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PURPOSE Neoadjuvant chemotherapy (NAC) has proven survival benefits for patients with invasive urothelial carcinoma of the bladder, yet its role for upper tract urothelial carcinoma (UTUC) remains undefined. We conducted a multicenter, single-arm, phase II trial of NAC with gemcitabine and split-dose cisplatin (GC) for patients with high-risk UTUC before extirpative surgery to evaluate response, survival, and tolerability. METHODS Eligible patients with defined criteria for high-risk localized UTUC received four cycles of split-dose GC before surgical resection and lymph node dissection. The primary study end point was rate of pathologic response (defined as < ypT2N0). Secondary end points included progression-free survival (PFS), overall survival (OS), and safety and tolerability. RESULTS Among 57 patients evaluated, 36 (63%) demonstrated pathologic response (95% CI, 49 to 76). A complete pathologic response (ypT0N0) was noted in 11 patients (19%). Fifty-one patients (89%) tolerated at least three complete cycles of split-dose GC, 27 patients (47%) tolerated four complete cycles, and all patients proceeded to surgery. With a median follow up of 3.1 years, 2- and 5-year PFS rates were 89% (95% CI, 81 to 98) and 72% (95% CI, 59 to 87), while 2- and 5-year OS rates were 93% (95% CI, 86 to 100) and 79% (95% CI, 67 to 94), respectively. Pathologic complete and partial responses were associated with improved PFS and OS compared with nonresponders (≥ ypT2N any; 2-year PFS 100% and 95% v 76%, P < .001; 2-year OS 100% and 100% v 80%, P < .001). CONCLUSION NAC with split-dose GC for high-risk UTUC is a well-tolerated, effective therapy demonstrating evidence of pathologic response that is associated with favorable survival outcomes. Given that these survival outcomes are superior to historical series, these data support the use of NAC as a standard of care for high-risk UTUC, and split-dose GC is a viable option for NAC.

The aim of the study was to evaluate the performance of the Prophet forecasting procedure, part of the Facebook open-source Artificial Intelligence portfolio, for forecasting variations in radiological examination volumes. Daily CT and MRI examination volumes from our institution were extracted from the radiology information system (RIS) database. Data from January 1, 2015, to December 31, 2019, was used for training the Prophet algorithm, and data from January 2020 was used for validation. Algorithm performance was then evaluated prospectively in February and August 2020. Total error and mean error per day were evaluated, and computational time was logged using different Markov chain Monte Carlo (MCMC) samples. Data from 610,570 examinations were used for training; the majority were CTs (82.3%). During retrospective testing, prediction error was reduced from 19 to

Vaccination-associated adenopathy is a frequent imaging finding after administration of COVID-19 vaccines that may lead to a diagnostic conundrum in patients with manifest or suspected cancer, in whom it may be indistinguishable from malignant nodal involvement. To help the medical community address this concern in the absence of studies and evidence-based guidelines, this paper offers recommendations developed by a multidisciplinary panel of experts from three of the leading tertiary care cancer centers in the United States. According to these recommendations, some routine imaging examinations, such as those for screening, should be scheduled before or at least 6 weeks after the final vaccination dose to allow for any reactive adenopathy to resolve. However, there should be no delay of other clinically indicated imaging (e.g., for acute symptoms, short-interval treatment monitoring, urgent treatment planning or complications) due to prior vaccination. The vaccine should be administered on the side contralateral to the primary or suspected cancer, and both doses should be administered in the same arm. Vaccination information (date(s) administered, injection site(s), laterality, and type of vaccine) should be included in every pre-imaging patient questionnaire, and this information should be made readily available to interpreting radiologists. Clear and effective communication between patients, radiologists, referring physician teams and the general public should be considered of the highest priority when managing adenopathy in the setting of COVID-19 vaccination. Summary COVID-19-vaccination–related adenopathy is a frequent imaging finding that may lead to a diagnostic conundrum in patients with manifest or suspected cancer, in whom it may be indistinguishable from malignant nodal involvement. This special report offers recommendations developed by a multidisciplinary panel of experts from three of the leading tertiary care cancer centers in the United States.

