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The Vesical Imaging-Reporting and Data System (VI-RADS) has been introduced to provide preoperative bladder cancer staging and has proved to be reliable in assessing the presence of muscle invasion in the pre-TURBT (trans-urethral resection of bladder tumor). We aimed to assess through a systematic review and meta-analysis the inter-reader variability of VI-RADS criteria for discriminating non-muscle vs. muscle invasive bladder cancer (NMIBC, MIBC). PubMed, Web of Science, Cochrane, and Embase were searched up until 30 July 2020. The Quality Appraisal of Diagnostic Reliability (QAREL) checklist was utilized to assess the quality of included studies and a pooled measure of inter-rater reliability (Cohen&rsquo, s Kappa [&kappa, ] and/or Intraclass correlation coefficients (ICCs)) was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate the contribution of moderators to heterogeneity. In total, eight studies between 2018 and 2020, which evaluated a total of 1016 patients via 21 interpreting genitourinary (GU) radiologists, met inclusion criteria and were critically examined. No study was considered to be significantly flawed with publication bias. The pooled weighted mean &kappa, estimate was 0.83 (95%CI: 0.78&ndash, 0.88). Heterogeneity was present among the studies (Q = 185.92, d.f. = 7, p &lt, 0.001, I2 = 92.7%). Meta-regression analyses showed that the relative % of MIBC diagnosis and cumulative reader&rsquo, s experience to influence the estimated outcome (Coeff: 0.019, SE: 0.007, p= 0.003 and 0.036, SE: 0.009, p = 0.001). In the present study, we confirm excellent pooled inter-reader agreement of VI-RADS to discriminate NMIBC from MIBC underlying the importance that standardization and reproducibility of VI-RADS may confer to multiparametric magnetic resonance (mpMRI) for preoperative BCa staging.

440 Background: Neoadjuvant chemotherapy (NAC) has proven survival benefits for invasive urothelial carcinoma of the bladder, yet its role in upper tract urothelial carcinoma (UTUC) remains undefined. We conducted a phase II multicenter trial of NAC with gemcitabine and cisplatin (GC) in patients with high-risk UTUC prior to extirpative surgery to evaluate major outcomes of response, survival, and tolerability. Methods: Eligible patients with defined criteria for high-risk localized UTUC received four cycles of GC prior to surgical resection and lymph node dissection. The primary study endpoint was pathologic response rate (defined as < pT2N0). Patients with progressive disease prior or unable to proceed to surgery were considered treatment failures. Secondary endpoints included time to disease progression (PFS), overall survival (OS), and safety and tolerability. Results: Among 57 patients evaluated, 36 (63%) demonstrated pathologic response, meeting the primary endpoint of the study. A complete response was noted in 11 patients (19%), defined as pT0N0. Forty patients (70%) tolerated all four cycles of GC, and all patients proceeded to surgery. The 90-day ≥ grade 3 surgical complication rate was 7.0%. With a median follow up of 42.3 months among survivors, six patients succumbed to disease. Two and five-year PFS were 76% (95% CI 66, 89) and 61% (95% CI 47, 78). Two and five-year OS were 93% (95% CI 86, 100) and 79% (95% CI 67, 94). Patients demonstrating pathologic response had improved PFS and OS compared to those who did not (two-year PFS 91% vs 52%, log-rank p < 0.001, two-year OS 100% vs 80%, log-rank p < 0.001). Conclusions: NAC for high-risk UTUC demonstrates outcomes of favorable pathologic response, is well tolerated requiring minimal delay to surgery without significant perioperative complication risk, and thus should be considered a new standard of care option for patients with high-risk UTUC. Better survival outcomes in patients with favorable pathologic features after NAC indicate a potential clinical benefit to this approach. Clinical trial information: NCT01261728.

MRI is used in the evaluation of ovarian and adnexal lesions. MRI can further characterize lesions seen on ultrasound to help decrease the number of false-positive lesions and avoid unnecessary surgery in benign lesions. Currently, the reporting of ovarian and adnexal findings on MRI is inconsistent due to the lack of standardized descriptor terminology. The development of uniform reporting descriptors can lead to improved interpretation agreement and communication between radiologists and referring physicians. The Ovarian-Adnexal Reporting and Data Systems MRI Committee was formed under the direction of the ACR to create a standardized lexicon for adnexal lesions with the goal of improving the quality and consistency of imaging reports. This white paper describes the consensus process in the creation of a standardized lexicon for ovarian and adnexal lesions for MRI and the resultant lexicon.

New biomarkers for metastatic prostate cancer are needed. The aim of this study was to evaluate the prognostic value of (18)F-FDG PET whole-body tumor burden parameters in patients with metastatic prostate cancer who received first-line abiraterone or enzalutamide therapy. Methods: This was a retrospective study of patients with metastatic castration-sensitive prostate cancer (mCSPC, n = 25) and metastatic castration-resistant prostate cancer (mCRPC, n = 71) who underwent (18)F-FDG PET/CT within 90 d before first-line treatment with abiraterone or enzalutamide at a tertiary-care academic cancer center. Whole-body tumor burden on PET/CT was quantified as metabolic tumor volume (MTV) and total lesion glycolysis (TLG) and correlated with overall survival (OS) probabilities using Kaplan–Meier curves and Cox models. Results: The median follow-up in survivors was 56.3 mo (interquartile range, 37.7–66.8 mo); the median OSs for patients with mCRPC and mCSPC were 27.8 and 76.1 mo, respectively (P < 0.001). On univariate analysis, the OS probability of mCRPC patients was significantly associated with plasma levels of alkaline phosphatase (hazard ratio [HR], 1.90; P < 0.001), plasma levels of lactate dehydrogenase (HR, 1.01; P < 0.001), hemoglobin levels (HR, 0.80; P = 0.013), whole-body SUV(max) (HR, 1.14; P < 0.001), the number of (18)F-FDG–avid metastases (HR, 1.08; P < 0.001), whole-body metabolic tumor volume (HR, 1.86; P < 0.001), and TLG (HR, 1.84; P < 0.001). On multivariable analysis with stepwise variable selection, hemoglobin levels (HR, 0.81; P = 0.013) and whole-body TLG (HR, 1.88; P < 0.001) were independently associated with OS. In mCSPC patients, no significant association was observed between these variables and OS. Conclusion: In patients with mCRPC receiving first-line treatment with abiraterone or enzalutamide, (18)F-FDG PET WB TLG is independently associated with OS and might be used as a quantitative prognostic imaging biomarker.

Purpose Prostate-specific membrane antigen positron emission tomography (PSMA-PET) has shown promise for detecting nodal and distant prostate cancer (PCa) metastases. However, its performance for local tumor staging is not as well established. The purpose of this study was to review the diagnostic performance of PSMA-PET for determining seminal vesical invasion (SVI) and extraprostatic extension (EPE). Methods Pubmed and Embase databases were searched until January 12, 2020. Studies assessing accuracy of PSMA-PET in determining SVI and EPE were included. Study quality was evaluated with the revised Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled sensitivity and specificity were calculated using hierarchical summary receiver operating characteristics modeling. Heterogeneity was explored using meta-regression analyses for anatomical imaging component (MRI vs CT) and by testing for a threshold effect. Results Twelve studies (615 patients) were included. Pooled sensitivity and specificity were 0.68 (95% CI 0.53-0.81) and 0.94 (95% CI 0.90-0.96) for SVI and 0.72 (95% CI 0.56-0.84) and 0.87 (95% CI 0.72-0.94) for EPE. Meta-regression analyses showed that for SVI, PET/MRI demonstrated greater sensitivity than PET/CT (0.87 [95% CI 0.75-0.98] vs 0.60 [95% CI 0.47-0.74]; p = 0.02 for joint model) while specificity was comparable (0.91 [95% CI 0.84-0.97] vs. 0.96 [95% CI 0.93-0.99]) but not for EPE (p = 0.08). A threshold effect was present for studies assessing EPE (correlation coefficient = 0.563 [95% CI, −0.234-0.908] between sensitivity and false-positive rate). Conclusion PSMA-PET has moderate sensitivity and excellent specificity for assessing local tumor extent in patients with PCa. PET/MRI showed potential for greater sensitivity than PET/CT in assessing SVI.

