of metabolic functional metrics from label-free, two-photon human tissue images using multiscale deep-learning-based denoising algorithms.

Significance: Label-free, two-photon excited fluorescence (TPEF) imaging captures morphological and functional metabolic tissue changes and enables enhanced understanding of numerous diseases. However, noise and other artifacts present in these images severely complicate the extraction of biologically useful information. Aim: We aim to employ deep neural architectures in the synthesis of a multiscale denoising algorithm optimized for restoring metrics of metabolic activity from low-signal-to-noise ratio (SNR), TPEF images. Approach: TPEF images of reduced nicotinamide adenine dinucleotide (phosphate) (NAD(P)H) and flavoproteins (FAD) from freshly excised human cervical tissues are used to assess the impact of various denoising models, preprocessing methods, and data on metrics of image quality and the recovery of six metrics of metabolic function from the images relative to ground truth images. Results: Optimized recovery of the redox ratio and mitochondrial organization is achieved using a novel algorithm based on deep denoising in the wavelet transform domain. This algorithm also leads to significant improvements in peak-SNR (PSNR) and structural similarity index measure (SSIM) for all images. Interestingly, other models yield even higher PSNR and SSIM improvements, but they are not optimal for recovery of metabolic function metrics. Conclusions: Denoising algorithms can recover diagnostically useful information from low SNR label-free TPEF images and will be useful for the clinical translation of such imaging.

Angiomyolipoma with minimal fat: can it be differentiated from clear cell renal cell carcinoma by using standard MR techniques?

PURPOSE: To retrospectively assess whether magnetic resonance (MR) imaging with opposed-phase and in-phase gradient-echo (GRE) sequences and MR feature analysis can differentiate angiomyolipomas (AMLs) that contain minimal fat from clear cell renal cell carcinomas (RCCs), with particular emphasis on small (<3-cm) masses. MATERIALS AND METHODS: Institutional review board approval and a waiver of informed consent were obtained for this HIPAA-compliant study. MR images from 108 pathologically proved renal masses (88 clear cell RCCs and 20 minimal fat AMLs from 64 men and 44 women) at two academic institutions were evaluated. The signal intensity (SI) of each renal mass and spleen on opposed-phase and in-phase GRE images was used to calculate an SI index and tumor-to-spleen SI ratio. Two radiologists who were blinded to the pathologic results independently assessed the subjective presence of intravoxel fat (ie, decreased SI on opposed-phase images compared with that on in-phase images), SI on T1-weighted and T2-weighted images, cystic degeneration, necrosis, hemorrhage, retroperitoneal collaterals, and renal vein thrombosis. Results were analyzed by using the Wilcoxon rank sum test, two-tailed Fisher exact test, and multivariate logistic regression analysis for all renal masses and for small masses. A P value of less than .05 was considered to indicate a statistically significant difference. RESULTS: There were no differences between minimal fat AMLs and clear cell RCCs for the SI index (8.05%±14.46 vs 14.99%±19.9; P=.146) or tumor-to-spleen ratio (-8.96%±16.6 and -15.8%±22.4; P=.227) when all masses or small masses were analyzed. Diagnostic accuracy (area under receiver operating characteristic curve) for the SI index and tumor-to-spleen ratio was 0.59. Intratumoral necrosis and larger size were predictive of clear cell RCC (P<.001) for all lesions, whereas low SI (relative to renal parenchyma SI) on T2-weighted images, smaller size, and female sex correlated with minimal fat AML (P<.001) for all lesions. CONCLUSION: The diagnostic accuracy of opposed-phase and in-phase GRE MR imaging for the differentiation of minimal fat AML and clear cell RCC is poor. In this cohort, low SI on T2-weighted images relative to renal parenchyma and small size suggested minimal fat AML, whereas intratumoral necrosis and large size argued against this diagnosis.

Arterial spin-labeling MR imaging of renal masses: correlation with histopathologic findings.

