Reliability of MR Enterography Features for Describing Fibrostenosing Crohn Disease.

Background Clinical decision making and drug development for fibrostenosing Crohn disease is constrained by a lack of imaging definitions, scoring conventions, and validated end points. Purpose To assess the reliability of MR enterography features to describe Crohn disease strictures and determine correlation with stricture severity. Materials and Methods A retrospective study of patients with symptomatic terminal ileal Crohn disease strictures who underwent MR enterography at tertiary care centers (Cleveland Clinic: September 2013 to November 2020; Mayo Clinic: February 2008 to March 2019) was conducted by using convenience sampling. In the development phase, blinded and trained radiologists independently evaluated 26 MR enterography features from baseline and follow-up examinations performed more than 6 months apart, with no bowel resection performed between examinations. Follow-up examinations closest to 12 months after baseline were selected. Reliability was assessed using the intraclass correlation coefficient (ICC). In the validation phase, after five features were redefined, reliability was re-estimated in an independent convenience sample using baseline examinations. Multivariable linear regression analysis identified features with at least moderate interrater reliability (ICC ≥0.41) that were independently associated with stricture severity. Results Ninety-nine (mean age, 40 years ± 14 [SD]; 50 male) patients were included in the development group and 51 (mean age, 45 years ± 16 [SD]; 35 female) patients were included in the validation group. In the development group, nine features had at least moderate interrater reliability. One additional feature demonstrated moderate reliability in the validation group. Stricture length (ICC = 0.85 [95% CI: 0.75, 0.91] and 0.91 [95% CI: 0.75, 0.96] in development and validation phase, respectively) and maximal associated small bowel dilation (ICC = 0.74 [95% CI: 0.63, 0.80] and 0.73 [95% CI: 0.58, 0.87] in development and validation group, respectively) had the highest interrater reliability. Stricture length, maximal stricture wall thickness, and maximal associated small bowel dilation were independently (regression coefficients, 0.09-3.97; P < .001) associated with stricture severity. Conclusion MR enterography definitions and scoring conventions for reliably assessing features of Crohn disease strictures were developed and validated, and feature correlation with stricture severity was determined. © RSNA, 2024 Supplemental material is available for this article. See also the article by Rieder and Ma et al in this issue. See also the editorial by Galgano and Summerlin in this issue.

Visceral adipose tissue volume effect in Crohn's disease using reduced exposure CT enterography.

PURPOSE: The purpose of this investigation was to assess the effect of visceral adipose tissue volume (VA) on reader efficacy in diagnosing and characterizing small bowel Crohn's disease using lower exposure CT enterography (CTE). Secondarily, we investigated the effect of lower exposure and VA on reader diagnostic confidence. METHODS: Prospective paired investigation of 256 CTE, 129 with Crohn's disease, were reconstructed at 100% and simulated 50% and 30% exposure. The senior author provided the disease classification for the 129 patients with Crohn's disease. Patient VA was measured, and exams were evaluated by six readers for presence or absence of Crohn's disease and phenotype using a 0-10-point scale. Logistic regression models assessed the effect of VA on sensitivity and specificity. RESULTS: The effect of VA on sensitivity was significantly reduced at 30% exposure (odds radio [OR]: 1.00) compared to 100% exposure (OR: 1.12) (p = 0.048). There was no statistically significant difference among the exposures with respect to the effect of visceral fat on specificity (p = 0.159). The study readers' probability of agreement with the senior author on disease classification was 60%, 56%, and 53% at 100%, 50%, and 30% exposure, respectively (p = 0.004). When detecting low severity Crohn's disease, readers' mean sensitivity was 83%, 75%, and 74% at 100%, 50%, and 30% exposure, respectively (p = 0.002). In low severity disease, sensitivity also tended to increase as visceral fat increased (ORs per 1000 cm3 increase in visceral fat: 1.32, 1.31, and 1.18, p = 0.010, 0.016, and 0.100, at 100%, 50%, and 30% exposure). CONCLUSIONS: While the interaction is complex, VA plays a role in detecting and characterizing small bowel Crohn's disease when exposure is altered, particularly in low severity disease.

Impact of Prostate Urethral Lift Device on Prostate Magnetic Resonance Image Quality.