BACKGROUND: Cancers of unknown primary (CUP) have traditionally been treated empirically, with a dismal prognosis. Compared with standard diagnostic tests, including CT and MRI, imaging with (18)F-fluorodeoxyglucose (FDG) PET or PET/CT has shown the capacity to better identify the primary tumor site and detect additional sites of metastasis. However, its clinical impact is not well established. We performed a systematic review and meta-analysis of prior studies to assess the impact of FDG-PET or PET/CT on the management of patients with CUP. MATERIALS AND METHODS: Pubmed and EMBASE databases were searched up to February 4, 2021. Studies that reported the proportion of patients with CUP who experienced a management change after FDG-PET or PET/CT were included, and the proportions were pooled using the random-effects model. Study quality was assessed using QUADAS-2. Subgroup analysis was conducted to explore heterogeneity. RESULTS: Thirty-eight studies (involving 2795 patients) were included. The pooled proportion of patients with management changes was 35% (95% confidence interval 31%–40%). There was substantial heterogeneity among the studies (Q-test, p

Tumor cure with conventional fractionated radiotherapy is 65%, dependent on tumor cell-autonomous gradual buildup of DNA double-strand break (DSB) misrepair. Here we report that single-dose radiotherapy (SDRT), a disruptive technique that ablates more than 90% of human cancers, operates a distinct dual-target mechanism, linking acid sphingomyelinase-mediated (ASMase-mediated) microvascular perfusion defects to DNA unrepair in tumor cells to confer tumor cell lethality. ASMase-mediated microcirculatory vasoconstriction after SDRT conferred an ischemic stress response within parenchymal tumor cells, with ROS triggering the evolutionarily conserved SUMO stress response, specifically depleting chromatin-associated free SUMO3. Whereas SUMO3, but not SUMO2, was indispensable for homology-directed repair (HDR) of DSBs, HDR loss of function after SDRT yielded DSB unrepair, chromosomal aberrations, and tumor clonogen demise. Vasoconstriction blockade with the endothelin-1 inhibitor BQ-123, or ROS scavenging after SDRT using peroxiredoxin-6 overexpression or the SOD mimetic tempol, prevented chromatin SUMO3 depletion, HDR loss of function, and SDRT tumor ablation. We also provide evidence of mouse-to-human translation of this biology in a randomized clinical trial, showing that 24 Gy SDRT, but not 3×9 Gy fractionation, coupled early tumor ischemia/reperfusion to human cancer ablation. The SDRT biology provides opportunities for mechanism-based selective tumor radiosensitization via accessing of SDRT/ASMase signaling, as current studies indicate that this pathway is tractable to pharmacologic intervention.

Urachal carcinomas (UrC) are rare non-urothelial bladder neoplasms, however the potential role for MR imaging in UrC has not been well established. Our objective was to assess the value of magnetic resonance imaging (MRI) in primary and recurrent UrC.This retrospective single-center study included all patients with UrC that underwent MRI between January 2005 and May 2020. Two radiologists reviewed MRIs independently followed by consensus with a third radiologist. For primary UrC, tumor location, size, morphology, invasion of peritoneum and/or local structures other than bladder and concordance between Mayo stage on MRI and pathology were assessed. MRI performed for recurrent UrC evaluated the pattern of recurrence. The reference standard was histopathological analysis.Ninety-six patients with UrC were identified of which 17 were included (9 men and 8 women, median age 50 years [IQR 42-62]). At initial MR staging (n = 10), all primary UrC were located at the bladder dome with median longest axis dimension of 6.0 cm. Most (70%) were mixed solid-and-cystic. Invasion of the peritoneum and/or local structures other than bladder was identified in 30%. Concordance between consensus MRI Mayo stage and final pathologic Mayo stage was 90%. At MR restaging (n = 7), UrC recurrence was most commonly seen at the bladder dome (71%). Overall, MRI showed a sensitivity of 85% and specificity of 50% for detecting recurrent tumor.MRI demonstrates value in evaluation of disease extent in primary and recurrent UrC, with high concordance between Mayo stage at MRI and pathology, and in the detection of local recurrences.