Our objective was to evaluate the impact of (18)F-FDG PET CT on the management of urachal adenocarcinoma (UrC-ADC). Methods: A retrospective analysis of patients with UrC-ADC from 2001 to 2019 at Memorial Sloan Kettering was performed. Mayo stage before (18)F-FDG PET/CT, rate of detection of the primary malignancy and metastases on (18)F-FDG PET/CT, Mayo stage after (18)F-FDG PET/CT, and change in patient management were determined. Results: Of 21 patients with UrC-ADC before (18)F-FDG PET/CT, Mayo staging was I/II in 8, III in 3, and IV in 10. (18)F-FDG PET/CT detected previously unidentified metastases in 8 (38%) of 21 patients, resulting in upstaging of disease in 3 (14%) patients and a change in treatment in 4 (19%) patients. Conclusion: (18)F-FDG PET/CT has clinical utility in patients with UrC-ADC by identifying metastatic disease not appreciated on anatomic imaging, leading to changes in staging and patient management.

For clinically significant, locally confined prostate cancer, whole-gland radical prostatectomy and radiotherapy are established effective treatment strategies that, however, come at a cost of significant morbidity related to urinary and sexual side effects. The concept of risk stratification paired with a better understanding of prognostic factors has led to the development of alternative management options including active surveillance and focal therapy for appropriately selected patients with localized disease. High-intensity focused ultrasound (HIFU) is one such minimally invasive, image-guided treatment option for prostate cancer. Due to the relative novelty of HIFU and the increased use of magnetic resonance imaging in prostate cancer, many radiologists are not yet familiar with imaging findings related to HIFU, their temporal evolution as well as imaging appearance of recurrent disease after this type of focal therapy. HIFU induces sharply demarcated, localized coagulative necrosis of a tumor through thermal energy delivered via an endorectal or transurethral ultrasound transducer. In this pictorial review, we aim at providing relevant background information that will guide the reader through the general principles of HIFU in the prostate, as well as demonstrate the imaging appearance of expected post-HIFU changes versus recurrent tumor.

Visual Abstract, With the successful development and increased use of targeted radionuclide therapy for treating cancer comes the increased risk of radiation injury to bone marrow—both direct suppression and stochastic effects, leading to neoplasia. Herein, we report a novel radioprotector drug, a liposomal formulation of γ-tocotrienol (GT3), or GT3-Nano for short, to mitigate bone marrow radiation damage during targeted radionuclide therapy. Methods: GT3 was loaded into liposomes using passive loading. 64Cu-GT3-Nano and 3H-GT3-Nano were synthesized to study the in vivo biodistribution profile of the liposome and GT3 individually. The radioprotection efficacy of GT3-Nano was assessed after acute 137Cs whole-body irradiation at a sublethal (4 Gy), a lethal (9 Gy), or a single high-dose administration of 153Sm-ethylenediamine-N,N,N′,N′-tetrakis(methylene phosphonic acid) (EDTMP). Flow cytometry and fluorescence microscopy were used to analyze hematopoietic cell population dynamics and the cellular site of GT3-Nano localization in the spleen and bone marrow, respectively. Results: Bone marrow uptake and retention (percentage injected dose per gram of tissue) at 24 h was 6.98 ± 2.34 for 64Cu-GT3-Nano and 7.44 ± 2.52 for 3H-GT3-Nano. GT3-Nano administered 24 h before or after 4 Gy of total-body irradiation (TBI) promoted rapid and complete hematopoietic recovery, whereas recovery of controls stalled at 60%. GT3-Nano demonstrated dose-dependent radioprotection, achieving 90% survival at 50 mg/kg against lethal 9-Gy TBI. Flow cytometry of the bone marrow indicated that progenitor bone marrow cells MPP2 and CMP were upregulated in GT3-Nano–treated mice. Immunohistochemistry showed that GT3-Nano accumulates in CD105-positive sinusoid epithelial cells. Conclusion: GT3-Nano is highly effective in mitigating the marrow-suppressive effects of sublethal and lethal TBI in mice. GT3-Nano can facilitate rapid recovery of hematopoietic components in mice treated with the endoradiotherapeutic agent 153Sm-EDTMP.

Objectives To investigate the association between CT imaging traits and texture metrics with proteomic data in patients with high-grade serous ovarian cancer (HGSOC). Methods This retrospective, hypothesis-generating study included 20 patients with HGSOC prior to primary cytoreductive surgery. Two readers independently assessed the contrast-enhanced computed tomography (CT) images and extracted 33 imaging traits, with a third reader adjudicating in the event of a disagreement. In addition, all sites of suspected HGSOC were manually segmented texture features which were computed from each tumor site. Three texture features that represented intra- and inter-site tumor heterogeneity were used for analysis. An integrated analysis of transcriptomic and proteomic data identified proteins with conserved expression between primary tumor sites and metastasis. Correlations between protein abundance and various CT imaging traits and texture features were assessed using the Kendall tau rank correlation coefficient and the Mann-Whitney U test, whereas the area under the receiver operating characteristic curve (AUC) was reported as a metric of the strength and the direction of the association. P values Results Four proteins were associated with CT-based imaging traits, with the strongest correlation observed between the CRIP2 protein and disease in the mesentery (p p = 0.047, τ = 0.326). Conclusion This study provides the first insights into the potential associations between standard-of-care CT imaging traits and texture measures of intra- and inter-site heterogeneity, and the abundance of several proteins. Key Points • CT-based texture features of intra- and inter-site tumor heterogeneity correlate with the abundance of several proteins in patients with HGSOC. • CT imaging traits correlate with protein abundance in patients with HGSOC.

To review the diagnostic performance of contemporary imaging modalities for determining local disease extent and nodal metastasis in patients with newly diagnosed cervical cancer. Pubmed and Embase databases were searched for studies published from 2000 to 2019 that used ultrasound (US), CT, MRI, and/or PET for evaluating various aspects of local extent and nodal metastasis in patients with newly diagnosed cervical cancer. Sensitivities and specificities from the studies were meta-analytically pooled using bivariate and hierarchical modeling. Of 1311 studies identified in the search, 115 studies with 13,999 patients were included. MRI was the most extensively studied modality (MRI, CT, US, and PET were evaluated in 78, 12, 9, and 43 studies, respectively). Pooled sensitivities and specificities of MRI for assessing all aspects of local extent ranged between 0.71–0.88 and 0.86–0.95, respectively. In assessing parametrial invasion (PMI), US demonstrated pooled sensitivity and specificity of 0.67 and 0.94, respectively—performance levels comparable with those found for MRI. MRI, CT, and PET performed comparably for assessing nodal metastasis, with low sensitivity (0.29–0.69) but high specificity (0.88–0.98), even when stratified to anatomical location (pelvic or paraaortic) and level of analysis (per patient vs. per site). MRI is the method of choice for assessing any aspect of local extent, but where not available, US could be of value, particularly for assessing PMI. CT, MRI, and PET all have high specificity but poor sensitivity for the detection of lymph node metastases. • Magnetic resonance imaging is the method of choice for assessing local extent. • Ultrasound may be helpful in determining parametrial invasion, especially in lower-resourced countries. • Computed tomography, magnetic resonance imaging, and positron emission tomography perform similarly for assessing lymph node metastasis, with high specificity but low sensitivity.

Accurate staging of bladder cancer (BC) is critical, with local tumor staging directly influencing management decisions and affecting prognosis. However, clinical staging based on clinical examination, including cystoscopy and transurethral resection of bladder tumor (TURBT), often understages patients compared to final pathology at radical cystectomy and lymph node (LN) dissection, mainly due to underestimation of the depth of local invasion and the presence of LN metastasis. MRI has now become established as the modality of choice for the local staging of BC and can be additionally utilized for the assessment of regional LN involvement and tumor spread to the pelvic bones and upper urinary tract (UUT). The recent development of the Vesical Imaging-Reporting and Data System (VI-RADS) recommendations has led to further improvements in bladder MRI, enabling standardization of image acquisition and reporting. Multiparametric magnetic resonance imaging (mpMRI) incorporating morphological and functional imaging has been proven to further improve the accuracy of primary and recurrent tumor detection and local staging, and has shown promise in predicting tumor aggressiveness and monitoring response to therapy. These sequences can also be utilized to perform radiomics, which has shown encouraging initial results in predicting BC grade and local stage. In this article, the current state of evidence supporting MRI in local, regional, and distant staging in patients with BC is reviewed. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:649-667.