PURPOSE: Prostatic urethral lift with UroLift is a minimally invasive approach to treat symptomatic benign prostatic hypertrophy. This device causes artifacts on prostate magnetic resonance images. Our aim was to evaluate the impact of artifact on prostate magnetic resonance image quality. MATERIALS AND METHODS: This was a single-center retrospective review of patients with UroLift who subsequently had prostate magnetic resonance imaging. Two readers graded UroLift artifact on each pulse sequence using a 5-point scale (1-nondiagnostic; 5-no artifact). Prostate Imaging Quality scores were assigned for the whole data set. The volume of gland obscured by artifact was measured. Linear and logistic regression models were used to identify predictors of poor image quality. RESULTS: Thirty-seven patients were included. Poor image quality occurs more in the transition zone than the peripheral zone (15% vs 3%), at base/mid regions vs the apex (13%, 9%, and 5%, respectively) and on diffusion-weighted images vs T2-weighted and dynamic contrast-enhanced sequences (27%, 0.3%, 0%, respectively; P < .001). Suboptimal image quality (ie, Prostate Imaging Quality score <2) was found in 16%-24% of exams. The percentage of gland obscured by the UroLift artifact was higher on diffusion-weighted images and dynamic contrast-enhanced sequences than T2-weighted (32%, 9%, and 6%, respectively; P < .001). CONCLUSIONS: UroLift artifact negatively affects prostate magnetic resonance image quality with greater impact in the mid-basal transition zone, obscuring a third of the gland on diffusion-weighted images. Patients considering this procedure should be counseled on the impact of this device on image quality and its potential implications for any image-guided prostate cancer workup.

A Phase IB/IIA Study of Ex Vivo Expanded Allogeneic Bone Marrow-Derived Mesenchymal Stem Cells for the Treatment of Perianal Fistulizing Crohn's Disease.

BACKGROUND: Mesenchymal stem cells have been used for the treatment of perianal Crohn's fistulizing disease by direct injection. However, no studies to date have included patients with proctitis, anal canal involvement, and multiple branching tracts. OBJECTIVE: This study aimed to determine safety and efficacy of mesenchymal stem cells for refractory perianal Crohn's disease. DESIGN: Phase IB/IIA randomized controlled trial. SETTINGS: Tertiary IBD referral center. PATIENTS: Adult Crohn's disease patients with perianal fistulizing disease. INTERVENTION: Seventy-five million mesenchymal stem cells were administered with a 22-G needle by direct injection after curettage and primary closure of the fistula tract. A repeat injection of 75 million mesenchymal stem cells at 3 months was given if complete clinical and radiographic healing were not achieved. MAIN OUTCOMES MEASURES: Adverse and serious adverse events occurred at postprocedure day 1, week 2, week 6, month 3, month 6, and month 12. Clinical healing, radiographic healing per MRI, and patient-reported outcomes were collected at the same time points. RESULTS: A total of 23 patients were enrolled and treated; 18 were treatment patients and 5 were control. There were no adverse or serious adverse events reported related to mesenchymal stem cell therapy. At 6 months, 83% of the treatment group and 40% of the control group had complete clinical and radiographic healing. The perianal Crohn's disease activity index, Wexner incontinence score, and VanAssche score had all significantly decreased in treatment patients at 6 months; none significantly decreased in the control group. LIMITATIONS: Single institution and single blinded. CONCLUSIONS: Bone marrow-derived mesenchymal stem cells offer a safe and effective alternative treatment approach for severe perianal fistulizing Crohn's disease. See Video Abstract at http://links.lww.com/DCR/C128 . UN ESTUDIO DE FASE IB/IIA DE CLULAS MADRE MESENQUIMALES DERIVADAS DE MDULA SEA ALOGNICA EXPANDIDA EX VIVO PARA EL TRATAMIENTO DE LA ENFERMEDAD DE CROHN FISTULIZANTE PERIANAL: ANTECEDENTES:Las células madre mesenquimales se han utilizado para el tratamiento de la enfermedad fistulizante de Crohn perianal mediante inyección dirigida. Sin embargo, ningún estudio hasta la fecha ha incluido pacientes con proctitis, afectación del canal anal y vías de ramificación múltiples.OBJETIVO:Determinar la seguridad y eficacia de las células madre mesenquimales para la enfermedad de Crohn perianal refractaria.DISEÑO:Ensayo de control aleatorizado de fase IB/IIA.AJUSTES:Centro de referencia de enfermedad inflamatoria intestinal terciaria.PACIENTES:Pacientes adultos con enfermedad de Crohn con enfermedad fistulizante perianal.INTERVENCIÓN:Se administraron 75 millones de células madre mesenquimales con una aguja 22G mediante inyección directa después del legrado y cierre primario del trayecto de la fístula. Se administró una inyección repetida de 75 millones de células madre mesenquimales a los 3 meses si no se lograba una curación clínica y radiográfica completa.PRINCIPALES MEDIDAS DE RESULTADOS:eventos adversos y adversos graves en el día 1, la semana 2, la semana 6, el mes 3, el mes 6 y el mes 12 después del procedimiento. Curación clínica, curación radiográfica por imagen de resonancia magnética y resultados informados por el paciente en los mismos puntos de tiempo.RESULTADOS:Un total de 23 pacientes fueron reclutados y tratados; 18 fueron de tratamiento y 5 de control. No se informaron eventos adversos o adversos graves relacionados con la terapia con células madre mesenquimales. A los seis meses, el 83 % del grupo de tratamiento y el 40 % del control tenían una curación clínica y radiográfica completa. El índice de actividad de la enfermedad de Crohn perianal, la puntuación de incontinencia de Wexner y la puntuación de VanAssche habían disminuido significativamente en los pacientes de tratamiento a los seis meses; ninguno disminuyó significativamente en el grupo de control.LIMITACIONES:Institución única y simple ciego.CONCLUSIONES:Las células madre mesenquimales derivadas de la médula ósea ofrecen un d tratamiento alternativo seguro y eficaz para la enfermedad de Crohn fistulizante perianal grave. Consulte Video Resumen en http://links.lww.com/DCR/C128 . (Traducción-Dr Yolanda Colorado ).