PURPOSE: To assess the value of arterial spin-labeling (ASL) perfusion magnetic resonance (MR) imaging in the characterization of solid renal masses by using histopathologic findings as the standard of reference. MATERIALS AND METHODS: This prospective study was compliant with HIPAA and approved by the institutional review board. Informed consent was obtained from all patients before imaging. Forty-two consecutive patients suspected of having renal masses underwent ASL MR imaging before their routine 1.5-T clinical MR examination. Mean and peak tumor perfusion levels were obtained by one radiologist, who was blinded to the final histologic diagnosis, by using region of interest analysis. Perfusion values were correlated with histopathologic findings by using analysis of variance. A linear correlation model was used to evaluate the relationship between tumor size and perfusion in clear cell renal cell carcinoma (RCC). P < .05 was considered indicative of a statistically significant difference. RESULTS: Histopathologic findings were available in 34 patients (28 men, six women; mean age ± standard deviation, 60.4 years ± 11.7). The mean perfusion of papillary RCC (27.0 mL/min/100 g ± 15.1) was lower than that of clear cell RCC (171.6 mL/min/100 g ± 61.2, P = .001), chromophobe RCC (152.9 mL/min/100 g ± 80.7, P = .04), unclassified RCC (208.0 mL/min/100 g ± 41.1, P = .001), and oncocytoma (373.9 mL/min/100 g ± 99.2, P < .001). The mean and peak perfusion levels of oncocytoma (373.9 mL/min/100 g ± 99.2 and 512.3 mL/min/100 g ± 146.0, respectively) were higher than those of papillary RCC (27.0 mL/min/100 g ± 15.1 and 78.2 mL/min/100 g ± 39.7, P < .001 for both), chromophobe RCC (152.9 mL/min/100 g ± 80.7 and 260.9 mL/min/100 g ± 61.9; P < .001 and P = .02, respectively), and unclassified RCC (208.0 mL/min/100 g ± 41.1 and 273.3 mL/min/100 g ± 83.4; P = .01 and P = .03, respectively). The mean tumor perfusion of oncocytoma was higher than that of clear cell RCC (P < .001). CONCLUSION: ASL MR imaging enables distinction among different histopathologic diagnoses in renal masses on the basis of their perfusion level. Oncocytomas demonstrate higher perfusion levels than RCCs, and papillary RCCs exhibit lower perfusion levels than other RCC subtypes.

Central gland and peripheral zone prostate tumors have significantly different quantitative imaging signatures on 3 Tesla endorectal, in vivo T2-weighted MR imagery.

PURPOSE: To identify and evaluate textural quantitative imaging signatures (QISes) for tumors occurring within the central gland (CG) and peripheral zone (PZ) of the prostate, respectively, as seen on in vivo 3 Tesla (T) endorectal T2-weighted (T2w) MRI. MATERIALS AND METHODS: This study used 22 preoperative prostate MRI data sets (16 PZ, 6 CG) acquired from men with confirmed prostate cancer (CaP) and scheduled for radical prostatectomy (RP). The prostate region-of-interest (ROI) was automatically delineated on T2w MRI, following which it was corrected for intensity-based acquisition artifacts. An expert pathologist manually delineated the dominant tumor regions on ex vivo sectioned and stained RP specimens as well as identified each of the studies as either a CG or PZ CaP. A nonlinear registration scheme was used to spatially align and then map CaP extent from the ex vivo RP sections onto the corresponding MRI slices. A total of 110 texture features were then extracted on a per-voxel basis from all T2w MRI data sets. An information theoretic feature selection procedure was then applied to identify QISes comprising T2w MRI textural features specific to CG and PZ CaP, respectively. The QISes for CG and PZ CaP were evaluated by means of Quadratic Discriminant Analysis (QDA) on a per-voxel basis against the ground truth for CaP on T2w MRI, mapped from corresponding histology. RESULTS: The QDA classifier yielded an area under the Receiver Operating characteristic curve of 0.86 for the CG CaP studies, and 0.73 for the PZ CaP studies over 25 runs of randomized three-fold cross-validation. By comparison, the accuracy of the QDA classifier was significantly lower when (a) using all 110 texture features (with no feature selection applied), as well as (b) a randomly selected combination of texture features. CONCLUSION: CG and PZ prostate cancers have significantly differing textural quantitative imaging signatures on T2w endorectal in vivo MRI.

Prediction of prostate cancer extracapsular extension with high spatial resolution dynamic contrast-enhanced 3-T MRI.

OBJECTIVES: To assess the value of dynamic contrast-enhanced (DCE) combined with T2-weighted (T2W) endorectal coil (ERC) magnetic resonance imaging (MRI) at 3 T for determining extracapsular extension (ECE) of prostate cancer. METHODS: In this IRB-approved study, ERC 3-T MRI of the prostate was performed in 108 patients before radical prostatectomy. T2W fast spin-echo and DCE 3D gradient echo images were acquired. The interpretations of readers with varied experience were analysed. MRI-based staging results were compared with radical prostatectomy histology. Descriptive statistics were generated for prediction of ECE and staging accuracies were determined by the area under the receiver-operating characteristic curve. RESULTS: The overall sensitivity, specificity, positive predictive value and negative predictive value for ECE were 75 %, 92 %, 79 % and 91 %, respectively. Diagnostic accuracy for staging was 86 %, 80 % and 91 % for all readers, experienced and less experienced readers, respectively. CONCLUSIONS: ERC 3-T MRI of the prostate combining DCE and T2W imaging is an accurate pretherapeutic staging tool for assessment of ECE in clinical practice across varying levels of reader experience. KEY POINTS : • Endorectal coil (ERC) magnetic resonance imaging is widely used for imaging prostatic disease. • ERC 3-T MRI is reasonably accurate for local prostate cancer staging. • High diagnostic accuracy is achievable across different levels of reader experience. • MRI facilitates therapeutic decisions in patients with prostate cancer.

