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Purpose Using multiparametric MRI data and the pathologic data from radical prostatectomy specimens, we simulated the treatment planning of dose-escalated high-dose-rate brachytherapy (HDR-BT) to the Multiparametric MRI dominant intraprostatic lesion (mpMRI-DIL) to compare the dose potentially delivered to the pathologically confirmed locations of the high-grade component of the cancer. Methods and Materials Pathologist-annotated prostatectomy midgland histology sections from 12 patients were registered to preprostatectomy mpMRI scans that were interpreted by four radiologists. To simulate realistic HDR-BT, we registered each observer's mpMRI-DILs and corresponding histology to two transrectal ultrasound images of other HDR-BT patients with a 15-Gy whole-gland prescription. We used clinical inverse planning to escalate the mpMRI-DILs to 20.25 Gy. We compared the dose that the histopathology would have received if treated with standard treatment plans to the dose mpMRI-targeting would have achieved. The histopathology was grouped as high-grade cancer (any Gleason Grade 4 or 5) and low-grade cancer (only Gleason Grade 3). Results 212 mpMRI-targeted HDR-BT plans were analyzed. For high-grade histology, the mpMRI-targeted plans achieved significantly higher median [IQR] D98 and D90 values of 18.2 [16.7–19.5] Gy and 19.4 [17.8–20.9] Gy, respectively, in comparison with the standard plans (p = 0.01 and p = 0.003). For low-grade histology, the targeted treatment plans would have resulted in a significantly higher median D90 of 17.0 [16.1–18.4] Gy in comparison with standard plans (p = 0.015); the median D98 was not significantly higher (p = 0.2). Conclusions In this retrospective pilot study of 12 patients, mpMRI-based dose escalation led to increased dose to high-grade, but not low-grade, cancer. In our data set, different observers and mpMRI sequences had no substantial effect on dose to histologic cancer.

Small bowel obstruction (SBO) is a common cause of emergency presentations for abdominal pain and can be complicated by mesenteric ischemia. Computed tomography is currently central to diagnosis and management planning. Currently accepted signs identify secondary effects of the root physiological insult, which is vascular obstruction. We hypothesized that with advancements in CT technology and reconstruction algorithms, we can now more closely interrogate the mesenteric vasculature for obstruction and more accurately predict the need for surgical intervention. We retrospectively audited the charts of all patients presenting with a clinical diagnosis of SBO at a single institution in a 12-month period. Two blinded consultant radiologists were then asked to analyze 3D MIP reconstruction CT scans for vascular obstruction in addition to any currently accepted signs of ischemia. Comparison between vascular cutoff and accepted current signs in the need for surgical intervention and the presence of any signs of ischemia in theater were recorded. Vascular cutoff had a comparable, with a trend towards superiority, sensitivity and specificity and inter-observer agreement to currently accepted signs of ischemia. The absence of a cut off sign has an excellent negative predictive value for ischemia with only 2 (3.7%) patients demonstrating ischemia at surgery where the vascular cutoff sign was not seen to be present. Interrogating vascular obstruction using 3D MIP reconstructions in small bowel obstruction may be a more sensitive and specific sign for prediction of surgical intervention, possibly occurring earlier in the obstruction pathway.

Multiparametric magnetic resonance imaging (mpMRI) has demonstrated the ability to localize intraprostatic lesions. It is our goal to determine how to optimally target the underlying histopathological cancer within the setting of high-dose-rate brachytherapy (HDR-BT).Ten prostatectomy patients had pathologist-annotated mid-gland histology registered to pre-procedural mpMRI, which were interpreted by four different observers. Simulated HDR-BT plans with realistic catheter placements were generated by registering the mpMRI lesions and corresponding histology annotations to previously performed clinical HDR-BT implants. Inverse treatment planning was used to generate treatment plans that treated the entire gland to a single dose of 15 Gy, as well as focally targeted plans that aimed to escalate dose to the mpMRI lesions to 20.25 Gy. Three margins to the lesion were explored: 0 mm, 1 mm, and 2 mm. The analysis compared the dose that would have been delivered to the corresponding histologically-defined cancer with the different treatment planning techniques.mpMRI-targeted plans delivered a significantly higher dose to the histologically-defined cancer (p0.001), in comparison to the standard treatment plans. Additionally, adding a 1 mm margin resulted in significantly higher D98, and D90 to the histologically-defined cancer in comparison to the 0 mm margin targeted plans (p = 0.019p = 0.0026). There was no significant difference between plans using 1 mm and 2 mm margins.Adding a 1 mm margin to intraprostatic mpMRI lesions significantly increased the dose to histologically-defined cancer, in comparison applying no margin. No significant effect was observed by further expanding the margins.