Standardization of MRI Screening and Reporting in Individuals With Elevated Risk of Pancreatic Ductal Adenocarcinoma: Consensus Statement of the PRECEDE Consortium.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignancies, with a dismal survival rate. Screening the general population for early detection of PDAC is not recommended, but because early detection improves survival, high-risk individuals, defined as those meeting criteria based on a family history of PDAC and/or the presence of known pathogenic germline variant genes with PDAC risk, are recommended to undergo screening with MRI and/or endoscopic ultrasound at regular intervals. The Pancreatic Cancer Early Detection (PRECEDE) Consortium was formed in 2018 and is composed of gastroenterologists, geneticists, pancreatic surgeons, radiologists, statisticians, and researchers from 40 sites in North America, Europe, and Asia. The overarching goal of the PRECEDE Consortium is to facilitate earlier diagnosis of PDAC for high-risk individuals to increase survival of the disease. A standardized MRI protocol and reporting template are needed to enhance the quality of screening examinations, improve consistency of clinical management, and facilitate multiinstitutional research. We present a consensus statement to standardize MRI screening and reporting for individuals with elevated risk of pancreatic cancer.

A phase IB/IIA study of remestemcel-L, an allogeneic bone marrow-derived mesenchymal stem cell product, for the treatment of medically refractory ulcerative colitis: an interim analysis.

AIM: There have been no studies into the direct injection of mesenchymal stem cells (MSCs) for luminal ulcerative colitis (UC). Our aim was to investigate the efficacy of MSCs delivered locally via endoscopic delivery, as is done in the setting of perianal disease, to treat the local site of inflammation directly. METHOD: A phase IB/IIA randomized control clinical trial of remestemcel-L, an ex vivo expanded allogeneic bone marrow-derived MSC product, at a dose of 150 million MSCs versus placebo (2:1 fashion) delivered via direct injection using a 23-gauge sclerotherapy needle at the time of colonoscopy was designed to assess the safety and efficacy of endoscopic delivery of MSCs for UC. The main outcome measures were adverse events, Mayo score and Mayo endoscopic severity score at 2 weeks, 6 weeks and 3 months post-MSC delivery. RESULTS: Six patients were enrolled and treated; four received MSCs and two placebo. All had been on prior anti-tumour necrosis factor or anti-integrin therapy. There were no adverse events related to MSCs. In the treatment group (n = 4), the Mayo endoscopic severity score decreased in all patients by 2 weeks after MSC delivery. At 3 months, all patients were extremely satisfied or satisfied with their MSC treatment based on the inflammatory bowel disease patient-reported treatment impact (IBD-PRTI), and treatment response was described as excellent or good in all patients. In the control group (n = 2), the Mayo endoscopic severity score did not increase as a result of being off alternative therapy. At 3 months, patients were dissatisfied according to the IBD-PRTI, and treatment response was poor or unchanged. CONCLUSION: MSCs may offer a safe therapeutic option for the treatment of medically refractory UC. Early data suggest improved clinical and endoscopic scores by 2 weeks after MSC delivery.

Reporting Templates for MRI and Water-Soluble Contrast Enema in Patients With Ileal Pouch-Anal Anastomosis: Experience From a Large Referral Center.

Ileal pouch-anal anastomosis (IPAA) surgery is the reference standard surgical procedure for treatment of ulcerative colitis and most patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of workup for pouch dysfunction. The purpose of this article is to propose structured reporting templates for MRI and water-soluble contrast enema (WSCE), based on our referral pouch center's experience, in patients who have undergone IPAA surgery. We review salient surgical technique, pouch anatomy, and imaging protocols, with an emphasis on a systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting templates for MRI and WSCE.

Novel Dual-Energy Computed Tomography Enterography Iodine Density Maps Provide Unique Depiction of Crohn Disease Activity.