PURPOSE: To study the risk of metastatic prostate cancer development in men with Grade Group 2 disease being managed with active surveillance (AS) at Memorial Sloan Kettering Cancer Center. MATERIALS AND METHODS: 219 men with Grade Group 2 prostate cancer were managed with AS between 2000–2017. Biopsy was performed every 2–3 years or upon changes in magnetic resonance imaging, prostate-specific antigen (PSA) level, or digital rectal examination. The primary outcome was development of distant metastasis. The Kaplan-Meier method was used to estimate treatment-free survival. RESULTS: The median age at diagnosis was 67 years (IQR 61, 72), the median PSA was 5 ng/mL (IQR 4, 7), and most patients (69%) had non-palpable disease. During follow-up, 64 men received treatment: 36/64 (56%) radical prostatectomy; 20/64 (31%) radiotherapy; 3/64 (5%) hormone therapy; and 5/64 (8%) focal therapy. Of the 36 patients who underwent radical prostatectomy, 32/36 (89%) had Grade Group 2 disease on pathology and 4/36 (11%) had Grade Group 3. Treatment-free survival was 61% (95% CI 52%–70%) at 5 years and 49% (95% CI 37%–60%) at 10 years. Three men experienced biochemical recurrence, no men developed distant metastasis, and no men died of prostate cancer during the follow-up. The median follow-up was 3.1 years (IQR 1.9, 4.9). CONCLUSIONS: AS appears to be a safe initial management strategy in the short term for carefully selected and closely monitored men with Grade Group 2 prostate cancer managed at a tertiary cancer center. Definitive conclusions await further follow-up.

The question referred to in the title of this article is a relatively common situation when performing prostate MRI in some healthcare settings. Moreover, the answer is not always straightforward. The decisions on type of receiver coil for prostate MRI and whether or not an endorectal coil (ERC) should be used is based on several factors. These relate to the patient (e.g., body habitus, presence of metallic devices in the pelvis), the focus of the exam (diagnosis, staging, recurrence), and characteristics of the MRI system (e.g., magnetic field strength and hardware components including coil design and number of elements/channels available in the surface coil). Historically, the combined use of an ERC and a surface coil was the optimal combination for maximizing the signal-to-noise ratio (SNR), particularly for low-strength magnetic fields (1.5T). However, there are several disadvantages associated with the use of an ERC, and several studies have advocated equivalent clinical performance of modern MRI systems for diagnosis and staging of prostate cancer (PCa), either with ERC or surface alone. Accordingly, there is a wide variation in the precise imaging technique across institutions. This article focuses on the most relevant aspects of the decision of whether to use an ERC for PCa MR imaging.

OBJECTIVE. The purpose of this article is to review the natural history and management of bladder cancer, with insight into MRI applications for the assessment of muscle invasiveness of bladder cancer using the newly developed Vesical Imaging Reporting and Data System (VI-RADS) score. CONCLUSION. Multiparametric MRI and the VI-RADS score have been consistently validated across several different institutions as appropriate tools for local staging of bladder cancer and have been proven to contribute to the diagnostic workup and management of urinary bladder cancer.

Objective To report a case of pelvic angiosarcoma in a 27-year-old man with Li-Fraumeni Syndrome (LFS) and evaluate the presentation and timeline of genitourinary (GU) tract involvement in LFS patients. Methods We retrospectively identified 39 LFS patients treated at our institution between 2000 and 2014; 7 (18%) had experienced a GU malignancy or an LFS-related malignancy involving the GU tract. Clinical characteristics, including dates of onset of first GU tract malignancies; pathologic findings; multimodal management; and familial history of LFS were reviewed. Results Median age at first malignancy was 14.0 years (interquartile range [IQR] 5.5-24.0). There was a slight male predominance (4 of 7). Median time between first malignancy and the malignancy involving the GU tract was 10.1 years (IQR 8.0-19.5). Six of the 7 patients (86%) had a form of sarcoma involving the GU tract; 1 developed adrenocortical carcinoma. The cancer pedigree of all patients showed LFS-associated malignancies in family members. Multimodal management included surgical resection in 6 patients with adjuvant chemotherapy or radiotherapy in 1 patient each. One patient received chemotherapy only. Following diagnosis of malignancy involving the GU tract, 5 of the 7 patients developed additional primary malignancies. At a median follow-up of 4.7 years (IQR 3.0-12.1), 2 patients are alive, 3 died of disease, and 1 died of unknown cause. One patient was lost at follow-up. Conclusion Continued follow-up of LFS cancer patients aimed at the determination of optimal screening, management, and surveillance protocols is recommended and may result in longer survival expectations.

Context A noninvasive multiparametric magnetic resonance imaging (MRI)-based scoring system for predicting muscle-invasive bladder cancer (MIBC), the “Vesical Imaging Reporting and Data System” (VI-RADS), was recently developed by an international multidisciplinary panel. Since then, a few studies evaluating the value of VI-RADS for predicting MIBC have been published. Objective To review the diagnostic performance of VI-RADS for the prediction of MIBC. Evidence acquisition PubMed and EMBASE databases were searched up to November 10, 2019. We included diagnostic accuracy studies using VI-RADS to predict MIBC using cystectomy or transurethral resection as the reference standard. Methodological quality was evaluated with Quality Assessment of Diagnostic Accuracy Studies-2. Sensitivity and specificity were pooled and plotted using hierarchical summary receiver operating characteristics (HSROC) modeling. Meta-regression analyses were done to explore heterogeneity. Evidence synthesis Six studies (1770 patients) were included. Pooled sensitivity and specificity were 0.83 (95% confidence interval [CI] 0.70–0.90) and 0.90 (95% CI 0.83–0.95), and the area under the HSROC curve was 0.94 (95% CI 0.91–0.95). Heterogeneity was present among the studies (Q = 29.442, p 205 vs ≤205), magnetic field strength (3 vs 1.5 T), T2-weighted image slice thickness (3 vs 4 mm), and VI-RADS cutoff score (≥3 vs ≥4) were significant factors affecting heterogeneity (p ≤ 0.03). Conclusions VI-RADS shows good sensitivity and specificity for determining MIBC. Technical factors associated with MRI acquisition and cutoff scores need to be taken into consideration as they may affect performance. Patient summary A recently established noninvasive magnetic resonance imaging–based scoring system shows good diagnostic performance in detecting muscle-invasive bladder cancer.

We report oncologic outcomes for men with Grade Group 1 prostate cancer managed with active surveillance at a tertiary cancer center.A total of 2,907 patients were managed with active surveillance between 2000 and 2017, of whom 2,664 had Grade Group 1 disease. Patients were recommended confirmatory biopsy to verify eligibility and were followed semiannually with prostate specific antigen, digital rectal examination and review of symptoms. Magnetic resonance imaging was increasingly used in recent years. Biopsy was repeated every 2 to 3 years or after a sustained prostate specific antigen increase or changes in magnetic resonance imaging/digital rectal examination. The Kaplan-Meier method was used to estimate probabilities of treatment, progression and development of metastasis.Median patient age at diagnosis was 62 years. For men with Grade Group 1 prostate cancer the treatment-free probability at 5, 10 and 15 years was 76% (95% CI 74-78), 64% (95% CI 61-68) and 58% (95% CI 51-64), respectively. At 5, 10 and 15 years there were 1,146, 220 and 25 men at risk for metastasis, respectively. Median followup for those without metastasis was 4.3 years (95% CI 2.3-6.9). Distant metastasis developed in 5 men. Upon case note review only 2 of these men were deemed to have disease that could have been cured on immediate treatment. The risk of distant metastasis was 0.6% (95% CI 0.2-2.0) at 10 years.Active surveillance is a safe strategy over longer followup for appropriately selected patients with Grade Group 1 disease following a well-defined monitoring plan.