Purpose:We determined the diagnostic performance of 18F-FDG (fluorodeoxyglucose) positron emission tomography/computerized tomography for detecting nodal metastases in patients with muscle invasive...

Summary Background Accurate survival estimates are important for cancer control planning. Although observed survival estimates are unavailable for many countries, where they are available, wide variations are reported. Understanding the impact of specific treatment and imaging modalities can help decision makers to effectively allocate resources to improve cancer survival in their local context. Methods We developed a microsimulation model of stage-specific cancer survival in 200 countries and territories for 11 cancers (oesophagus, stomach, colon, rectum, anus, liver, pancreas, lung, breast, cervix uteri, and prostate) comprising 60% of global diagnosed cancer cases. The model accounts for country-specific availability of treatment (chemotherapy, surgery, radiotherapy, and targeted therapy) and imaging modalities (ultrasound, x-ray, CT, MRI, PET, single-photon emission CT), as well as quality of care. We calibrated the model to reported survival estimates from CONCORD-3 (which reports global trends in cancer survival in 2000–14). We estimated 5-year net survival for diagnosed cancers in each country or territory and estimated potential survival gains from increasing the availability of individual treatment and imaging modalities, and more comprehensive packages of scale-up of these interventions. We report the mean and 95% uncertainty intervals (UIs) for all outcomes, calculated as the 2·5 and 97·5 percentiles of the simulation results. Findings The estimated global 5-year net survival for all 11 cancers combined is 42·6% (95% uncertainty interval 40·3–44·3), with survival in high-income countries being an average of 12 times (range 4–17) higher than that in low-income countries. Expanding availability of surgery or radiotherapy or improving quality of care would yield the largest survival gains in low-income (2·5–3·4 percentage point increase in survival) and lower-middle-income countries (2·4–6·1 percentage point increase), whereas upper-middle-income and high-income countries are more likely to benefit from improved availability of targeted therapy (0·7 percentage point increase for upper-middle income and 0·4 percentage point increase for high income). Investing in medical imaging will also be necessary to achieve substantial survival gains, with traditional modalities estimated to provide the largest gains in low-income settings, while MRI and PET would yield the largest gains in higher-income countries. Simultaneous expansion of treatment, imaging, and quality of care could improve 5-year net survival by more than ten times in low-income countries (3·8% [95% UI 0·5–9·2] to 45·2% [40·2–52·1]) and could more than double 5-year net survival in lower-middle-income countries (20·1% [7·2–31·7] to 47·1% [42·8–50·8]). Interpretation Scaling up both treatment and imaging availability could yield synergistic survival gains for patients with cancer. Expanding traditional modalities in lower-income settings might be a feasible pathway to improve survival before scaling up more modern technologies. Funding Harvard T H Chan School of Public Health.

INTRODUCTION AND OBJECTIVE:Neoadjuvant chemotherapy (NAC) has established survival benefits prior to cystectomy for bladder cancer, yet its role in upper tract urothelial carcinoma (UTUC) prior to ...

PURPOSE: To determine the diagnostic performance of (18)F-FDG PET/CT for detecting nodal metastases in patients with muscle-invasive urothelial bladder cancer prior to radical cystectomy. MATERIALS AND METHODS: Preoperative (18)F-FDG PET/CT scans (n = 208) were retrospectively reviewed. Scans were routinely performed in 185 patients with muscle-invasive urothelial bladder cancer between August 2012 and February 2017, all of whom underwent radical cystectomy and pelvic lymph node dissection. Analyses were stratified by clinical node involvement and chemotherapy status. The diagnostic performance of (18)F-FDG PET/CT was assessed according to sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: Lymph node metastases at time of PLND were present in 21.8% of those without suspicious nodes on computed tomography (clinically node negative) and 52.6% of those with suspicious nodes on CT (clinically node positive). Median metastatic focus size was 5 mm. In clinically node negative patients, (18)F-FDG PET/CT rarely detected nodal metastases (sensitivity 7–23%). In clinically node positive patients, a negative (18)F-FDG PET/CT was useful in ruling out lymph node metastases (sensitivity 92–100%). This study was limited by its mixed population and focus on pelvic nodal metastases only. CONCLUSIONS: (18)F-FDG PET/CT appears to be most useful for better characterization of enlarged nodes identified by CT. Routine preoperative (18)F-FDG PET/CT has limited utility in clinically node-negative patients.

