Early stage glioblastoma: retrospective multicentric analysis of clinical and radiological features.

OBJECTIVES: The aim of this study was to report our experience with early stage glioblastoma (e-GB) and to investigate the possible clinical and imaging features that may be helpful to the radiologist to correctly diagnose this entity. METHODS: We performed a retrospective research of patients diagnosed with glioblastoma at two hospitals during a 10-year period. We reviewed all pre-operative MR and included only patients with early stage GB lesions, characterized by hyperintense on T2-weighted signal, with or without contrast-enhancement at post-contrast T1-weighted images, without "classic" imaging appearance of GB (necrosis, haemorrhage, oedema). All preoperative MR were evaluated by an experienced neuroradiologist and information on patients' demographics, clinical presentation, follow-up, and histopathology results study were collected. When available, preoperative CT examination was also evaluated. RESULTS: We found 14 e-GBs in 13 patients (9 males, 4 females, median age 63 years) among 660 patients diagnosed with GB between 2010 and 2020. In 10 lesions, serial imaging revealed the transformation of e-GB in classic glioblastoma in a median time of 3 months. Clinical presentation included stroke-like symptoms, vertigo, seizures and confusion. Preoperative plain CT was performed in 8/13 cases and in 7 e-GBs presented as a hyperdense lesion. Ten out of 14 lesions transformed in classic GB before surgical intervention or biopsy. All lesions revealed typical immunohistochemical pattern of primary glioblastoma. CONCLUSIONS: E-GB is a rare entity that can often lead to misdiagnosis. However, the radiologist should be aware of its imaging appearance to suggest the diagnosis and to request close imaging follow-up, hopefully improving the prognosis of this very aggressive disease.

Multiparametric MRI of the bladder: inter-observer agreement and accuracy with the Vesical Imaging-Reporting and Data System (VI-RADS) at a single reference center.

OBJECTIVES: To evaluate accuracy and inter-observer variability using Vesical Imaging-Reporting and Data System (VI-RADS) for discrimination between non-muscle invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC). METHODS: Between September 2017 and July 2018, 78 patients referred for suspected bladder cancer underwent multiparametric MRI of the bladder (mpMRI) prior to transurethral resection of bladder tumor (TURBT). All mpMRI were reviewed by two radiologists, who scored each lesion according to VI-RADS. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each VI-RADS cutoff. Receiver operating characteristics curves were used to evaluate the performance of mpMRI. The Ƙ statistics was used to estimate inter-reader agreement. RESULTS: Seventy-five patients were included in the final analysis, 53 with NMIBC and 22 with MIBC. Sensitivity and specificity were 91% and 89% for reader 1 and 82% and 85% for reader 2 respectively when the cutoff VI-RADS > 2 was used to define MIBC. At the same cutoff, PPV and NPV were 77% and 96% for reader 1 and 69% and 92% for reader 2. When the cutoff VI-RADS > 3 was used, sensitivity and specificity were 82% and 94% for reader 1 and 77% and 89% for reader 2. Corresponding PPV and NPV were 86% and 93% for reader 1 and 74% and 91% for reader 2. Area under curve was 0.926 and 0.873 for reader 1 and 2 respectively. Inter-reader agreement was good for the overall score (Ƙ = 0.731). CONCLUSIONS: VI-RADS is accurate in differentiating MIBC from NMIBC. Inter-reader agreement is overall good. KEY POINTS: • Traditionally, the local staging of bladder cancer relies on transurethral resection of bladder tumor. • However, transurethral resection of bladder tumor carries a significant risk of understaging a cancer; therefore, more accurate, faster, and non-invasive staging techniques are needed to improve outcomes. • Multiparametric MRI has proved to be the best imaging modality for local staging; therefore, its use in suitable patients has the potential to expedite radical treatment when necessary and non-invasive diagnosis in patients with poor fitness.

State-of-the-art imaging techniques in the management of preoperative staging and re-staging of prostate cancer.