Tissue-print and print-phoresis as platform technologies for the molecular analysis of human surgical specimens: mapping tumor invasion of the prostate capsule.

Molecular profiling of human biopsies and surgical specimens is frequently complicated by their inherent biological heterogeneity and by the need to conserve tissue for clinical diagnosis. We have developed a set of novel 'tissue print' and 'print-phoresis' technologies to facilitate tissue and tumor-marker profiling under these circumstances. Tissue printing transfers cells and extracellular matrix components from a tissue surface onto nitrocellulose membranes, generating a two-dimensional anatomical image on which molecular markers can be visualized by specific protein and RNA- and DNA-detection techniques. Print-phoresis is a complementary new electrophoresis method in which thin strips from the print are subjected to polyacrylamide gel electrophoresis, providing a straightforward interface between the tissue-print image and gel-based proteomic techniques. Here we have utilized these technologies to identify and characterize markers of tumor invasion of the prostate capsule, an event generally not apparent to the naked eye that may result in tumor at the surgical margins ('positive margins'). We have also shown that tissue-print technologies can provide a general platform for the generation of marker maps that can be superimposed directly onto histopathological and radiological images, permitting molecular identification and classification of individual malignant lesions.

Empirical ordering of stains in cytology-are we saving or losing?

INTRODUCTION: Bronchoalveolar lavage (BAL) and body cavity fluids (pleural and peritoneal) have a useful role in the detection of infectious diseases, especially when combined with ancillary stains (Grocott methenamine silver, acid-fast bacilli, Fite, and cytomegalovirus). However, empirical ordering of stains and duplicate testing by concurrent microbiology cultures leads to unnecessary wastage of resources. The aim of our study was to optimize the use of resources. MATERIALS AND METHODS: We performed a retrospective review of all BALs and body cavity fluids from 2016 to 2018 to determine the baseline stain order rate, which was then used in conjunction with clinical information to create a reasonable target for 2019. The methods implemented included communication with the clinical team to modify current ordering practice, monitoring stain orders prospectively through 2019, and updating the cytology requisition form to limit upfront ordering of ancillary stains. RESULTS: From 2016 to 2018, of the 1270 specimens reviewed, 323 (55%) were BALs and 108 (16%) were body cavity fluids that had had ≥2 stains preordered. This was reduced by the end of 2019 to 10% of BALs and 3.4% of body cavity fluids, leading to $25,935.24 in costs savings (including 275 hours of technician time and 39.3 hours of pathologist time). CONCLUSIONS: We found that ancillary microorganism stains have limited utility in cytology specimens and should only be ordered when indicated after a review of the initial smears. In today's era of cost savings, upfront ordering of ancillary stains can lead to significant wastage of resources that can be prevented by improving workflow.

High-grade Urothelial Carcinoma with Malignant Melanocytic Differentiation.

Urothelial carcinoma usually shows divergent differentiation and variant histology with squamous and glandular morphology being most common. In this report, we present a case of divergent malignant melanocytic differentiation in a high-grade urothelial carcinoma. A 98-year-old East Asian woman with an anterior bladder wall mass underwent resection, which revealed a high-grade poorly differentiated tumor. A minor component of high-grade papillary urothelial carcinoma and carcinoma in situ is also present. The majority of the tumor cells are morphologically and immunohistochemically consistent with melanoma, a minority of cells are positive for urothelial markers, and rare cells coexpress both melanocytic and urothelial markers. Cells that express melanocytic markers or urothelial markers are intimately admixed together. Taken together, a diagnosis of high-grade urothelial carcinoma with malignant melanocytic differentiation was rendered. This is the first report in the literature of malignant melanocytic differentiation in a high-grade urothelial carcinoma, a finding that may have important diagnostic and therapeutic implications.

Gland context networks: A novel approach for improving prostate cancer identification.