OBJECTIVE: To create a map of iodine densities within affected segments of small-bowel Crohn disease (CD) derived from contrast-enhanced dual-energy computed tomography enterography (DECTE) studies. METHODS: Twenty CD patients imaged with intravenous contrast-enhanced DECTE between June 2016 and December 2017 were retrospectively identified. Ten patients without clinical evidence of CD and 8 normal-appearing jejunal segments in CD patients were controls. Using prototype software, 8 manual contours were drawn along the mucosa of affected segments. Relatively normal-appearing bowel was included at the edges. These contours served as a basis for iodine density calculation and 3-dimensional iodine density map rendering. Color-coded iodine densities allowed detection and quantification of the most and least dense portion of each segment and also permitted relative comparison between segments. RESULTS: The average iodine density per CD involved segment ranged 1.0 to 3.3 mg/mL, which differed significantly from normal ileum (P < 0.0001) and normal-appearing jejunum in patients with CD (P = 0.0009). Standard deviations ranged from 0.8 to 1.7 mg/mL, which differed significantly from normal ileum (P = 0.0039) and normal-appearing jejunum in patients with CD (P = 0.0056). The amplitude of the power spectrum ranged from 0.66 to 3.3 demonstrating patches of iodine rather than uniform distribution. This differed significantly from normal ileum (P = 0.0005) and normal-appearing jejunum in patients with CD (P = 0.0004). CONCLUSIONS: Heterogeneous CD activity and distribution can be displayed as iodine density maps created from DECTE.

Crohn's Disease Activity Quantified by Iodine Density Obtained From Dual-Energy Computed Tomography Enterography.

OBJECTIVE: The objective of this study was to assess if bowel wall iodine density obtained from dual-source, dual-energy computed tomography enterography (DECTE) could be a biomarker of Crohn's disease activity. METHODS: Twenty-two patients with Crohn's disease imaged with DECTE from February 2016 to May 2018 were retrospectively identified by departmental report search. Iodine maps were created with commercial software (Syngovia). Iodine content was normalized to the aorta, and then manual dual-energy region-of-interest cursors were placed over the visibly assessed maximal and minimal iodine density within segments of involved as well as unaffected small bowel. The mixed Hounsfield unit value, maximum iodine density (Imax), and minimum iodine density (Imin) were recorded. The length of affected bowel demonstrating maximum disease activity as a percentage of overall involvement was subjectively assessed. A weighted iodine density (Iweighted) was calculated. The clinical assessment of disease activity using erythrocyte sedimentation rate, C-reactive protein, fecal calprotectin, colonoscopy/endoscopy, and surgery, if available, served as the reference standard. The Crohn's disease activity index was also used as a separate additional reference standard. RESULTS: Significant heterogeneity within the affected segments was present. The average Imax and Imin of affected bowel was 4.27 ± 1.11 (2.4-7.4) mg/mL and 2.71 ± 0.51 (2.2-3.9) mg/mL, respectively. Iodine density of normal-appearing small bowel was 1.40 ± 0.26 (0.9-1.9) mg/mL. The Imax and Imin of affected bowel differed significantly from normal bowel (P < 0.0001). Mixed Hounsfield unit (101.82 ± 27.5) also statistically differed (46.33 ± 19.62) (P < 0.0001). Using overall clinical assessment as the reference standard, all patients with Imin of greater than 2.6 mg/mL, Iweighted of greater than 3.3 mg/mL, or Imax of greater than 4.7 mg/mL had clinically active disease. Sixteen of 17 patients with Imin of greater than 2.2 mg/mL and 14/15 with Iweighted of greater than 3 mg/mL had clinically active disease. Using Crohn's disease activity index as the reference standard, all patients with Imin of greater than 2.7 mg/mL, Iweighted of greater than 3.6 mg/mL, or Imax of greater than 5.4 mg/mL had clinically active disease. The median effective dose was 4.64 ± 1.68 mSv (range, 2.03-8.12 mSv). CONCLUSIONS: Iodine density obtained from DECTE highlights regions of maximal activity within affected bowel segments. An iodine density of 2 mg/mL appears to be a threshold between normal bowel segments and those with active Crohn's disease. Iodine density measurement thresholds Imin of greater than 2.6 mg/mL, Iweighted of greater than 3.3 mg/mL, and Imax of greater than 4.7 mg/mL correlate with established clinical markers of disease activity, with Imin seemingly most useful in daily clinical practice.

Exploratory Study of Apparent Diffusion Coefficient Histogram Metrics in Assessing Pancreatic Malignancy.