PURPOSE Provide evidence- and expert-based recommendations for optimal use of imaging in advanced prostate cancer. Due to increases in research and utilization of novel imaging for advanced prostate cancer, this guideline is intended to outline techniques available and provide recommendations on appropriate use of imaging for specified patient subgroups. METHODS An Expert Panel was convened with members from ASCO and the Society of Abdominal Radiology, American College of Radiology, Society of Nuclear Medicine and Molecular Imaging, American Urological Association, American Society for Radiation Oncology, and Society of Urologic Oncology to conduct a systematic review of the literature and develop an evidence-based guideline on the optimal use of imaging for advanced prostate cancer. Representative index cases of various prostate cancer disease states are presented, including suspected high-risk disease, newly diagnosed treatment-naïve metastatic disease, suspected recurrent disease after local treatment, and progressive disease while undergoing systemic treatment. A systematic review of the literature from 2013 to August 2018 identified fully published English-language systematic reviews with or without meta-analyses, reports of rigorously conducted phase III randomized controlled trials that compared ≥ 2 imaging modalities, and noncomparative studies that reported on the efficacy of a single imaging modality. RESULTS A total of 35 studies met inclusion criteria and form the evidence base, including 17 systematic reviews with or without meta-analysis and 18 primary research articles. RECOMMENDATIONS One or more of these imaging modalities should be used for patients with advanced prostate cancer: conventional imaging (defined as computed tomography [CT], bone scan, and/or prostate magnetic resonance imaging [MRI]) and/or next-generation imaging (NGI), positron emission tomography [PET], PET/CT, PET/MRI, or whole-body MRI) according to the clinical scenario.

There is increasing scrutiny from healthcare organizations towards the utility and associated costs of imaging. MRI has traditionally been used as a high-end modality, and although shown extremely important for many types of clinical scenarios, it has been suggested as too expensive by some. This editorial will try and explain how value should be addressed and gives some insights and practical examples of how value of MRI can be increased. It requires a global effort to increase accessibility, value for money, and impact on patient management. We hope this editorial sheds some light and gives some indications of where the field may wish to address some of its research to proactively demonstrate the value of MRI. Level of Evidence: 5. Technical Efficacy: Stage 5. J. Magn. Reson. Imaging 2019;49:e14–e25.

To assess the utility of morphologic and quantitative CT features in differentiating abdominal wall endometriosis (AWE) from other masses of the abdominal wall. Retrospective IRB-approved study of 105 consecutive women from two institutions who underwent CT and biopsy/resection of abdominal wall masses. CTs were independently reviewed by two radiologists blinded to final histopathologic diagnoses. Associations between CT features and pathology were tested using Fisher’s Exact Test. Sensitivity, specificity, positive, and negative predictive values were calculated. P values were adjusted for multiple variable testing. 24.8% (26/105) of patients had histologically proven abdominal wall endometriosis. The other most common diagnoses included adenocarcinoma NOS (21%; 22/105), desmoid (14.3%; 15/105), and leiomyosarcoma (8.6%; 9/105). CT features significantly associated with endometriosis for both readers were location below the umbilicus (P = 0.0188), homogeneous density (P = 0.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e., “gorgon” sign) (P