Prostate cancer (PCa) is a pervasive condition that is manifested in a wide range of histologic patterns in biopsy samples. Given the importance of identifying abnormal prostate tissue to improve prognosis, many computerized methodologies aimed at assisting pathologists in diagnosis have been developed. It is often argued that improved diagnosis of a tissue region can be obtained by considering measurements that can take into account several properties of its surroundings, therefore providing a more robust context for the analysis. Here we propose a novel methodology that can be used for systematically defining contextual features regarding prostate glands. This is done by defining a Gland Context Network (GCN), a representation of the prostate sample containing information about the spatial relationship between glands as well as the similarity between their appearance. We show that such a network can be used for establishing contextual features at any spatial scale, therefore providing information that is not easily obtained from traditional shape and textural features. Furthermore, it is shown that even basic features derived from a GCN can lead to state-of-the-art classification performance regarding PCa. All in all, GCNs can assist in defining more effective approaches for PCa grading.

Diagnosis of "cribriform" prostatic adenocarcinoma: an interobserver reproducibility study among urologic pathologists with recommendations.

Accurate diagnosis of cribriform Gleason pattern 4 (CrP4) prostate adenocarcinoma (PCa) is important due to its independent association with adverse clinical outcomes and as a growing body of evidence suggests that it impacts clinical decision making in PCa management. To identify reproducible features for diagnosis of CrP4, we assessed interobserver agreement among 27 experienced urologic pathologists of 60 digital images from 44 radical prostatectomies (RP) that represented a broad spectrum of potential CrP4. The following morphologic features were correlated with the consensus diagnosis (defined as 75% agreement) for each image: partial vs. transluminal glandular bridging, intraglandular stroma, <12 vs. ≥12 lumina, well vs. poorly formed lumina, mucin (mucinous fibroplasia, extravasation, or extracellular pool), size (compared to benign glands and number of lumina), number of attachments with gland border by tumor cells forming a "glomeruloid-like" pattern, a clear luminal space along the periphery of gland occupying <50% of glandular circumference, central nerve, dense (cell mass occupying >50% of luminal space) vs. loose, and regular vs. irregular contour. Interobserver reproducibility for the overall diagnostic agreement was fair (k=0.40). Large CrP4 had better agreement (k=0.49) compared to small CrP4 (k=0.40). Transluminal bridging, dense cellular proliferation, a clear luminal space along the periphery of gland occupying <50% of gland circumference, lack of intraglandular mucin, and lack of contact between the majority of intraglandular cells with stroma were significantly associated with consensus for CrP4. In contrast, partial bridging, majority of intraglandular cells in contact with stroma, mucinous fibroplasia, only one attachment to the gland border by tumor cells forming a "glomeruloid-like" pattern, and a clear luminal space along the periphery of gland accounting for >50% of the glandular circumference were associated with consensus against CrP4. In summary, we identified reproducible morphological features for and against CrP4 diagnosis, which could be used to refine and standardize the diagnostic criteria for CrP4.

Label-free, High-Resolution Optical Metabolic Imaging of Human Cervical Precancers Reveals Potential for Intraepithelial Neoplasia Diagnosis.

While metabolic changes are considered a cancer hallmark, their assessment has not been incorporated in the detection of early or precancers, when treatment is most effective. Here, we demonstrate that metabolic changes are detected in freshly excised human cervical precancerous tissues using label-free, non-destructive imaging of the entire epithelium. The images rely on two-photon excited fluorescence from two metabolic co-enzymes, NAD(P)H and FAD, and have micron-level resolution, enabling sensitive assessments of the redox ratio and mitochondrial fragmentation, which yield metrics of metabolic function and heterogeneity. Simultaneous characterization of morphological features, such as the depth-dependent variation of the nuclear:cytoplasmic ratio, is demonstrated. Multi-parametric analysis combining several metabolic metrics with morphological ones enhances significantly the diagnostic accuracy of identifying high-grade squamous intraepithelial lesions. Our results motivate the translation of such functional metabolic imaging to in vivo studies, which may enable improved identification of cervical lesions, and other precancers, at the bedside.

Renal cell carcinoma: dynamic contrast-enhanced MR imaging for differentiation of tumor subtypes--correlation with pathologic findings.