PURPOSE: To evaluate whole-lesion 3D-histogram apparent diffusion coefficient (ADC) metrics for assessment of pancreatic malignancy. METHODS: Forty-two pancreatic malignancies (36 pancreatic adenocarcinoma [PDAC], 6 pancreatic neuroendocrine [PanNET]) underwent abdominal magnetic resonance imaging (MRI) with diffusion-weighted imaging before endoscopic ultrasound biopsy or surgical resection. Two radiologists independently placed 3D volumes of interest to derive whole-lesion histogram ADC metrics. Mann-Whitney tests and receiver operating characteristic analyses were used to assess metrics' diagnostic performance for lesion histology, T-stage, N-stage, and grade. RESULTS: Whole-lesion ADC histogram metrics lower in PDACs than PanNETs for both readers (P ≤ .026) were mean ADC (area under the curve [AUC] = 0.787-0.792), mean of the bottom 10th percentile (mean0-10) (AUC = 0.787-0.880), mean of the 10th-25th percentile (mean10-25) (AUC = 0.884-0.917) and mean of the 25th-50th percentile (mean25-50) (AUC = 0.829-0.829). For mean10-25 (metric with highest AUC for identifying PDAC), for reader 1 a threshold > 0.94 × 10-3 mm2/s achieved sensitivity 94% and specificity 83%, and for reader 2 a threshold > 0.82 achieved sensitivity 97% and specificity 67%. Metrics lower in nodal status ≥ N1 than N0 for both readers (P ≤ .043) were mean0-10 (AUC = 0.789-0.822) and mean10-25 (AUC = 0.800-0.822). For mean10-25 (metric with highest AUC for identifying N0), for reader 1 a threshold <1.17 achieved sensitivity 87% and specificity 67%, and for reader 2 a threshold <1.04 achieved sensitivity 87% and specificity 83%. No metric was associated with T-stage (P > .195) or grade (P > .215). CONCLUSION: Volumetric ADC histogram metrics may serve as non-invasive biomarkers of pancreatic malignancy. Mean10-25 outperformed standard mean for lesion histology and nodal status, supporting the role of histogram analysis.

Apparent Diffusion Coefficient Values of Prostate Cancer: Comparison of 2D and 3D ROIs.

OBJECTIVE: The purpose of this study was to compare the reproducibility and diagnostic performance of 2D and 3D ROIs for prostate apparent diffusion coefficient (ADC) measurements. MATERIALS AND METHODS: The study included 56 patients with prostate cancer undergoing 3-T MRI including DWI (b = 50 and 1000 s/mm2) before radical prostatectomy. Histologic findings from prostatectomy specimens were reviewed to denote each patient's dominant tumor and a benign region with visually decreased ADC. Three readers independently measured the ADCs of both areas using an ROI placed on a single slice through the lesion (2D) and an ROI encompassing all slices through the lesion (3D). Readers repeated measurements after 3 weeks. Assessment included Bland-Altman analysis (coefficient of repeatability [CR] in which lower values indicated higher reliability) and ROC analysis. RESULTS: For intrareader variability, the CRs across readers for all ROIs were 9.9% for 2D and 9.3% for 3D. For tumor ROIs the CRs were 10.6% for 2D and 9.6% for 3D. For interreader variability, the CRs across readers for all ROIs were 17.1% for 2D and 20.5% for 3D and for tumor ROIs were 17.9% for 2D and 22.2% for 3D. For combined reader data, the AUCs for benign and malignant findings were 0.77 for 2D and 0.78 for 3D (p = 0.146). For differentiating Gleason score (GS) 3 + 3 from GS > 3 + 3 tumors, the AUCs were 0.92 for 2D and 0.92 for 3D ROIs (p = 0.649). For differentiating GS ≤ 3 + 4 from GS ≥ 4 + 3 tumors, the AUCs were 0.70 for 2D and 0.67 for 3D ROIs (p = 0.004). CONCLUSION: Use of a 3D ROI did not improve intrareader or interreader reproducibility or diagnostic performance compared with use of a 2D ROI for prostate ADC measurements. Interreader reproducibility of 2D ROIs was suboptimal nonetheless.

Proposed Adjustments to PI-RADS Version 2 Decision Rules: Impact on Prostate Cancer Detection.