We aimed to review the current state-of-the-art imaging methods used for primary and secondary staging of prostate cancer, mainly focusing on multiparametric magnetic resonance imaging and positron-emission tomography/computed tomography with new radiotracers. An expert panel of urologists, radiologists and nuclear medicine physicians with wide experience in prostate cancer led a PubMed/MEDLINE search for prospective, retrospective original research, systematic review, meta-analyses and clinical guidelines for local and systemic staging of the primary tumor and recurrence disease after treatment. Despite magnetic resonance imaging having low sensitivity for microscopic extracapsular extension, it is now a mainstay of prostate cancer diagnosis and local staging, and is becoming a crucial tool in treatment planning. Cross-sectional imaging for nodal staging, such as computed tomography and magnetic resonance imaging, is clinically useless even in high-risk patients, but is still suggested by current clinical guidelines. Positron-emission tomography/computed tomography with newer tracers has some advantage over conventional images, but is not cost-effective. Bone scan and computed tomography are often useless in early biochemical relapse, when salvage treatments are potentially curative. New imaging modalities, such as prostate-specific membrane antigen positron-emission tomography/computed tomography and whole-body magnetic resonance imaging, are showing promising results for early local and systemic detection. Newer imaging techniques, such as multiparametric magnetic resonance imaging, whole-body magnetic resonance imaging and positron-emission tomography/computed tomography with prostate-specific membrane antigen, have the potential to fill the historical limitations of conventional imaging methods in some clinical situations of primary and secondary staging of prostate cancer.

An evaluation of morphological and functional multi-parametric MRI sequences in classifying non-muscle and muscle invasive bladder cancer.

OBJECTIVES: Our goal is to determine the ability of multi-parametric magnetic resonance imaging (mpMRI) to differentiate muscle invasive bladder cancer (MIBC) from non-muscle invasive bladder cancer (NMIBC). METHODS: Patients underwent mpMRI before tumour resection. Four MRI sets, i.e. T2-weighted (T2W) + perfusion-weighted imaging (PWI), T2W plus diffusion-weighted imaging (DWI), T2W + DWI + PWI, and T2W + DWI + PWI + dif-fusion tensor imaging (DTI) were interpreted qualitatively by two radiologists, blinded to histology results. PWI, DWI and DTI were also analysed quantitatively. Accuracy was determined using histopathology as the reference standard. RESULTS: A total of 82 tumours were analysed. Ninety-six percent of T1-labeled tumours by the T2W + DWI + PWI image set were confirmed to be NMIBC at histopathology. Overall accuracy of the complete mpMRI protocol was 94% in differentiating NMIBC from MIBC. PWI, DWI and DTI quantitative parameters were shown to be significantly different in cancerous versus non-cancerous areas within the bladder wall in T2-labelled lesions. CONCLUSIONS: MpMRI with DWI and DTI appears a reliable staging tool for bladder cancer. If our data are validated, then mpMRI could precede cystoscopic resection to allow a faster recognition of MIBC and accelerated treatment pathways. KEY POINTS: • A critical step in BCa staging is to differentiate NMIBC from MIBC. • Morphological and functional sequences are reliable techniques in differentiating NMIBC from MIBC. • Diffusion tensor imaging could be an additional tool in BCa staging.

Metabolic atrophy and 3-T 1H-magnetic resonance spectroscopy correlation after radiation therapy for prostate cancer.

OBJECTIVE: To correlate 3-T magnetic resonance spectroscopic imaging (MRSI) with prostate-specific antigen (PSA) levels in patients with prostate cancer treated with external beam radiation therapy to assess the potential advantages of MRSI. MATERIALS AND METHODS: A total of 50 patients (age range 65-83 years) underwent PSA and MRSI surveillance before and at 3, 6, 12, 18 and 24 months after radiotherapy. RESULTS: Of the 50 patients examined, 13 patients completely responded to therapy showing metabolic atrophy (MA), defined as a choline-plus-creatine/citrate (CC/C) ratio <0.2, at 3 months; in this group none had biochemical relapse (PSA nadir + 2 ng/mL) by the end of the follow-up. Of the 50 patients, 35 showed a partial response to therapy (CC/C ratio between 0.2 and 0.8) at 3 and 6 months and, of these 35 patients, 30 reached MA at 12 months, while five developed a recurrence (CC/C ratio >0.8). Three of those patients with recurrence had a biochemical relapse at 18 months and the other two at 24 months. Two of the 50 patients did not respond to the treatment, showing persistent disease from the 3rd month (CC/C ratio >0.8); one patient had biochemical relapse at 6 and the other at 12 months. CONCLUSIONS: MRSI was shown to have a greater potential than PSA level in monitoring patients after radiotherapy, because it anticipates PSA nadir, and biochemical relapse in particular.

Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with Silk Vista Baby flow diverter in a 10-month-old infant.