Purpose To compare ADC values measured from diffusion-weighted MR (DW-MR) images of the prostate obtained with both endorectal and phased-array coils (ERC + PAC) to those from DW-MRI images obtained with an eight-channel torso phased-array coil (PAC) at 3.0 T. Methods The institutional review board issued a waiver of informed consent for this HIPAA-compliant study. Twenty-five patients with biopsy-proven prostate cancer underwent standard 3-T MRI using 2 different coil arrangements (ERC + PAC and PAC only) in the same session. DW-MRI at five b -values (0, 600, 1000, 1200, and 1500 s/mm 2 ) were acquired using both coil arrangements. On b = 0 images, signal-to-noise ratios (SNRs) were measured as the ratio of the mean signal from PZ and TZ ROIs to the standard deviation from the mean signal in an artifact-free ROI in the rectum. Matching regions-of-interest (ROIs) were identified in the peripheral zone and transition zone on ERC-MRI and PAC-MRI. For each ROI, mean ADC values for all zero and non-zero b -value combinations were computed. Results Mean SNR with ERC-MRI at PZ (66.33 ± 27.07) and TZ (32.69 ± 12.52) was 9.27 and 5.52 times higher than with PAC-MRI ((7.32 ± 2.30) and (6.13 ± 1.56), respectively) ( P b -values in the PZ and TZ were significantly lower with PAC-MRI than with ERC-MRI ( P Conclusion Lower SNR of DW-MR images of the prostate obtained with a PAC can significantly decrease ADC values at higher b -values compared to similar measurements obtained using the ERC. To address these requirements, clinical MR systems should have image processing capabilities which incorporate the noise distribution.

Rationale and Objectives To identify the presence and extent of artifacts in prostate diffusion-weighted magnetic resonance imaging (DW-MRI) and discuss tradeoffs between imaging at 1.5 T (1.5 T) and 3.0 T (3.0 T). In addition, we aim to provide quantitative estimates of signal-to-noise ratios (SNRs) at both field strengths. Materials and Methods The institutional review board waived informed consent for this Health Insurance Portability and Accountability Act–compliant, retrospective study of 53 consecutive men who underwent 3.0 T endorectal DW-MRI and 53 consecutive men who underwent 1.5 T endorectal DW-MRI between October and December 2010. One radiologist and one physicist, blinded to patient characteristics, image acquisition parameters, and field strength, scored DW-MRI artifacts. On b = 0 images, SNR was measured as the ratio of the mean signal from a region of interest (ROI) at the level of the verumontanum (the “reference region”) to the standard deviation from the mean signal in an artifact-free ROI in the rectum. Results Both readers found geometric distortion and signal graininess significantly more often at 3.0 T than at 1.5 T ( P P = .001) and blurring more often at 1.5 T ( P = .006). Mean SNR at the urethra (87.92 ± 27.76) at 3.0 T was 1.43 times higher than at 1.5 T (64.51 ± 14.96) ( P Conclusions At 3.0 T (as compared to 1.5 T), increased SNR on prostate DW-MRI comes at the expense of geometric distortion and can also lead to more pronounced ghosting artifacts. Therefore, to take full advantage of the benefits of 3.0 T, further improvements in acquisition techniques are needed to address DW-MRI artifacts corresponding to higher field strengths.

Primary malignant tumors of the uterus include: 1. Tumors of the uterine cervix 80% are squamous carcinomas arising from the ectocervix 15% are adenocarcinomas from the endocervical canal. 2. Tumors of the endometrium 90% are type 1 tumors: endometrioid carcinoma grades 1 and 2 10% are more aggressive type 2 tumors: grade 3 endometrioid and clear cell carcinoma, papillary serous carcinoma, and poorly differentiated tumors. 3. Uterine sarcomas Endometrial stromal sarcoma (ESS) and adenosarcoma arising from the stroma of the uterus Leiomyosarcoma arising from its smooth muscle.