OBJECTIVE. Despite a substantial increase in the use of MRI for pretreatment evaluation of prostate cancer, its prognostic value in patients undergoing radiation therapy (RT) is not well known. Therefore, the purpose of this study was to systematically review the literature and perform a meta-analysis on the prognostic value of pretreatment MRI in patients with prostate cancer who underwent external beam radiation therapy (EBRT) or brachytherapy. MATERIALS AND METHODS. PubMed and Embase databases were searched for studies published on or before March 13, 2019. We included studies that evaluated pretreatment MRI as a prognostic factor in prostate cancer regarding biochemical recurrence (BCR), metastatic failure, and overall or cancer-specific mortality. Effect sizes were measured in terms of the hazard ratio (HR) and were meta-analytically pooled using the random-effects model. The quality of the studies was independently evaluated using the Quality in Prognostic Studies tool. RESULTS. Twelve studies (2205 patients) were included. All studies assessed BCR; metastasis was evaluated in three studies, and mortality was evaluated in one study. Extraprostatic extension (EPE), seminal vesicle invasion (SVI), large tumor size or volume, number of sextants involved, and tumor involvement of prostatic apex were significant prognostic factors of BCR (pooled HRs = 1.50-4.47). EPE, larger tumor size, greater tumor volume, presence of metastatic pelvic lymph nodes (LNs), and presence of SVI were significant risk factors for metastasis (pooled HRs = 1.12-11.96). Pelvic LN metastasis was significantly predictive of cancer-specific mortality (HR = 4.45 [95% CI, 1.30-15.23]). CONCLUSION. Several pretreatment MRI findings were significant prognostic factors in patients with prostate cancer who underwent RT.

Context Recent studies suggested that magnetic resonance imaging (MRI) followed by targeted biopsy (“MRI-stratified pathway”) detects more clinically significant prostate cancers (csPCa) than the systematic transrectal ultrasound-guided prostate biopsy (TRUS-Bx) pathway, but controversy persists. Several randomized clinical trials (RCTs) were recently published, enabling generation of higher-level evidence to evaluate this hypothesis. Objective To perform a systematic review and meta-analysis of RCTs comparing the detection rates of csPCa in the MRI-stratified pathway and the systematic TRUS-Bx pathway in patients with a suspicion of prostate cancer (PCa). Evidence acquisition PubMed, EMBASE, and Cochrane databases were searched up to March 18, 2019. RCTs reporting csPCa detection rates of both pathways in patients with a clinical suspicion of prostate cancer were included. Relative csPCa detection rates of the MRI-stratified pathway were pooled using random-effect model. Study quality was assessed using the Cochrane risk of bias tool for randomized trials. A comparison of detection rates of clinically insignificant PCa (cisPCa) and any PCa was also performed. Evidence synthesis Nine RCTs (2908 patients) were included. The MRI-stratified pathway detected more csPCa than the TRUS-Bx pathway (relative detection rate 1.45 [95% confidence interval {CI} 1.09–1.92] for all patients, and 1.42 [95% CI 1.02–1.97] and 1.60 [95% CI 1.01–2.54] for biopsy-naive and prior negative biopsy patients, respectively). Detection rates were not significantly different between pathways for cisPCa (0.89 [95% CI 0.49–1.62]), but higher in the MRI-stratified pathway for the detection of any PCa (1.39 [95% CI 1.05–1.84]). Conclusions The MRI-stratified pathway detected more csPCa than the systematic TRUS-guided biopsy pathway in men with a clinical suspicion of PCa, for both biopsy-naive patients and those with prior negative biopsy. The detection rate of any PCa was higher in the MRI-stratified pathway, but not significantly different from that of cisPCa. Patient summary Our meta-analysis of clinical trials shows that the magnetic resonance imaging-stratified pathway detects more clinically significant prostate cancers than the transrectal ultrasound-guided prostate biopsy pathway in men with a suspicion of prostate cancer.

International audience; The original version of this article unfortunately contained mistakes. The figures 7D, 7E and 7F were missing in the article and arrows were missing in the figures 6C, 8B and 11C. The year of publication and volume number for references 19, 79 and 87 have been updated. Also, the Table 2 layout has been improved for better readability. The Publisher apologizes for the mistakes and the inconvenience caused.Erratum for Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management. [Abdom Radiol (NY). 2017]

Purpose To evaluate interradiologist agreement on assessments of computed tomography (CT) imaging features of high-grade serous ovarian cancer (HGSOC), to assess their associations with time-to-disease progression (TTP) and HGSOC transcriptomic profiles (Classification of Ovarian Cancer [CLOVAR]), and to develop an imaging-based risk score system to predict TTP and CLOVAR profiles. Materials and Methods This study was a multireader, multi-institutional, institutional review board-approved, HIPAA-compliant retrospective analysis of 92 patients with HGSOC (median age, 61 years) with abdominopelvic CT before primary cytoreductive surgery available through the Cancer Imaging Archive. Eight radiologists from the Cancer Genome Atlas Ovarian Cancer Imaging Research Group developed and independently recorded the following CT features: characteristics of primary ovarian mass(es), presence of definable mesenteric implants and infiltration, presence of other implants, presence and distribution of peritoneal spread, presence and size of pleural effusions and ascites, lymphadenopathy, and distant metastases. Interobserver agreement for CT features was assessed, as were univariate and multivariate associations with TTP and CLOVAR mesenchymal profile (worst prognosis). Results Interobserver agreement for some features was strong (eg, α = .78 for pleural effusion and ascites) but was lower for others (eg, α = .08 for intraparenchymal splenic metastases). Presence of peritoneal disease in the right upper quadrant (P = .0003), supradiaphragmatic lymphadenopathy (P = .0004), more peritoneal disease sites (P = .0006), and nonvisualization of a discrete ovarian mass (P = .0037) were associated with shorter TTP. More peritoneal disease sites (P = .0025) and presence of pouch of Douglas implants (P = .0045) were associated with CLOVAR mesenchymal profile. Combinations of imaging features contained predictive signal for TTP (concordance index = 0.658; P = .0006) and CLOVAR profile (mean squared deviation = 1.776; P = .0043). Conclusion These results provide some evidence of the clinical and biologic validity of these image features. Interobserver agreement is strong for some features, but could be improved for others. © RSNA, 2017 Online supplemental material is available for this article.

Purpose A long natural history and a predominant osseous pattern of metastatic spread are impediments to the adoption of precision medicine in patients with prostate cancer. To establish the feasibility of clinical genomic profiling in this disease, we performed targeted deep sequencing of tumor and normal DNA from patients with locoregional, metastatic noncastrate, and metastatic castration-resistant prostate cancer. Patients and Methods Patients consented to genomic analysis of their tumor and germline DNA. A hybridization capture-based clinical assay was used to identify single-nucleotide variations, small insertions and deletions, copy number alterations, and structural rearrangements in more than 300 cancer-related genes in tumors and matched normal blood. Results We successfully sequenced 504 tumors from 451 patients with prostate cancer. Potentially actionable alterations were identified in DNA damage repair, phosphatidylinositol 3-kinase, and mitogen-activated protein kinase pathways. Twenty-seven percent of patients harbored a germline or a somatic alteration in a DNA damage repair gene that may predict for response to poly (ADP-ribose) polymerase inhibition. Profiling of matched tumors from individual patients revealed that somatic TP53 and BRCA2 alterations arose early in tumors from patients who eventually developed metastatic disease. In contrast, comparative analysis across disease states revealed that APC alterations were enriched in metastatic tumors, whereas ATM alterations were specifically enriched in castration-resistant prostate cancer. Conclusion Through genomic profiling of prostate tumors that represent the disease clinical spectrum, we identified a high frequency of potentially actionable alterations and possible drivers of disease initiation, metastasis, and castration resistance. Our findings support the routine use of tumor and germline DNA profiling for patients with advanced prostate cancer for the purpose of guiding enrollment in targeted clinical trials and counseling families at increased risk of malignancy.