We report the successful treatment of multiple ruptured fusiform middle cerebral artery (MCA) aneurysms in a 10-month-old girl. This previously healthy infant presented with subarachnoid hemorrhage and was found to have multiple irregular dilatations of the superior division branch of the right MCA. Cerebral angiography was performed and confirmed the presence of multiple fusiform aneurysms of the MCA. After discussion with the multidisciplinary team, it was decided to treat the aneurysms with a endovascular approach, using a flow diverter. Microsurgical clipping was deemed risky because of the high likelihood of parent artery occlusion, and expectant management was also considered inappropriate because of the risk of rebleeding. Dual antiplatelet therapy was started, and a flow diverter was successfully delivered in the superior division branch of the right MCA. The postoperative course was uneventful, MRI at 12 months did not show any sign of recurrence, and at 3 years of age the patient had a normal neurological examination.

Republished: Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with silk vista baby flow diverter in a 10-months-old infant.

We report the successful treatment of multiple ruptured fusiform middle cerebral artery (MCA) aneurysms in a 10-month-old girl. This previously healthy infant presented with subarachnoid haemorrhage and was found to have multiple irregular dilatations of the superior division branch of the right MCA. Cerebral angiography was performed and confirmed the presence of multiple fusiform aneurysms of the MCA. After multidisciplinary team discussion, it was decided to treat the aneurysms with endovascular approach, using a flow-diverter. Microsurgical clipping was deemed risky because of the high likelihood of parent artery occlusion and expectant management was also considered inappropriate because of the risk of re-bleeding. Dual antiplatelet therapy was started, and a flow-diverter was successfully delivered in the superior division branch of the right MCA. The post-operative course was uneventful, MRI at 12 months did not show any sign of recurrence and at 3 years of age the patient had a normal neurological examination.

Is MRI follow-up relevant in patients with GH-secreting pituitary adenomas primarily treated and responsive to long-acting somatostatin analogues (SMSa)?

OBJECTIVE: Primary SMSa treatment can be associated with hormonal control and tumor shrinkage in patients with GH-secreting pituitary adenomas. The aim of this study was to evaluate whether regular MRI follow-up was necessary in patients with acromegaly-treated and responsive to first-generation long-acting SMSa. PATIENTS AND METHODS: In this retrospective monocentric study we included patients with GH/IGF-1 hypersecretion and pituitary adenomas with normal visual field, primarily treated with first-generation long-acting SMSa between 1995 and 2015 and regularly monitored (clinical evaluation, GH/IGF-1 levels and pituitary MRI) for at least 3 years. RESULTS: We included 83 patients (32 men and 51 women, mean age at diagnosis 50 ± 12 years) with mean GH = 19.3 ± 25.6 ng/mL, IGF-1 = 284 ± 110% ULN and pituitary adenoma height = 12.9 ± 4.7 mm. Mean follow-up was 8.9 ± 4.9 years in 36 controlled patients and 2.0 ± 1.6 years in 47 partial responders to SMSa alone. No significant increase in pituitary adenoma height was observed. Pituitary adenoma height decreased significantly in controlled patients (diagnosis: 11.9 ± 4.8 mm, SMSa: 9.6 ± 3.3 mm, P < 0.001), and in partially responders (diagnosis: 13.6 ± 4.5 mm, SMSa: 11.5 ± 4.5 mm, P < 0.001). CONCLUSION: During SMSa treatment, no significant increase in GH-secreting adenoma size was observed. Primary SMSa treatment was associated with a significantly decrease in adenoma height in our population. Our cohort data suggest that regular MRI follow-up does not seem relevant in patients with acromegaly who are responsive to SMSa treatment.

Mechanical Thrombectomy of Distal Occlusions Using a Direct Aspiration First Pass Technique Compared with New Generation of Mini-0.017 Microcatheter Compatible-Stent Retrievers: A Meta-Analysis.