Positron emission tomography (PET) is a highly sensitive tool for detecting and quantifying molecular activity throughout the body, and its use in oncology is now widespread. PET imaging is based on the detection of probes that consist at minimum of a targeting agent (e.g., an antibody, peptide, or small molecule) and a positron-emitting radionuclide that provides the signal for imaging. A variety of radionuclides with different half-lives are available for labeling, including fluorine 18 (18F), carbon 11 (11C), nitrogen 13 (13N), iodine 124 (124I), zirconium 89 (89Zr), and copper 64 (64Cu), and different radionuclides may be used to label the same targeting agent. The glucose analog fluorodeoxyglucose (FDG), labeled with 18F, is at present the most common PET radiotracer used in routine clinical care. However, a number of other probes now in the pipeline promise to significantly expand the role of PET in prostate cancer management. Furthermore, prostate-specific probes that can be imaged with PET have been identified and are undergoing clinical translation.

To identify the presence and extent of artifacts in prostate diffusion-weighted magnetic resonance imaging (DW-MRI) and discuss tradeoffs between imaging at 1.5 T (1.5 T) and 3.0 T (3.0 T). In addition, we aim to provide quantitative estimates of signal-to-noise ratios (SNRs) at both field strengths.The institutional review board waived informed consent for this Health Insurance Portability and Accountability Act-compliant, retrospective study of 53 consecutive men who underwent 3.0 T endorectal DW-MRI and 53 consecutive men who underwent 1.5 T endorectal DW-MRI between October and December 2010. One radiologist and one physicist, blinded to patient characteristics, image acquisition parameters, and field strength, scored DW-MRI artifacts. On b = 0 images, SNR was measured as the ratio of the mean signal from a region of interest (ROI) at the level of the verumontanum (the "reference region") to the standard deviation from the mean signal in an artifact-free ROI in the rectum.Both readers found geometric distortion and signal graininess significantly more often at 3.0 T than at 1.5 T (P.0001, all comparisons). Reader 2 (but not reader 1) found ghosting artifacts more often at 3.0 T (P = .001) and blurring more often at 1.5 T (P = .006). Mean SNR at the urethra (87.92 ± 27.76) at 3.0 T was 1.43 times higher than at 1.5 T (64.51 ± 14.96) (P.0001).At 3.0 T (as compared to 1.5 T), increased SNR on prostate DW-MRI comes at the expense of geometric distortion and can also lead to more pronounced ghosting artifacts. Therefore, to take full advantage of the benefits of 3.0 T, further improvements in acquisition techniques are needed to address DW-MRI artifacts corresponding to higher field strengths.

CONTEXT: Comparative reviews of whole-body magnetic resonance imaging (WB-MRI) and positron emission tomography/computed tomography (CT; with different radiotracers) have shown that metastasis detection in advanced cancers is more accurate than with currently used CT and bone scans. However, the ability of WB-MRI and positron emission tomography/CT to assess therapeutic benefits has not been comprehensively evaluated. There is also considerable variability in the availability and quality of WB-MRI, which is an impediment to clinical development. Expert recommendations for standardising WB-MRI scans are needed, in order to assess its performance in advanced prostate cancer (APC) clinical trials. OBJECTIVE: To design recommendations that promote standardisation and diminish variations in the acquisition, interpretation, and reporting of WB-MRI scans for use in APC. EVIDENCE ACQUISITION: An international expert panel of oncologic imagers and oncologists with clinical and research interests in APC management assessed biomarker requirements for clinical care and clinical trials. Key requirements for a workable WB-MRI protocol, achievable quality standards, and interpretation criteria were identified and synthesised in a white paper. EVIDENCE SYNTHESIS: The METastasis Reporting and Data System for Prostate Cancer guidelines were formulated for use in all oncologic manifestations of APC. CONCLUSIONS: Uniformity in imaging data acquisition, quality, and interpretation of WB-MRI are essential for assessing the test performance of WB-MRI. The METastasis Reporting and Data System for Prostate Cancer standard requires validation in clinical trials of treatment approaches in APC. PATIENT SUMMARY: METastasis Reporting and Data System for Prostate Cancer represents the consensus recommendations on the performance, quality standards, and reporting of whole-body magnetic resonance imaging, for use in all oncologic manifestations of advanced prostate cancer. These new criteria require validation in clinical trials of established and new treatment approaches in advanced prostate cancer.