Purpose To test the impact of existing Prostate Imaging Reporting and Data System (PI-RADS) version 2 (V2) decision rules, as well as of proposed adjustments to these decision rules, on detection of Gleason score (GS) 7 or greater (GS ≥7) prostate cancer. Materials and Methods Two radiologists independently provided PI-RADS V2 scores for the dominant lesion on 343 prostate magnetic resonance (MR) examinations. Diagnostic performance for GS ≥7 tumor was assessed by using MR imaging-ultrasonography fusion-targeted biopsy as the reference. The impact of existing PI-RADS V2 decision rules, as well as a series of exploratory proposed adjustments, on the frequency of GS ≥7 tumor detection, was evaluated. Results A total of 210 lesions were benign, 43 were GS 6, and 90 were GS ≥7. Lesions were GS ≥7 in 0%-4.1% of PI-RADS categories 1 and 2, 11.4%-27.1% of PI-RADS category 3, 44.4%-49.3% of PI-RADS category 4, and 72.1%-73.7% of PI-RADS category 5 lesions. PI-RADS category 4 or greater had sensitivity of 78.9%-87.8% and specificity of 75.5%-79.1 for detecting GS ≥7 tumor. The frequency of GS ≥7 tumor for existing PI-RADS V2 decision rules was 30.0%-33.3% in peripheral zone (PZ) lesions upgraded from category 3 to 4 based on dynamic contrast enhancement (DCE) score of positive; 50.0%-66.7% in transition zone (TZ) lesions upgraded from category 3 to 4 based on diffusion-weighted imaging (DWI) score of 5; and 71.7%-72.7% of lesions in both zones upgraded from category 4 to 5 based on size of 15 mm or greater. The frequency of GS ≥7 tumor for proposed adjustments to the decision rules was 30.0%-60.0% for TZ lesions upgraded from category 3 to 4 based on DWI score of 4; 33.3%-57.1% for TZ lesions upgraded from category 3 to 4 based on DCE score of positive when incorporating new criteria (unencapsulated sheetlike enhancement) for DCE score of positive in TZ; and 56.4%-61.9% for lesions in both zones upgraded from category 4 to 5 based on size of 10-14 mm. Other proposed adjustments yielded GS ≥7 tumor in less than 15% of cases for one or more readers. Conclusion Existing PI-RADS V2 decision rules exhibited reasonable performance in detecting GS ≥7 tumor. Several proposed adjustments to the criteria (in TZ, upgrading category 3 to 4 based on DWI score of 4 or modified DCE score of positive; in PZ or TZ, upgrading category 4 to 5 based on size of 10-14 mm) may also have value for this purpose. © RSNA, 2016 Online supplemental material is available for this article.

Dynamic contrast-enhanced MRI of the prostate: An intraindividual assessment of the effect of temporal resolution on qualitative detection and quantitative analysis of histopathologically proven prostate cancer.

PURPOSE: To assess the effects of temporal resolution (RT ) in dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) on qualitative tumor detection and quantitative pharmacokinetic parameters in prostate cancer. MATERIALS AND METHODS: This retrospective Institutional Review Board (IRB)-approved study included 58 men (64 ± 7 years). They underwent 3T prostate MRI showing dominant peripheral zone (PZ) tumors (24 with Gleason ≥ 4 + 3), prior to prostatectomy. Continuously acquired DCE utilizing GRASP (Golden-angle RAdial Sparse Parallel) was retrospectively reconstructed at RT of 1.4 sec, 3.7 sec, 6.0 sec, 9.7 sec, and 14.9 sec. A reader placed volumes-of-interest on dominant tumors and benign PZ, generating quantitative pharmacokinetic parameters (ktrans , ve ) at each RT . Two blinded readers assessed each RT for lesion presence, location, conspicuity, and reader confidence on a 5-point scale. Data were assessed by mixed-model analysis of variance (ANOVA), generalized estimating equation (GEE), and receiver operating characteristic (ROC) analysis. RESULTS: RT did not affect sensitivity (R1all : 69.0%-72.4%, all Padj = 1.000; R1GS≥4 + 3 : 83.3-91.7%, all Padj = 1.000; R2all : 60.3-69.0%, all Padj = 1.000; R2GS≥4 + 3 : 58.3%-79.2%, all Padj = 1.000). R1 reported greater conspicuity of GS ≥ 4 + 3 tumors at RT of 1.4 sec vs. 14.9 sec (4.29 ± 1.23 vs. 3.46 ± 1.44; Padj = 0.029). No other tumor conspicuity pairwise comparison reached significance (R1all : 2.98-3.43, all Padj ≥ 0.205; R2all : 2.57-3.19, all Padj ≥ 0.059; R1GS≥4 + 3 : 3.46-4.29, all other Padj ≥ 0.156; R2GS≥4 + 3 : 2.92-3.71, all Padj ≥ 0.439). There was no effect of RT on reader confidence (R1all : 3.17-3.34, all Padj = 1.000; R2all : 2.83-3.19, all Padj ≥ 0.801; R1GS≥4 + 3 : 3.79-4.21, all Padj = 1.000; R2GS≥4 + 3 : 3.13-3.79, all Padj = 1.000). ktrans and ve of tumor and benign tissue did not differ across RT (all adjusted P values [Padj ] = 1.000). RT did not significantly affect area under the curve (AUC) of Ktrans or ve for differentiating tumor from benign (all Padj = 1.000). CONCLUSION: Current PI-RADS recommendations for RT of 10 seconds may be sufficient, with further reduction to the stated PI-RADS preference of RT ≤ 7 seconds offering no benefit in tumor detection or quantitative analysis. LEVEL OF EVIDENCE: 3 J. MAGN. RESON. IMAGING 2017;45:1464-1475.

Reduced Field-of-View Diffusion-Weighted Magnetic Resonance Imaging of the Prostate at 3 Tesla: Comparison With Standard Echo-Planar Imaging Technique for Image Quality and Tumor Assessment.