Background Salvage partial gland ablation (sPGA) has been proposed to treat some localized radiorecurrent prostate cancer. The role of prostate biopsy and magnetic resonance imaging (MRI) characteristics to identify patients eligible for sPGA is unknown. Objective To evaluate the ability of MRI and prostate biopsy characteristics to identify an index lesion suitable for sPGA and validate this selection using detailed tumor maps created from whole-mount slides from salvage radical prostatectomy (sRP) specimens. Design, setting, and participants Men who underwent sRP for recurrent prostate cancer following primary radiotherapy with external beam radiotherapy (EBRT) and/or brachytherapy between 2000 and 2014 at a single high-volume cancer center were eligible. Those with tumor maps, MRI and biopsy data were included in analysis. Outcome measurements and statistical analysis Primary outcome was the ability of clinicopathologic and imaging criteria to identify patients who may be eligible for sPGA based on detailed tumor map from whole-mount sRP slides. Results and limitations Of 216 men who underwent sRP following whole gland radiotherapy, tumor maps, MRI, and biopsy data were available for 77. Of these, 15 (19%) were determined to be eligible for sPGA based on biopsy-proven unilateral disease in contiguous sextant segments, a dominant lesion on MRI concordant with biopsy location or no focal region of interest, and no imaging evidence of extraprostatic disease. Review of tumor maps identified 6 additional men who would have met criteria for sPGA, resulting in sensitivity of 71% (95% C.I. 48%–89%) and specificity of 100% (lower bound of 95% C.I. 94%). None of the 15 men who met the criteria for sPGA on clinical data were identified incorrectly on tumor maps to require full gland surgery (upper bound of 95% C.I. 22%). Median tumor volume of the index lesion was 0.4 cc and recurrent cancer was noted in the apex, mid-gland, and base in 81%, 100%, and 29% of men. Conclusions In men with recurrent prostate cancer after radiotherapy, biopsy findings and MRI can be used to select index lesions potentially amenable for sPGA and can guide patient evaluation for inclusion in clinical trials of sPGA following radiation failure. Larger, prospective studies are required to evaluate both the role of MRI and clinical criteria in guiding focal salvage therapy and the effectiveness of this modality for radiorecurrent prostate cancer.

5019 Background: Preferential fat accumulation in the visceral compartment (i.e. central adiposity) increases cardiovascular risk in the general population independent of body mass index (BMI). We investigated how body fat distribution modulates the cardiometabolic risk of male germ cell tumor (GCT) survivors after cisplatin-based chemotherapy. Methods: For 456 patients in The Platinum Study enrolled at Memorial Sloan Kettering Cancer Center, visceral (VAT) and subcutaneous (SAT) adipose tissue compartments were quantified on pre-chemotherapy computed tomography (CT) scans (median time between CT and chemotherapy: 13 days, range: 0-56). The VAT/SAT ratio was calculated as a quantitative indicator of central adiposity. Endpoints were (I) post-chemotherapy cardiovascular risk as per the office-based Framingham risk calculator, and (II) incidence of post-chemotherapy cardiometabolic disease defined as need for new anti-hypertensive drugs, or lipid-lowering drugs, or medication used to treat diabetes. Changes in fat distribution after chemotherapy were analyzed in a subgroup with post-chemotherapy CTs (n = 108; median interval from chemotherapy start: 18 months, range: 7-185). Linear regression with interaction terms (endpoint 1, subgroup analysis) and Cox proportional hazard regression (endpoint 2) were applied. Results: For all 456 patients, median age at chemotherapy initiation was 31 years and median follow-up was 27 months (range: 7, 207). At baseline (pre-chemotherapy), the median BMI was 26.2 kg/m2, and 102 patients (22.4%) had a BMI of ≥30 kg/m2. The median VAT/SAT ratio at baseline CT was 0.49, and positively associated with higher post-chemotherapy Framingham risk scores after adjustment for age, BMI, and blood pressure measurements at chemotherapy start, as well as post-therapy follow-up time (adjusted β-estimate: 1.36, 95% CI: 1.15, 1.59, p < 0.001). A higher VAT/SAT ratio also inferred a higher likelihood of new onset cardiometabolic disease in patients with BMI ≥30 kg/m2 (age-adjusted HR: 3.11, 95%CI: 1.01, 9.62, p = 0.048), but not in those with BMI < 30 kg/m2. In the subgroup analysis, we observed a significant increase of BMI after chemotherapy (mean: +1.1 kg/m2, 95% CI: +0.58, +1.54; p < 0.001). Changes in BMI were positively associated with changes of the VAT/SAT ratio (β-estimate: 3.0, 95% CI: 2.23, 4.04; p < 0.001), meaning that weight gain occurred preferentially in the VAT compartment, while weight loss tended to be paralleled by an improved body fat distribution. Conclusions: In male GCT patients, central adiposity at baseline increases cardiometabolic risk after cisplatin-based chemotherapy, particularly for obese individuals. Quantification of an individual’s body fat distribution on pre-chemotherapy CT could potentially help to identify high risk individuals who may benefit from intensified risk-modulating interventions.

Prostate-specific membrane antigen positron emission tomography (PSMA PET) has recently gained interest as a promising tool for treatment response evaluation in metastatic castration-resistant prostate cancer (CRPC). We performed a systematic review and meta-analysis assessing the concordance between response evaluation using PSMA PET and serum prostate-specific antigen (PSA) level after systemic treatment and the association between PSMA PET and overall survival in metastatic CRPC patients. PubMed, Embase, and Cochrane library databases were searched until August 2020. Studies that reported the concordance between PSMA PET and PSA response were included. PSMA PET and PSA response evaluation were dichotomized into response vs. non-response to construct two-by-two contingency tables, an ≥30% increase in PSMA PET according to PET Response Criteria in Solid Tumors 1.0 and as an increase in serum PSA level of ≥25% as per Prostate Cancer Working Group 3 guidelines were defined as non-response. The percent agreement rates were pooled using random-effect model. Ten studies (268 patients) were included. The concordance rates ranged 0.50–0.84 with a pooled proportion of 0.73 (95% confidence interval 0.67–0.79). Patients were treated with 177Lu-PSMA therapy in five, chemotherapy in three, 223Ra in one, and more than one type in one study. Various PET parameters were used: the most widely evaluated was PSMA tumor volume (PSMA-TV). Similar proportions were found across different therapeutic agents, PET response parameters, and regarding directionality of discordance (PSA response/PSMA non-response vs. PSMA response/PSA non-response). Two studies reported that a decrease in PSMA-TV was associated with better overall survival. PSMA PET and PSA response assessments were discordant in nearly a fourth of metastatic CRPC patients. Further studies are warranted to establish the clinical meaning of this discordance and define appropriate management for such clinical situation.

International audience; Endometrial cancer is the most common gynecologic malignancy in the United States, with recent increasing incidence mostly owing to obesity. Preoperative MR imaging is essential to stratify patients according to their risk of recurrence and to guide surgical management. In the combination of T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhancement, MR imaging provides a "one-stop shop" approach for patient-specific accurate staging including the evaluation of the depth of myometrial invasion, cervical stromal invasion, extrauterine extension, and lymph node status.

The purposes of this study were to determine the cause of avascular hypoechoic lesions detected at scrotal ultrasound and to assess usefulness of sonographic and clinical features in differentiating benign from malignant etiologic factors.This retrospective study included 58 patients with avascular hypoechoic lesions detected at testicular ultrasound. The sonographic features recorded were lesion size and margins and presence of peripheral vascularity and focal calcifications. Also recorded were patient age, symptoms, risk factors, lesion palpability, and levels of serum tumor markers. The reference standard was pathologic results or at least 2-year stability documented with serial follow-up ultrasound studies. Features associated with malignant, including burnt-out, lesions and benign lesions were examined by Fisher exact test, Wilcox-on rank sum test, and the generalized estimating equations method for multivariable models.Sixty-three lesions were identified in 58 patients; 40 of the 63 (63.5%) were benign. Patients with malignant lesions had elevated serum tumor marker levels more often than patients who had benign lesions (26.1% versus 5.7%, p = 0.043). The clinical palpability of lesions and history of testicular cancer were not statistically significantly different between patients with malignant and those with benign lesions. Poorly defined margins of a lesion and focal calcification within the lesion were more often found in malignant lesions. Maximal size of a lesion and peripheral vascularity were not associated with either the benign or the malignant nature of a lesion.Although most avascular hypoechoic testicular lesions are benign, a substantial proportion are malignant. The ultrasound characteristics of a lesion, the patient's clinical presentation, and serum tumor marker status may be useful in differentiating malignant from benign lesions.