BACKGROUND: There are no current evidence-based recommendations on mechanical thrombectomy (MT) in M2 or other distal occlusions. The objective of this paper was to investigate clinical and radiologic outcomes of MT in distal locations using the new generation of mini-0.017 microcatheter compatible-stent retrievers (SRs) compared with a direct aspiration first pass technique (ADAPT) MT. METHODS: A systematic search was performed for studies published from January 2016 to March 2019. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies that reported clinical and radiologic outcomes of patients undergoing MT using new generation of SRs or ADAPT in distal locations. The cumulative prevalence was estimated for each outcome. Heterogeneity of the data was assessed by the Higgins index (I2), and a random-effects model was applied. RESULTS: Fifteen studies and 494 patients were included; 7 studies reported on patients treated with a new SR and 8 studies analyzed patients treated with ADAPT. The rate of thrombolysis in cerebral infarction score 2b-3 after MT for distal occlusions was 80.6% (383 of 494; 95% confidence interval [CI], 74.8%-86.3%; I2 = 64.4%). Successful recanalization was comparable after SR use with low-profile devices and ADAPT (176 of 226; 82%; 95% CI, 72.6%-1.5%; I2 = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%-86.9%; I2 = 60.8%, respectively; P = 0.4). The rate of the modified Rankin scale score of 0-2 at 3 months was higher in the ADAPT group (160 of 251; 68.9%; 95% CI, 51.8%-85.9%; I2 = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%-80%; I2 = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%-9%; I2 = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%-19%; I2 = 13%; P = 0.008). CONCLUSIONS: MT in distal locations using the new generation of SR yields comparable results compared with ADAPT in terms of recanalization; however, the use of SR is associated with lower functional independence and higher mortality rate.

Early myocardial damage and microvascular dysfunction in asymptomatic patients with systemic sclerosis: A cardiovascular magnetic resonance study with cold pressor test.

PURPOSE: Cardiac involvement in Systemic Sclerosis (SSc) is increasingly recognized as a mayor cause of morbidity and mortality. The aim of present study is to investigate the early stages of cardiac involvement in SSc by Cardiovascular magnetic resonance (CMR), combining the non-invasive detection of myocardial inflammation and fibrosis using T2 and T1 mapping techniques and the assessment of microcirculatory impairment through perfusion response to cold pressor test (CPT). METHODS: 40 SSc patients (30 females, mean age: 42.1 years) without cardiac symptoms and 10 controls underwent CMR at 1.5 T unit. CMR protocol included: native and contrast-enhanced T1 mapping, T2 mapping, T2-weighted, cineMR and late gadolinium enhancement (LGE) imaging. Microvascular function was evaluated by comparing myocardial blood flow (MBF) on perfusion imaging acquired at rest and after CPT. Native myocardial T1 and T2 relaxation times, extracellular volume fraction (ECV), T2 signal intensity ratio, biventricular volumes and LGE were assessed in each patient. RESULTS: SSc patients had significantly higher mean myocardial T1 (1029±32ms vs. 985±18ms, p<0.01), ECV (30.1±4.3% vs. 26.7±2.4%, p<0.05) and T2 (50.1±2.8ms vs. 47±1.5ms, p<0.01) values compared with controls. No significant differences were found between absolute MBF values at rest and after CPT; whereas lower MBF variation after CPT was observed in SSc patients (+33 ± 14% vs. +44 ± 12%, p<0.01). MBF variation had inverse correlation with native T1 values (r: -0.32, p<0.05), but not with ECV. CONCLUSIONS: Myocardial involvement in SSc at preclinical stage increases native T1, T2 and ECV values, reflecting inflammation and fibrosis, and reduces vasodilatory response to CPT, as expression of microvascular dysfunction.

Prostate Imaging Reporting and Data System 3 Category Cases at Multiparametric Magnetic Resonance for Prostate Cancer: A Systematic Review and Meta-analysis.

CONTEXT: The Prostate Imaging Reporting and Data System (PI-RADS) 3 score represents a "grey zone" that need to be further investigated to solve the issue of whether to biopsy these equivocal cases or not. OBJECTIVE: To critically analyze the current evidence on PI-RADS 3 cases. We evaluated the prevalence of PI-RADS 3 cases in the literature and detection rate of prostate cancer (PC) and clinically significant PC (csPC) at biopsy with regard to factors determining these rates. EVIDENCE ACQUISITION: We searched in the Medline and Cochrane Library database from the literature from January 2009 to January 2019, following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. EVIDENCE SYNTHESIS: A total of 28 studies were included in our analysis (total number of PI-RADS 3 cases: 1759, range 20-187). The prevalence of PI-RADS 3 cases reported in available studies was 17.3% (range 6.4-45.7%). The PC detection rate was 36% (95% confidence interval [CI] 33.8-37.4; range 10.3-55.8%), whereas that of csPC was 18.5% (95% CI 16.6-20.3; range 3.4-46.5%). Detection rates of PC and csPC were found to be similar in men who underwent a target biopsy versus those with a systematic biopsy (23.5% vs 23.9% and 11.4% vs 12.3%, respectively) and lower than the rates achieved with the combined strategy (36.9% and 19.6%, respectively). A prostate-specific antigen density (PSAD) of ≥0.15ng/ml/ml may represent an index to decide whether to submit a PI-RADS 3 case to biopsy. CONCLUSIONS: In most investigations, PI-RADS 3 cases were not evaluated separately. A PI-RADS 3 lesion remains an equivocal lesion. Evaluation of clinical predictive factors in terms of csPC risk is a main aspect of helping clinicians in the biopsy decision process. PATIENT SUMMARY: Management of Prostate Imaging Reporting and Data System 3 cases remains an unmet need, and the detection rate of clinically significant prostate cancer (csPC) among this population varies widely. Performing a combined target plus a systematic biopsy yields the highest detection of csPC. A prostate-specific antigen density of lower than 0.15ng/ml/ml may select patients for a follow-up strategy.