OBJECTIVE: The purpose of this study was to compare image quality and tumor assessment at prostate magnetic resonance imaging (MRI) between reduced field-of-view diffusion-weighted imaging (rFOV-DWI) and standard DWI (st-DWI). METHODS: A total of 49 patients undergoing prostate MRI and MRI/ultrasound fusion-targeted biopsy were included. Examinations included st-DWI (field of view [FOV], 200 × 200 mm) and rFOV-DWI (FOV, 140 × 64 mm) using a 2-dimensional (2D) spatially-selective radiofrequency pulse and parallel transmission. Two readers performed qualitative assessments; a third reader performed quantitative evaluation. RESULTS: Overall image quality, anatomic distortion, visualization of capsule, and visualization of peripheral/transition zone edge were better for rFOV-DWI for reader 1 (P ≤ 0.002), although not for reader 2 (P ≥ 0.567). For both readers, sensitivity, specificity, and accuracy for tumor with a Gleason Score (GS) of 3 + 4 or higher were not different (P ≥ 0.289). Lesion clarity was higher for st-DWI for reader 2 (P = 0.008), although similar for reader 1 (P = 0.409). Diagnostic confidence was not different for either reader (P ≥ 0.052). Tumor-to-benign apparent diffusion coefficient ratio was not different (P = 0.675). CONCLUSIONS: Potentially improved image quality of rFOV-DWI did not yield improved tumor assessment. Continued optimization is warranted.

Optimizing Safety of Iliac Bone Harvest Using an Acumed Drill: A Simulated Radiographic Study of 100 Patients.

OBJECTIVE: To determine the potential risk of visceral injury during Acumed drill iliac crest cancellous bone graft harvest. DESIGN: Radiographic iliac crest anatomic analysis with simulated drill course to measure cancellous bone available for harvest and proximity of vulnerable pelvic structures. SETTING: Single institution, tertiary care university hospital. PATIENTS AND PARTICIPANTS: One hundred pelvic computed tomography scans performed on children 8 to 12 years old without traumatic or neoplastic pathology. INTERVENTIONS: Radiographic simulation of Acumed drill course within iliac bone. MAIN OUTCOME MEASURES: (1) Potential for pelvic visceral injury. (2) Volume of cancellous bone safely available for harvest. RESULTS: Superior and medial cortical thickness at the reference point remained stable across age groups; however, lateral cortical thickness increased with age (3.13 to 3.74 mm, P < .001). Cancellous bone width increased with age at all depths measured (P < .001). Through radiographic simulation, the drill could reach the bowel in 4% of cases and only through gross deviation (>30°) from the plane of the ilium. There were no cases of simulated bowel perforation within 3 cm of the reference point. The maximum cancellous volume safely harvested increased with age: 24 cc in 8-year-olds to 36 cc in 12-year-olds (P < .001). CONCLUSIONS: Acumed assisted iliac crest bone graft harvest is a safe technique in which substantial amount of cancellous bone can be obtained. The low risk of bowel perforation can be further minimized by limiting the depth of drill bit penetration to less than 3 cm.

Likert score 3 prostate lesions: Association between whole-lesion ADC metrics and pathologic findings at MRI/ultrasound fusion targeted biopsy.

BACKGROUND: To assess associations between whole-lesion apparent diffusion coefficient (ADC) metrics and pathologic findings of Likert score 3 prostate lesions at MRI/ultrasound fusion targeted biopsy. METHODS: This retrospective Institutional Review Board-approved study received a waiver of consent. We identified patients receiving a highest lesion score of 3 on 3 Tesla multiparametric MRI reviewed by a single experienced radiologist using a 5-point Likert scale and who underwent fusion biopsy. A total of 188 score 3 lesions in 158 patients were included. Three-dimensional volumes-of-interest encompassing each lesion were traced on ADC maps. Logistic regression was used to predict biopsy results based on whole-lesion ADC metrics and patient biopsy history. Biopsy yield was compared between metrics. RESULTS: By lesion, targeted biopsy identified tumor in 22.3% and Gleason score (GS) > 6 tumor in 8.5%, although results varied by biopsy history: biopsy-naïve (n = 80), 20.0%/8.8%; prior negative biopsy (n = 53), 9.4%/1.9%; prior positive biopsy (n = 55): 40.0%/14.5%. Biopsy history, whole-lesion mean ADC, whole-lesion ADC10-25 , and whole-lesion ADC25-50 were each significantly associated with tumor or GS > 6 tumor at fusion biopsy (P ≤ 0.047). In men without prior negative prostate biopsy, whole-lesion ADC25-50 ≤ 1.04*10(-3) mm2 /s achieved 90.0% sensitivity and 50.0% specificity for GS > 6 tumor, which was significantly higher (P < 0.001) than specificity of PSA (17.5%) at identical sensitivity. CONCLUSION: For score 3 lesions in patients without prior negative biopsy, whole-lesion ADC metrics help detect GS > 6 cancer while avoiding negative biopsies. However, deferral of fusion biopsy may be considered for score 3 lesions in patients with prior negative biopsy (without applying whole-lesion ADC metrics) given exceedingly low (∼ 2%) frequency of GS > 6 tumor in this group.