BACKGROUND & AIMS: Higher anti-tumor necrosis factor-α (TNF) drug levels are associated with improved clinical healing of Crohn's perianal fistulas. It is unclear whether this leads to improved healing on radiologic assessment. We aimed to evaluate the association between anti-TNF drug levels and radiologic outcomes in perianal fistulising Crohn's disease. METHODS: A cross-sectional retrospective multicenter study was undertaken. Patients with perianal fistulising Crohn's disease on maintenance infliximab or adalimumab, with drug levels within 6 months of perianal magnetic resonance imaging were included. Patients receiving dose changes or fistula surgery between drug level and imaging were excluded. Radiologic disease activity was scored using the Van Assche Index, with an inflammatory subscore calculated using indices: T2-weighted imaging hyperintensity, collections >3 mm diameter, rectal wall involvement. Primary endpoint was radiologic healing (inflammatory subscore ≤6). Secondary endpoint was radiologic remission (inflammatory subscore =0). RESULTS: Of 193 patients (infliximab, n = 117; adalimumab, n = 76), patients with radiologic healing had higher median drug levels compared with those with active disease (infliximab 6.0 vs 3.9 μg/mL; adalimumab 9.1 vs 6.2 μg/mL; both P < .05). Patients with radiologic remission also had higher median drug levels compared with those with active disease (infliximab 7.4 vs 3.9 μg/mL; P < .05; adalimumab 9.8 vs 6.2 μg/mL; P = .07). There was a significant incremental reduction in median inflammatory subscores with higher anti-TNF drug level tertiles. CONCLUSIONS: Higher anti-TNF drug levels were associated with improved radiologic outcomes on magnetic resonance imaging in perianal fistulising Crohn's disease, with an incremental improvement at higher drug level tertiles for both infliximab and adalimumab.

PURPOSE Multiparametric MRI (mpMRI) has shown promise in the detection and localization of prostate cancer foci. Although techniques have been previously introduced to delineate lesions from mpMRI, these techniques were evaluated in datasets with T2 maps available. The generation of T2 map is not included in the clinical prostate mpMRI consensus guidelines; the acquisition of which requires repeated T2-weighted (T2W) scans and would significantly lengthen the scan time currently required for the clinically recommended acquisition protocol, which includes T2W, diffusion-weighted (DW), and dynamic contrast-enhanced (DCE) imaging. The goal of this study is to develop and evaluate an algorithm that provides pixel-accurate lesion delineation from images acquired based on the clinical protocol. METHODS Twenty-five pixel-based features were extracted from the T2-weighted (T2W), apparent diffusion coefficient (ADC), and dynamic contrast-enhanced (DCE) images. The pixel-wise classification was performed on the reduced space generated by locality alignment discriminant analysis (LADA), a version of linear discriminant analysis (LDA) localized to patches in the feature space. Postprocessing procedures, including the removal of isolated points identified and filling of holes inside detected regions, were performed to improve delineation accuracy. The segmentation result was evaluated against the lesions manually delineated by four expert observers according to the Prostate Imaging-Reporting and Data System (PI-RADS) detection guideline. RESULTS The LADA-based classifier (60 ± 11%) achieved a higher sensitivity than the LDA-based classifier (51 ± 10%), thereby demonstrating, for the first time, that higher classification performance was attained on the reduced space generated by LADA than by LDA. Further sensitivity improvement (75 ± 14%) was obtained after postprocessing, approaching the sensitivities attained by previous mpMRI lesion delineation studies in which nonclinical T2 maps were available. CONCLUSION The proposed algorithm delineated lesions accurately and efficiently from images acquired following the clinical protocol. The development of this framework may potentially accelerate the clinical uses of mpMRI in prostate cancer diagnosis and treatment planning.