Prospective Assessment of Vesical Imaging Reporting and Data System (VI-RADS) and Its Clinical Impact on the Management of High-risk Non-muscle-invasive Bladder Cancer Patients Candidate for Repeated Transurethral Resection.

BACKGROUND: Vesical Imaging Reporting and Data System (VI-RADS) score is adopted to provide preoperative bladder cancer (BCa) staging. Repeated transurethral resection of bladder tumor (Re-TURBT) is recommended in most of high-risk non-muscle-invasive bladder cancers (HR-NMIBCs) due to possibility of persistent/understaged disease after initial TURBT. No diagnostic tools able to improve patient's stratification for such recommendation exist. OBJECTIVE: To (1) prospectively validate VI-RADS for discriminating between NMIBC and muscle-invasive bladder cancer (MIBC) at TURBT, and (2) evaluate the accuracy of VI-RADS for identifying HR-NMIBC patients who could avoid Re-TURBT and detecting those at higher risk for understaging after TURBT. DESIGN, SETTING, AND PARTICIPANTS: Patients with BCa suspicion were offered multiparametric magnetic resonance imaging (mpMRI) before TURBT. According to VI-RADS, a cutoff of ≥3 to define MIBC was assumed. TURBT reports were compared with preoperative VI-RADS scores to assess accuracy of mpMRI for discriminating between NMIBC and MIBC. HR-NMIBC Re-TURBT reports were compared with preoperatively recorded VI-RADS scores to assess mpMRI accuracy in predicting Re-TURBT outcomes. INTERVENTION: Multiparametric MRI of the bladder before TURBT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated for mpMRI performance in patients undergoing TURBT and for HR-NMIBC patients candidate for Re-TURBT. Performance of mpMRI was assessed by receiver operating characteristic curve analysis. Ƙ statistics was used to estimate inter- and intrareader variability. RESULTS AND LIMITATIONS: A total of 231 patients were enrolled. Multiparametric MRI showed sensitivity, specificity, PPV, and NPV for discriminating NMIBC from MIBC at initial TURBT of 91.9% (95% confidence interval [CI]: 82.2-97.3), 91.1% (95% CI: 85.8-94.9), 77.5% (95% CI: 65.8-86.7), and 97.1% (95% CI: 93.3-99.1), respectively. The area under the curve (AUC) was 0.94 (95% CI: 0.91-0.97). Among HR-NMIBC patients (n=114), mpMRI before TURBT showed sensitivity, specificity, PPV, and NPV of 85% (95% CI: 62.1-96.8), 93.6% (95% CI: 86.6-97.6), 74.5% (95% CI: 52.4-90.1), and 96.6% (95% CI: 90.5-99.3) respectively, to identify patients with MIBC at Re-TURBT. The AUC was 0.93 (95% CI: 0.87-0.97). CONCLUSIONS: VI-RADS is accurate for discriminating between NMIBC and MIBC. Within HR-NMIBC cases, VI-RADS could, in future, improve the selection of patients who are candidate for Re-TURBT. PATIENT SUMMARY: We investigated the accuracy of Vesical Imaging Reporting and Data System (VI-RADS) score to asses bladder cancer staging before transurethral resection of bladder tumors, and we explored the performance of VI-RADS score as a future preoperative predictive tool for the selection of high-risk non-muscle-invasive bladder cancer patients who are candidate for undergoing early repeated transurethral resection of the primary tumor site.