Use of MRI in Differentiation of Papillary Renal Cell Carcinoma Subtypes: Qualitative and Quantitative Analysis.

OBJECTIVE: The purpose of this study was to determine whether qualitative and quantitative MRI feature analysis is useful for differentiating type 1 from type 2 papillary renal cell carcinoma (PRCC). MATERIALS AND METHODS: This retrospective study included 21 type 1 and 17 type 2 PRCCs evaluated with preoperative MRI. Two radiologists independently evaluated various qualitative features, including signal intensity, heterogeneity, and margin. For the quantitative analysis, a radiology fellow and a medical student independently drew 3D volumes of interest over the entire tumor on T2-weighted HASTE images, apparent diffusion coefficient parametric maps, and nephrographic phase contrast-enhanced MR images to derive first-order texture metrics. Qualitative and quantitative features were compared between the groups. RESULTS: For both readers, qualitative features with greater frequency in type 2 PRCC included heterogeneous enhancement, indistinct margin, and T2 heterogeneity (all, p < 0.035). Indistinct margins and heterogeneous enhancement were independent predictors (AUC, 0.822). Quantitative analysis revealed that apparent diffusion coefficient, HASTE, and contrast-enhanced entropy were greater in type 2 PRCC (p < 0.05; AUC, 0.682-0.716). A combined quantitative and qualitative model had an AUC of 0.859. Qualitative features within the model had interreader concordance of 84-95%, and the quantitative data had intraclass coefficients of 0.873-0.961. CONCLUSION: Qualitative and quantitative features can help discriminate between type 1 and type 2 PRCC. Quantitative analysis may capture useful information that complements the qualitative appearance while benefiting from high interobserver agreement.

Aberrant Lower Extremity Arterial Anatomy in Microvascular Free Fibula Flap Candidates: Management Algorithm and Case Presentations.

An accurate and comprehensive understanding of lower extremity arterial anatomy is essential for the successful harvest and transfer of a free fibula osteoseptocutaneous flap (FFF). Minimum preoperative evaluation includes detailed history and physical including lower extremity pulse examination. Controversy exists regarding whether preoperative angiographic imaging should be performed for all patients. Elevation of an FFF necessitates division of the peroneal artery in the proximal lower leg and eradicates its downstream flow. For patients in whom the peroneal artery comprises the dominant arterial supply to the foot, FFF elevation is contraindicated. Detailed preoperative knowledge of patient-specific lower extremity arterial anatomy can help to avoid ischemia or limb loss resulting from FFF harvest. If preoperative angiographic imaging is omitted, careful attention must be paid to intraoperative anatomy. Should pedal perfusion rely on the peroneal artery, reconstructive options other than an FFF must be pursued. Given the complexity of surgical decision making, the authors propose an algorithm to guide the surgeon from the preoperative evaluation of the potential free fibula flap patient to the final execution of the surgical plan. The authors also provide 3 clinical patients in whom aberrant lower extremity anatomy was encountered and describe each patient's surgical course.

Dynamic contrast-enhanced MRI of the prostate with high spatiotemporal resolution using compressed sensing, parallel imaging, and continuous golden-angle radial sampling: preliminary experience.

PURPOSE: To demonstrate dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) of the prostate with both high spatial and temporal resolution via a combination of golden-angle radial k-space sampling, compressed sensing, and parallel-imaging reconstruction (GRASP), and to compare image quality and lesion depiction between GRASP and conventional DCE in prostate cancer patients. MATERIALS AND METHODS: Twenty prostate cancer patients underwent two 3T prostate MRI examinations on separate dates, one using standard DCE (spatial resolution 3.0 × 1.9 × 1.9 mm, temporal resolution 5.5 sec) and the other using GRASP (spatial resolution 3.0 × 1.1 × 1.1 mm, temporal resolution 2.3 sec). Two radiologists assessed measures of image quality and dominant lesion size. The experienced reader recorded differences in contrast arrival times between the dominant lesion and benign prostate. RESULTS: Compared with standard DCE, GRASP demonstrated significantly better clarity of the capsule, peripheral/transition zone boundary, urethra, and periprostatic vessels; image sharpness; and lesion conspicuity for both readers (P < 0.001-0.020). GRASP showed improved interreader correlation for lesion size (GRASP: r = 0.691-0.824, standard: r = 0.495-0.542). In 8/20 cases, only GRASP showed earlier contrast arrival in tumor than benign; in no case did only standard DCE show earlier contrast arrival in tumor. CONCLUSION: High spatiotemporal resolution prostate DCE is possible with GRASP, which has the potential to improve image quality and lesion depiction as compared with standard DCE.