PURPOSE: To retrospectively evaluate whether the enhancement patterns of pathologically proved clear cell, papillary, and chromophobe renal cell carcinomas (RCCs) measured on clinical dynamic contrast agent-enhanced magnetic resonance (MR) images permit accurate diagnosis of RCC subtype. MATERIALS AND METHODS: This study was Institutional Review Board approved and HIPAA compliant; informed consent was waived. One hundred twelve patients (76 men, 36 women; age range, 25-88 years; mean age, 58.1 years) underwent MR imaging of 113 renal masses (mean diameter, 5.4 cm) with pathologic diagnoses of clear cell (n = 75), papillary (n = 28), or chromophobe (n = 10) RCC. A 1.5-T clinical MR protocol was used before and after (corticomedullary and nephrographic phases) intravenous administration of contrast agent. Region-of-interest measurements within tumor and uninvolved renal cortex were used to calculate percentage signal intensity change and tumor-to-cortex enhancement index. Subtype groups were compared by using linear mixed-effects models. Receiver operating characteristic (ROC) curve analysis was performed for the comparison of clear cell and papillary RCCs. RESULTS: On both the corticomedullary and nephrographic phase images, clear cell RCCs showed greater signal intensity change (205.6% and 247.1%, respectively) than did papillary RCCs (32.1% and 96.6%, respectively) (P < .001). Chromophobe RCCs showed intermediate change (109.9% and 192.5%, respectively). The tumor-to-cortex enhancement indexes at corticomedullary and nephrographic phases were largest for clear cell RCCs (1.4 and 1.2, respectively), smallest for papillary RCCs (0.2 and 0.4, respectively), and intermediate for chromophobe RCCs (0.6 and 0.8, respectively). Signal intensity changes on corticomedullary phase images were the most effective parameter for distinguishing clear cell and papillary RCC (area under ROC curve, 0.99); a threshold value of 84% permitted distinction with 93% sensitivity and 96% specificity. CONCLUSION: Clear cell, papillary, and chromophobe RCCs demonstrate different patterns of enhancement on two-time point clinical dynamic contrast-enhanced MR images, allowing their differentiation with high sensitivity and specificity.

Characterization of TMPRSS2-ERG fusion high-grade prostatic intraepithelial neoplasia and potential clinical implications.

PURPOSE: More than 1,300,000 prostate needle biopsies are done annually in the United States with up to 16% incidence of isolated high-grade prostatic intraepithelial neoplasia (HGPIN). HGPIN has low predictive value for identifying prostate cancer on subsequent needle biopsies in prostate-specific antigen-screened populations. In contemporary series, prostate cancer is detected in approximately 20% of repeat biopsies following a diagnosis of HGPIN. Further, discrete histologic subtypes of HGPIN with clinical implication in management have not been characterized. The TMPRSS2-ERG gene fusion that has recently been described in prostate cancer has also been shown to occur in a subset of HGPIN. This may have significant clinical implications given that TMPRSS2-ERG fusion prostate cancer is associated with a more aggressive clinical course. EXPERIMENTAL DESIGN: In this study, we assessed a series of HGPIN lesions and paired prostate cancer for the presence of TMPRSS2-ERG gene fusion. RESULTS: Fusion-positive HGPIN was observed in 16% of the 143 number of lesions, and in all instances, the matching cancer shared the same fusion pattern. Sixty percent of TMPRSS2-ERG fusion prostate cancer had fusion-negative HGPIN. CONCLUSIONS: Given the more aggressive nature of TMPRSS2-ERG prostate cancer, the findings of this study raise the possibility that gene fusion-positive HGPIN lesions are harbingers of more aggressive disease. To date, pathologic, molecular, and clinical variables do not help stratify which men with HGPIN are at increased risk for a cancer diagnosis. Our results suggest that the detection of isolated TMPRSS2-ERG fusion HGPIN would improve the positive predictive value of finding TMPRSS2-ERG fusion prostate cancer in subsequent biopsies.

Two-photon images reveal unique texture features for label-free identification of ovarian cancer peritoneal metastases.

For cancer patients, treatment selection fundamentally relies on staging, with "under-staging" considered a common problem. Imaging modalities that can complement conventional white-light laparoscopy are needed to detect more accurately small metastatic lesions in patients undergoing operative cancer care. Biopsies from healthy parietal peritoneum and ovarian peritoneal metastases obtained from 8 patients were imaged employing a two-photon laser scanning microscope to generate collagen-second harmonic generation (SHG) and fluorescence images at 755 nm and 900 nm excitation and 460 ± 20 nm and 525 ± 25 nm emission. Forty-one images were analyzed by automated image processing algorithms and statistical textural analysis techniques, namely gray level co-occurrence matrices. Two textural features (contrast and correlation) were employed to describe the spatial intensity variations within the captured images and outcomes were used for discriminant analysis. We found that healthy tissues displayed large variations in contrast and correlation features as a function of distance, corresponding to repetitive, increased local intensity fluctuations. Metastatic tissue images exhibited decreased contrast and correlation related values, representing more uniform intensity patterns and smaller fibers, indicating the destruction of the healthy stroma by the cancerous infiltration. The textural outcomes resulted in high classification accuracy as evaluated quantitatively by discriminant analysis.