Improvement of prostate cancer detection combining a computer-aided diagnostic system with TRUS-MRI targeted biopsy.

PURPOSE: To validate a novel consensus method, called target-in-target, combining human analysis of mpMRI with automated CAD system analysis, with the aim to increasing the prostate cancer detection rate of targeted biopsies. METHODS: A cohort of 420 patients was enrolled and 253 patients were rolled out, due to exclusion criteria. 167 patients, underwent diagnostic 3T MpMRI. Two expert radiologists evaluated the exams adopting PI-RADSv2 and CAD system. When a CAD target overlapped with a radiologic one, we performed the biopsy in the overlapping area which we defined as target-in-target. Targeted TRUS-MRI fusion biopsy was performed in 63 patients with a total of 212 targets. The MRI data of all targets were quantitatively analyzed, and diagnostic findings were compared to pathologist's biopsy reports. RESULTS: CAD system diagnostic performance exhibited sensitivity and specificity scores of 55.2% and 74.1% [AUC = 0.63 (0.54 ÷ 0.71)] , respectively. Human readers achieved an AUC value, in ROC analysis, of 0.71 (0.63 ÷ 0.79). The target-in-target method provided a detection rate per targeted biopsy core of 81.8 % vs. a detection rate per targeted biopsy core of 68.6 % for pure PI-RADS based on target definitions. The higher per-core detection rate of the target-in-target approach was achieved irrespective of the presence of technical flaws and artifacts. CONCLUSIONS: A novel consensus method combining human reader evaluation with automated CAD system analysis of mpMRI to define prostate biopsy targets was shown to improve the detection rate per biopsy core of TRUS-MRI fusion biopsies. Results suggest that the combination of CAD system analysis and human reader evaluation is a winning strategy to improve targeted biopsy efficiency.

Clinical Utility of Multiparametric Magnetic Resonance Imaging as the First-line Tool for Men with High Clinical Suspicion of Prostate Cancer.

BACKGROUND: Transrectal ultrasound-guided biopsy (TRUS-Bx) is recommended by the European Urology Association (EAU) as the first diagnostic modality for men at risk of prostate cancer (PCa). Current EAU guidelines reserve the use of multiparametric MRI to target or guide any repeat biopsy (mpMRI-Bx). It remains uncertain if TRUS-Bx is effective as a first strategy in terms of costs, diagnostic performance, time to diagnosis, and triage for individualised therapy. OBJECTIVE: To determine the diagnostic and treatment costs and the effectiveness of pathways incorporating mpMRI-Bx compared to TRUS-Bx in men at high risk of PCa. DESIGN, SETTING, AND PARTICIPANTS: A cost and time analysis was performed using data from a randomised single-centre study of 1140 patients (prostate-specific antigen >4ng/ml) divided into two groups: 570 patients underwent an initial TRUS-Bx and 570 underwent 3-T mpMRI-Bx. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Budget analyses were used to compare the diagnostic strategies using reimbursement data from the Italian National Health Security system. Analyses of reimbursable diagnostic and treatment costs were undertaken separately. Histologic outcomes, pathway diagnostic accuracy, therapy choices, and time to diagnosis were compared. RESULTS AND LIMITATIONS: The cumulative diagnosis costs were 14.6% greater for the mpMRI-Bx pathway than for the TRUS strategy, and 5.2-6.0% higher for therapy. Diagnostic costs were €228 946 for mpMRI-Bx and €199 750 for TRUS-Bx, and the corresponding therapy costs were €1 912 000 and €1 802 800. The mpMRI-Bx strategy was highly effective in excluding clinically significant disease (Gleason ≥7; sensitivity and negative predictive value both 100%, 95% confidence interval 98-100%). The time to diagnosis was significantly shorter for the mpMRI-Bx (median 4.0 mo interquartile range [IQR] 3-6) than for the TRUS-Bx strategy (median 6 mo, IQR 4-12; p<0.001). Limitations include the lack of data on costs associated with treatment-related complications and follow-up data. CONCLUSIONS: The mpMRI-Bx strategy is effective for diagnosing patients with a clinical suspicion of PCa and provides more accurate diagnosis, with combined diagnosis and therapy costs only moderately higher than for the standard strategy. PATIENT SUMMARY: It is a matter of debate whether a diagnostic pathway that incorporates multiparametric magnetic resonance imaging (MRI) as the first-line test before performing any type of biopsy in men suspected of having prostate cancer (PCa) is cost-effective. Our analysis of the costs for men suspected of harbouring PCa revealed higher diagnostic costs for the MRI approach, with the benefits of greater diagnostic accuracy. Moreover, the combined diagnostic and treatment costs are only modestly higher whenever the same treatment for all patients is considered.