We report our initial experience with whole body and dedicated prostate magnetic resonance imaging as a single examination to assess local recurrence and metastatic disease in patients with suspected recurrent prostate cancer after radical prostatectomy.In this institutional review board approved, retrospective, single center study 76 consecutive patients with clinically suspected recurrent prostate cancer following radical prostatectomy underwent combined whole body and dedicated prostate magnetic resonance imaging at a single session from October 2014 to January 2016. Scans were evaluated to detect disease in the prostate bed and regional nodes, and at distant sites. Comparison was made to other imaging tests, and prostate bed, node and bone biopsies performed within 90 days.Whole body and dedicated prostate magnetic resonance imaging was completed successfully in all patients. Median prostate specific antigen was 0.36 ng/ml (range less than 0.05 to 56.12). Whole body and dedicated prostate magnetic resonance imaging identified suspected disease recurrence in 16 of 76 patients (21%), including local recurrence in the radical prostatectomy bed in 6, nodal metastases in 3, osseous metastases in 4 and multifocal metastatic disease in 3. In 43 patients at least 1 standard staging scan was done in addition to whole body and dedicated prostate magnetic resonance imaging. Concordance was demonstrated between the imaging modalities in 36 of 43 cases (84%). All metastatic lesions detected by other imaging tests were detected on magnetic resonance imaging. In addition, the magnetic resonance imaging modality detected osseous metastases in 4 patients with false-negative findings on other imaging tests, including 2 bone scans and 3 computerized tomography scans. It also excluded osseous disease in 1 patient with positiveCombined whole body and dedicated prostate magnetic resonance imaging is feasible in a clinical practice setting. It can provide incremental information compared to standard imaging in men with suspected prostate cancer recurrence after radical prostatectomy.

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

OBJECTIVE. The purpose of this study is to analyze the 18F-FDG PET/CT features of solid renal masses detected in patients with lymphoma and to evaluate the ability of PET/CT to differentiate renal cell carcinoma (RCC) from renal lymphomatous involvement. MATERIALS AND METHODS. Thirty-six patients with solid renal masses on PET/CT performed for staging or follow-up of lymphoma were evaluated retrospectively. The features recorded for each renal mass included the following standardized uptake values (SUVs) on PET/CT: the maximum SUV (SUVmax), the mean SUV (SUVmean), the ratio of the SUVmax of the tumor to that of the normal kidney cortex, the ratio of the SUVmean of the tumor to that of the normal kidney cortex, the ratio of the SUVmax of the tumor to that of the normal liver, and the ratio of the SUVmean of the tumor to that of the normal liver. Renal mass size and margins (well defined vs infiltrative) and the presence of calcifications were evaluated on CT. Renal biopsy results were used as the reference...

To assess the performance of the updated Prostate Imaging Reporting and Data System (PI-RADSv2) and the apparent diffusion coefficient (ADC) for predicting confirmatory biopsy results in patients considered for active surveillance of prostate cancer (PCA). IRB-approved, retrospective study of 371 consecutive men with clinically low-risk PCA (initial biopsy Gleason score ≤6, prostate-specific antigen

International audience; OBJECTIVE:To evaluate a recently published volume-based renal function prediction calculator intended to be used in small renal mass surgical counseling.METHODS:Retrospective data collection included three-dimensional calculation of renal mass and parenchyma of patients who have undergone extirpative therapy. The predicted glomerular filtration rate (GFR) was calculated using the online calculator. The predicted GFR was compared with the actual 6-month GFR. The Pearson correlation coefficient, paired t test and root-mean-square error (RMSE) are utilized for statistical analysis.RESULTS:After institutional review board approval, three institutions provided data for analysis. After patients with renal mass size >300 cc, renal size >400 cc or preoperative CKD ≥stage 3 had been excluded, we retrospectively analyzed data from 136 patients. The median mass volume was 22.2 cc (IQR 7-49). In multiple linear regression analysis, the most significant variables predicting postoperative GFR were partial versus radical nephrectomy and preoperative GFR with an overall R2 of .68 (F = 26.13, P < .001). The predicted GFR was 75.4 mL/min/1.73 m2 compared to an actual GFR of 70.7 mL/min/1.73 m2 (P < .001, paired t test). The predicted GFR was highly correlated with the actual postoperative GFR at 6 months (Pearson correlation, r = .65, P < .001). RMSE of the validation cohort was 16.87.CONCLUSIONS:The predictive tool to determine renal function benefit of nephron sparing surgery compared to radical nephrectomy online calculator effectively predicts GFR and could potentially be used to help urologists and patients discuss renal function prior to extirpative renal surgery.

Summary Metabolic imaging using hyperpolarized magnetic resonance can increase the sensitivity of MRI, though its ability to inform on relevant changes to biochemistry in humans remains unclear. In this work, we image pyruvate metabolism in patients, assessing the reproducibility of delivery and conversion in the setting of primary prostate cancer. We show that the time to max of pyruvate does not vary significantly within patients undergoing two separate injections or across patients. Furthermore, we show that lactate increases with Gleason grade. RNA sequencing data demonstrate a significant increase in the predominant pyruvate uptake transporter, monocarboxylate transporter 1. Increased protein expression was also observed in regions of high lactate signal, implicating it as the driver of lactate signal in vivo. Targeted DNA sequencing for actionable mutations revealed the highest lactate occurred in patients with PTEN loss. This work identifies a potential link between actionable genomic alterations and metabolic information derived from hyperpolarized pyruvate MRI.

Purpose To determine if the primary treatment approach (primary debulking surgery (PDS) versus neoadjuvant chemotherapy and interval debulking surgery (NACT-IDS)) influences the pattern of first recurrence in patients with completely cytoreduced advanced high-grade serous ovarian carcinoma (HGSOC). Materials and methods This retrospective study included 178 patients with newly diagnosed stage IIIC–IV HGSOC, complete gross resection during PDS (n = 124) or IDS (n = 54) from January 2008–March 2013, and baseline and first recurrence contrast-enhanced computed tomography scans. Clinical characteristics and number of disease sites at baseline were analyzed for associations with time to recurrence. In 135 patients who experienced recurrence, the overlap in disease locations between baseline and recurrence and the number of new disease locations at recurrence were analyzed according to the primary treatment approach. Results At univariate and multivariate analyses, NACT-IDS was associated with more overlapping locations between baseline and first recurrence (p ≤ 0.003) and fewer recurrences in new anatomic locations (p ≤ 0.043) compared with PDS. The same results were found in a subgroup that received intra-peritoneal adjuvant chemotherapy after either treatment approach. At univariate analysis, patient age, primary treatment approach, adjuvant chemotherapy route, and number of disease locations at baseline were associated with time to recurrence (p ≤ 0.009). At multivariate analysis, older patient age, NACT-IDS, and greater disease locations at baseline remained significant (p ≤ 0.018). Conclusion The distribution of disease at the time of first recurrence varied with the choice of primary treatment. Compared to patients treated with PDS, patients who underwent NACT-IDS experienced recurrence more often in the same locations as the original disease.

PURPOSE: To explore associations between magnetic resonance imaging (MRI) features of prostate cancer and expression levels of cell cycle genes, as assessed by the Prolaris® test. MATERIALS AND METHODS: Retrospective analysis of 118 PCa patients with genetic testing of biopsy specimen and prostate MRI from 08/2013 to 11/2015. Associations between the cell cycle risk (CCR) score and MRI features (i.e. PI-RADSv2 score, extracapsular extension (ECE), quantitative metrics) were analysed with Fisher’s exact test, nonparametric tests, and Spearman correlation coefficient. In 41 patients (34.7%), test results were compared to unfavourable features on prostatectomy specimen (i.e. Gleason group≥3, ECE, lymph node metastases). RESULTS: Fifty-four (45.8%), 60 (50.8%) and 4 (3.4%) patients had low, intermediate and high-risk cancers according to American Urological Association scoring system. Patients with ECE on MRI had significantly higher mean CCR scores (reader 1: 3.9 vs. 3.2, p=0.015; reader 2: 3.6 vs. 3.2, p=0.045). PI-RADSv2 scores and quantitative MRI features were not associated with CCR scores. In the prostatectomy subset, ECE on MRI (p=