Negative Multiparametric Magnetic Resonance Imaging for Prostate Cancer: What's Next?

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) of the prostate has excellent sensitivity in detecting clinically significant prostate cancer (csPCa). Nevertheless, the clinical utility of negative mpMRI (nMRI) is less clear. OBJECTIVE: To assess outcomes of men with nMRI and clinical follow-up after 7 yr of activity at a reference center. DESIGN, SETTING, AND PARTICIPANTS: All mpMRI performed from January 2010 to May 2015 were reviewed. We selected all patients with nMRI and divided them in group A (naïve patients) and group B (previous negative biopsy). All patients without a diagnosis of PCa had a minimum follow-up of 2 yr and at least two consecutive nMRI. Patients with positive mpMRI were also identified to assess their biopsy outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A Kaplan-Meier analysis was performed to assess both any-grade PCa and csPCa diagnosis-free survival probabilities. Univariable and multivariable Cox regression models were fitted to identify predictors of csPCa diagnosis. RESULTS AND LIMITATIONS: We identified 1545 men with nMRI, and 1255 of them satisfied the inclusion criteria; 659 belonged to group A and 596 to group B. Any-grade PCa and csPCa diagnosis-free survival probabilities after 2 yr of follow-up were 94% and 95%, respectively, in group A; in group B, they were 96%. After 48 mo of follow-up, any-grade PCa diagnosis-free survival probability was 84% in group A and 96% in group B (log rank p<0.001). Diagnosis-free survival probability for csPCa was unchanged after 48 mo of follow-up. On multivariable Cox regression analysis, increasing age (p=0.005) was an independent predictor of lower csPCa diagnosis probability, while increasing prostate-specific antigen (PSA) and PSA density (<0.001) independently predicted higher csPCa diagnosis probability. The prevalence of and positive predictive value for csPCa were 31.6% and 45.5%, respectively. Limitations include limited follow-up and the inability to calculate true csPCa prevalence in the study population. CONCLUSIONS: mpMRI is highly reliable to exclude csPCa. Nevertheless, systematic biopsy should be recommended even after nMRI, especially in younger patients with high or raising PSA levels. PATIENT SUMMARY: It is a matter of debate whether patients with negative multiparametric magnetic resonance imaging (mpMRI) of the prostate could obviate the need to perform a systematic biopsy. In this report, we looked at the outcomes of patients with negative mpMRI and midterm clinical follow-up at a reference center. We found mpMRI to be highly reliable to exclude significant prostate cancer; nonetheless, systematic biopsy must still be recommended after negative mpMRI in patients with high clinical suspicion of prostate cancer.

The role of 3 Tesla diffusion-weighted imaging in the differential diagnosis of benign versus malignant cervical lymph nodes in patients with head and neck squamous cell carcinoma.

OBJECTIVE: The aim of this study was to validate the role of diffusion-weighted imaging (DWI) at 3 Tesla in the differential diagnosis between benign and malignant laterocervical lymph nodes in patients with head and neck squamous cell carcinoma (HNSCC). MATERIALS AND METHODS: Before undergoing surgery, 80 patients, with biopsy proven HNSCC, underwent a magnetic resonance exam. Sensitivity (Se) and specificity (Spe) of conventional criteria and DWI in detecting laterocervical lymph node metastases were calculated. Histological results from neck dissection were used as standard of reference. RESULTS: In the 239 histologically proven metastatic lymphadenopathies, the mean apparent diffusion coefficient (ADC) value was 0.903 × 10(-3) mm(2)/sec. In the 412 pathologically confirmed benign lymph nodes, an average ADC value of 1.650 × 10(-3) mm(2)/sec was found. For differentiating between benign versus metastatic lymph nodes, DWI showed Se of 97% and Spe of 93%, whereas morphological criteria displayed Se of 61% and Spe of 98%. DWI showed an area under the ROC curve (AUC) of 0.964, while morphological criteria displayed an AUC of 0.715. CONCLUSIONS: In a DWI negative neck for malignant lymph nodes, the planned dissection could be converted to a wait-and-scan policy, whereas DWI positive neck would support the decision to perform a neck dissection.