Objective To describe contemporary management and outcomes of patients experiencing postoperative hemorrhage after minimally invasive radical prostatectomy. Materials and Methods We retrospectively analyzed data from patients who underwent minimally invasive radical prostatectomy at our institution between January 2010 and January 2017. Clinically significant hemorrhage was defined as a decrease in hemoglobin of ≥30% or 4 g/dL from preoperative to 4 or 14 hours postoperative measurement, receiving a blood transfusion within 30 days, or undergoing a secondary procedure to control bleeding. Patients were analyzed in 3 groups: (1) serially monitored only, (2) received a blood transfusion, and (3) underwent a secondary procedure. Outcomes included imaging studies performed, length of stay, emergency room visits, hospital readmissions, complication rates, and functional outcomes. Results Of 3749 men, 4% (151/3749) had clinically significant hemorrhage, 1.6% (60/3749) received a transfusion; 0.32% (12/3749) underwent a secondary procedure to control bleeding. In a 30-day composite outcome, increased healthcare utilization (emergency room visit, readmission, or Grade ≥3 complications), was seen in 25% of the serial monitoring group, 65% of the transfusion group, and 100% in the secondary procedure group. This rate in 3598 men without hemorrhage was 12.5%. One-year erectile function was poorest in men who underwent a secondary procedure. Urinary functional outcomes were similar in the 3 groups. Conclusion Most patients experiencing clinically significant hemorrhage will stabilize without transfusion, and a very small fraction require secondary intervention. Patients experiencing milder bleeding events utilized additional healthcare resources at approximately twice the rate of those who did not, warranting appropriate counseling and postoperative monitoring.

INTRODUCTION AND OBJECTIVES:Medical imaging is routinely used for the diagnosis and treatment of cancer. Via years of genomics testing hallmark mutations have been identified to characterize certai...

Accurate tumor detection and establishment of disease extent are important for optimal management of prostate cancer. Disease stage, beginning with identification of the index prostate lesion, followed by primary tumor, lymph node, and distant metastasis evaluation, provide crucial clinical information that not only have prognostic and predictive value, but guide patient management. A wide array of radiological imaging modalities including ultrasound, computed tomography, and magnetic resonance imaging have been used for the purpose of prostate cancer staging with variable diagnostic performance. Especially, the last years have seen remarkable technological advances in magnetic resonance imaging technology, enabling referring clinicians and radiologists to obtain even more valuable data regarding staging of prostate cancer. Marked improvements have been seen in detection of the index prostate lesion and evaluation of extraprostatic extension while further improvements are still needed in identifying metastatic lymph nodes. Novel approaches such as whole-body MRI are emerging for more accurate and reproducible assessment of bone metastasis. Post-treatment assessment of prostate cancer using radiological imaging is a topic with rapidly changing clinical context and special consideration is needed for the biochemical setting, that is, the relatively high serum prostate-specific antigen levels in studies assessing the value of radiological imaging for post-treatment assessment and emerging therapeutic approaches such as early salvage radiation therapy. The scope of this review is to provide the reader insight into the various ways radiology contribute to staging of prostate cancer in the context of both primary staging and post-treatment assessment. The strengths and limitations of each imaging modality are highlighted as well as topics that warrant future research.

OBJECTIVES:18F-fluorodihydrotestosterone (18F-FDHT) PET/CT potentially provides a noninvasive method for assessment of androgen receptor expression in patients with metastatic castration-resistant prostate cancer (mCRPC). The objective of this study was to assess simplified methods for quantifying 18F-FDHT uptake in mCRPC patients and to assess effects of tumour perfusion on these 18F-FDHT uptake metrics. METHODS: Seventeen mCRPC patients were included in this prospective observational multicentre study. Test and retest 30 minute dynamic 18F-FDHT PET/CT scans with venous blood sampling were performed in 14 patients. In addition, arterial blood sampling and dynamic 15O-H2O scans were obtained in a subset of six patients. Several simplified methods were assessed: Patlak plots, standardized uptake values normalized to bodyweight (SUVBW) or lean body mass (SUVLBM), SUV normalized to whole blood (SUVWB) or parent plasma activity concentration (SUVPP), SUV normalized to the area under the parent plasma (SUVAUC,PP) or whole blood input curve (SUVAUC,WB), and SUVBW corrected for sex hormone-binding globulin (SHBG) levels (SUVSHBG). Results were correlated with parameters derived from full pharmacokinetic 18F-FDHT and 15O-H2O analyses. Finally, repeatability of individual quantitative uptake metrics was assessed. RESULTS: Eighty seven 18F-FDHT avid lesions were evaluated. 18F-FDHT uptake was best described by an irreversible 2-tissue compartment model. Replacing the continuous metabolite corrected arterial plasma input function with an image derived input function (IDIF) in combination with venous sample data provided similar Ki results (R2 = 0.98). Patlak Ki and SUVAUC,PP showed excellent correlation (R2 > 0.9). SUVBW showed a moderate correlation to Ki (R2 = 0.70, presumably due to fast 18F-FDHT metabolism. When calculating SUVSHBG, correlation to Ki improved (R2 = 0.88). Repeatability of full kinetic modelling parameters was inferior to that of simplified methods (repeatability coefficients >36% vs.

International audience; Masses in the female pelvis can present a diagnostic challenge, but a systematic anatomy-based approach to MR image interpretation can help one navigate the spaces of the female pelvis and commonly encountered lesions in those spaces with greater confidence.Pelvic masses can present a diagnostic challenge owing to the difficulty in assessing their origin and the overlap in imaging features. The majority of pelvic tumors arise from gastrointestinal or genitourinary organs, with less common sites of origin including the connective tissues, nerves, and lymphovascular structures. Lesion evaluation usually starts with clinical assessment followed by imaging, or the lesion may be an incidental finding at imaging performed for other clinical indications. Since accurate diagnosis is essential for optimal management, imaging is useful for suggesting the correct diagnosis or narrowing the differential possibilities and distinguishing tumors from their mimics. Some masses may require histologic confirmation of the diagnosis with biopsy and/or up-front surgical resection. In this case, imaging is essential for presurgical planning to assess mass size and location, evaluate the relationship to adjacent pelvic structures, and narrow differential possibilities. Pelvic US is often the first imaging modality performed in women with pelvic symptoms. While US is often useful to detect a pelvic mass, it has significant limitations in assessing masses located deep in the pelvis or near gas-filled organs. CT also has limited value in the pelvis owing to its inferior soft-tissue contrast. MRI is frequently the optimal imaging modality, as it offers both multiplanar capability and excellent soft-tissue contrast. This article highlights the normal anatomy of the pelvic spaces in the female pelvis and focuses on MRI features of common tumors and tumor mimics that arise in these spaces. It provides an interpretative algorithm for approaching an unknown pelvic lesion at MRI. It also discusses surgical management, emphasizing the value of MRI as a road map to surgery and highlighting anatomic locations where surgical resection may present a challenge.

PURPOSE: To assess the associations between inter-site texture heterogeneity parameters derived from computed tomography (CT), survival, and BRCA mutation status in women with high-grade serous ovarian cancer (HGSOC). MATERIAL AND METHODS: retrospective study of 88 HGSOC patients undergoing CT and BRCA mutation status testing prior to primary cytoreductive surgery. Associations between texture metrics – namely inter-site cluster variance (SCV), inter-site cluster prominence (SCP), inter-site cluster entropy (SE) – and overall survival (OS), progression-free survival (PFS) as well as BRCA mutation status were assessed. RESULTS: Higher inter-site cluster variance (SCV) was associated with lower PFS (p=0.006) and OS (p=0.003). Higher inter-site cluster prominence (SCP) was associated with lower PFS (p=0.02) and higher inter-site cluster entropy (SE) correlated with lower OS (p=0.01). Higher values of all three metrics were significantly associated with lower complete surgical resection status in BRCA negative patients (SE p=0.039, SCV p=0.006, SCP p=0.02), but not in BRCA positive patients (SE p=0.7, SCV p=0.91, SCP p=0.67). None of the metrics were able to distinguish between BRCA mutation carrier versus non-mutation carrier. CONCLUSION: The assessment of tumoral heterogeneity in the era of personalized medicine is important, as increased heterogeneity has been associated with distinct genomic abnormalities and worse patient outcomes. A radiomics approach using standard-of-care CT scans might have a clinical impact by offering a noninvasive tool to predict outcome and therefore improving treatment effectiveness. However, it was not able to assess BRCA mutation status in women with HGSOC.

PET is increasingly used for prostate cancer (PCa) diagnostics. Important PCa radiotracers include (68)Ga-prostate-specific membrane antigen HBED-CC ((68)Ga-PSMA), (18)F-DCFPyL, (18)F-fluoromethylcholine ((18)F-FCH), and (18)F-dihydrotestosterone ((18)F-FDHT). Knowledge on the variability of tracer uptake in healthy tissues is important for accurate PET interpretation, because malignancy is suspected only if the uptake of a lesion contrasts with its background. Therefore, the aim of this study was to quantify uptake variability of PCa tracers in healthy tissues and identify stable reference regions for PET interpretation. Methods: A total of 232 PCa PET/CT scans from multiple hospitals was analyzed, including 87 (68)Ga-PSMA scans, 50 (18)F-DCFPyL scans, 68 (18)F-FCH scans, and 27 (18)F-FDHT scans. Tracer uptake was assessed in the blood pool, lung, liver, bone marrow, and muscle using several SUVs (SUV(max), SUV(mean), SUV(peak)). Variability in uptake between patients was analyzed using the coefficient of variation (COV%). For all tracers, SUV reference ranges (95th percentiles) were calculated, which could be applicable as image-based quality control for future PET acquisitions. Results: For (68)Ga-PSMA, the lowest uptake variability was observed in the blood pool (COV, 19.9%), which was significantly more stable than all other tissues (COV, 29.8%–35.2%; P = 0.001–0.024). For (18)F-DCFPyL, the lowest variability was observed in the blood pool and liver (COV, 14.4% and 21.7%, respectively; P = 0.001–0.003). The least variable (18)F-FCH uptake was observed in the liver, blood pool, and bone marrow (COV, 16.8%–24.2%; P = 0.001–0.012). For (18)F-FDHT, low uptake variability was observed in all tissues, except the lung (COV, 14.6%–23.6%; P = 0.001–0.040). The different SUV types had limited effect on variability (COVs within 3 percentage points). Conclusion: In this multicenter analysis, healthy tissues with limited uptake variability were identified, which may serve as reference regions for PCa PET interpretation. These reference regions include the blood pool for (68)Ga-PSMA and (18)F-DCFPyL and the liver for (18)F-FCH and (18)F-FDHT. Healthy tissue SUV reference ranges are presented and applicable as image-based quality control.

(18)F-fluorodihydrotestosterone ((18)F-FDHT) is a radiolabeled analog of the androgen receptor’s primary ligand that is currently being credentialed as a biomarker for prognosis, response, and pharmacodynamic effects of new therapeutics. As part of the biomarker qualification process, we prospectively assessed its reproducibility and repeatability in men with metastatic castration-resistant prostate cancer. Methods: We conducted a prospective multiinstitutional study of metastatic castration-resistant prostate cancer patients undergoing 2 (test/retest) (18)F-FDHT PET/CT scans on 2 consecutive days. Two independent readers evaluated all examinations and recorded SUVs, androgen receptor–positive tumor volumes, and total lesion uptake for the most avid lesion detected in each of 32 predefined anatomic regions. The relative absolute difference and reproducibility coefficient (RC) of each metric were calculated between the test and retest scans. Linear regression analyses, intraclass correlation coefficients (ICCs), and Bland–Altman plots were used to evaluate repeatability of (18)F-FDHT metrics. The coefficient of variation and ICC were used to assess interobserver reproducibility. Results: Twenty-seven patients with 140 (18)F-FDHT–avid regions were included. The best repeatability among (18)F-FDHT uptake metrics was found for SUV metrics (SUV(max,) SUV(mean), and SUV(peak)), with no significant differences in repeatability among them. Correlations between the test and retest scans were strong for all SUV metrics (R(2) ≥ 0.92; ICC ≥ 0.97). The RCs of the SUV metrics ranged from 21.3% (SUV(peak)) to 24.6% (SUV(max)). The test and retest androgen receptor–positive tumor volumes and TLU, respectively, were highly correlated (R(2) and ICC ≥ 0.97), although variability was significantly higher than that for SUV (RCs > 46.4%). The prostate-specific antigen levels, Gleason score, weight, and age did not affect repeatability, nor did total injected activity, uptake measurement time, or differences in uptake time between the 2 scans. Including the most avid lesion per patient, the 5 most avid lesions per patient, only lesions 4.2 mL or more, only lesions with an SUV of 4 g/mL or more, or normalizing of SUV to area under the parent plasma activity concentration–time curve did not significantly affect repeatability. All metrics showed high interobserver reproducibility (ICC > 0.98; coefficient of variation < 0.2%–10.8%). Conclusion: Uptake metrics derived from (18)F-FDHT PET/CT show high repeatability and interobserver reproducibility.

Bone lesions on prostate MRI often raise concern about metastases. This study aimed to evaluate the prevalence of bone metastases on staging prostate MRI and evaluate associations between their MRI features and clinical/pathologic characteristics. Retrospective, IRB-approved study of 3765 patients undergoing prostate MRI for newly diagnosed PCa between 2000 and 2014. The reference standard to calculate the prevalence of bone metastases was bone biopsy and/or ≥1-year follow-up after MRI. In a subsample of 228 patients, the MRI characteristics of bone lesions were recorded by two radiologists independently. Associations between MRI and clinical/pathologic findings, including National Comprehensive Cancer Network (NCCN) risk categories, were calculated. 57/3765 patients (1.5%, 95% CI 1.2–2.0%) had bone metastases. No patient with NCCN low-risk PCa (Gleason

We determined whether multiparametric magnetic resonance imaging targeted biopsies may replace systematic biopsies to detect higher grade prostate cancer (Gleason score 7 or greater) and whether biopsy may be avoided based on multiparametric magnetic resonance imaging among men with Gleason 3+3 prostate cancer on active surveillance.We identified men with previously diagnosed Gleason score 3+3 prostate cancer on active surveillance who underwent multiparametric magnetic resonance imaging and a followup prostate biopsy. Suspicion for higher grade cancer was scored on a standardized 5-point scale. All patients underwent a systematic biopsy. Patients with multiparametric magnetic resonance imaging regions of interest also underwent magnetic resonance imaging targeted biopsy. The detection rate of higher grade cancer was estimated for different multiparametric magnetic resonance imaging scores with the 3 biopsy strategies of systematic, magnetic resonance imaging targeted and combined.Of 206 consecutive men on active surveillance 135 (66%) had a multiparametric magnetic resonance imaging region of interest. Overall, higher grade cancer was detected in 72 (35%) men. A higher multiparametric magnetic resonance imaging score was associated with an increased probability of detecting higher grade cancer (Wilcoxon-type trend test p0.0001). Magnetic resonance imaging targeted biopsy detected higher grade cancer in 23% of men. Magnetic resonance imaging targeted biopsy alone missed higher grade cancers in 17%, 12% and 10% of patients with multiparametric magnetic resonance imaging scores of 3, 4 and 5, respectively.Magnetic resonance imaging targeted biopsies increased the detection of higher grade cancer among men on active surveillance compared to systematic biopsy alone. However, a clinically relevant proportion of higher grade cancer was detected using only systematic biopsy. Despite the improved detection of disease progression using magnetic resonance imaging targeted biopsy, systematic biopsy cannot be excluded as part of surveillance for men with low risk prostate cancer.

A successful paradigm shift toward personalized management strategies for patients with prostate cancer (PCa) is heavily dependent on the availability of noninvasive diagnostic tools capable of accurately establishing the true extent of disease at the time of diagnosis and estimating the risk of subsequent disease progression and related mortality. Although there is still considerable scope for improvement in its diagnostic, predictive, and prognostic capabilities, multiparametric prostate magnetic resonance imaging (MRI) is currently regarded as the imaging modality of choice for local staging of PCa. A negative MRI, that is, the absence of any MRI-visible intraprostatic lesion, has a high negative predictive value for the presence of clinically significant PCa and can substantiate the consideration of active surveillance as a preferred initial management approach. MRI-derived quantitative and semi-quantitative parameters can be utilized to noninvasively characterize MRI-visible prostate lesions and identify those patients who are most likely to benefit from radical treatment, and differentiate them from patients with benign or indolent prostate pathology that may also be visible on MRI. This literature review summarizes current strategies how MRI can be used to determine a tailored management strategy for an individual patient.