INTRODUCTION Multiparametric magnetic resonance imaging (mpMRI) of the prostate has become integral in the investigation of suspected prostate cancer. Regions of interest are graded using the PIRADS scoring system, and in our institution, lesions graded as PIRADS 3-5 undergo sampling by MRI-guided biopsy. Limited data currently exists on PIRADS grading and biopsy results. METHODS Retrospective review of 343 MRI-guided biopsies (MRGB) performed between April 2013 and December 2016 was conducted. This included patients irrespective of whether they were biopsy naive, biopsy negative or known low-grade malignancy. A Gleason score (G) >= 3+4 was considered to reflect clinically significant disease (CSD). RESULTS Of the 18 PIRADS 2 cases (at referrer request) who went to biopsy, 16 were negative and two had small volume Gleason 6 cancer. A total of 75 PIRADS 3 cases were biopsied with 88% negative or small volume Gleason 6 cancer, only 12% yielded ≥ G 3+4. Of the 133 PIRADS 4 lesions, 24% were negative, 25% were G6 and 51% were ≥ G 3+4. A total of 117 PIRADS 5 cases were biopsied with 7% negative, 13% Gleason 6 and 80% considered significant (≥ G 3+4). Of all biopsies, 230 (67%) had a positive result (≥ G6) with 171 of these (75%) being considered CSD, with overall CSD of 50% (171/343). CONCLUSIONS This paper demonstrates the incidence of CSD for different PIRADS grades. The low incidence of CSD in PIRADS 3 lesions suggests that in low clinical risk men, follow up in priority to biopsy may be an alternative treatment pathway.

A new method of diagnosing and defining functional popliteal artery entrapment syndrome is described. By combining ultrasonography and magnetic resonance imaging techniques with dynamic plantarflexion of the ankle against resistance, functional entrapment can be demonstrated and the location of the arterial occlusion identified. This combination of imaging modalities will also define muscular anatomy for guiding intervention such as surgery or Botox injection.

Prostate cancer is the third leading causes of death in men. However, the disease is curable if diagnosed early. During the past decades, multi-parametric magnetic resonance imaging (mpMRI) has been shown to be superior to trans-rectal ultrasound (TRUS) in detecting and localizing prostate cancer lesions to guide prostate biopsies and radiation therapies. The goal of this paper is to develop a simple and accurate graph-based regression framework for voxel-wise detection and grading of prostate cancer using mpMRIs. In the framework, groups of features were first extracted from the mpMRIs, and a graph-based multi-kernel model was proposed to learn the weights of the groups of features and the similarity matrix simultaneously. A Lapalacian regression model was then used to estimate the PI-RADS score of each voxels which characterizes how likely a voxel is cancerous. Experimental results of detection and grading of prostate lesions evaluated by six metrics show that the proposed method yielded convincing results.

Prostate segmentation on T2w MRI is important for several diagnostic and therapeutic procedures for prostate cancer. Manual segmentation is time-consuming, labor-intensive, and subject to high interobserver variability. This study investigated the suitability of computer-assisted segmentation algorithms for clinical translation, based on measurements of interoperator variability and measurements of the editing time required to yield clinically acceptable segmentations. A multioperator pilot study was performed under three pre- and postediting conditions: manual, semiautomatic, and automatic segmentation. We recorded the required editing time for each segmentation and measured the editing magnitude based on five different spatial metrics. We recorded average editing times of 213, 328, and 393 s for manual, semiautomatic, and automatic segmentation respectively, while an average fully manual segmentation time of 564 s was recorded. The reduced measured postediting interoperator variability of semiautomatic and automatic segmentations compared to the manual approach indicates the potential of computer-assisted segmentation for generating a clinically acceptable segmentation faster with higher consistency. The lack of strong correlation between editing time and the values of typically used error metrics ([Formula: see text]) implies that the necessary postsegmentation editing time needs to be measured directly in order to evaluate an algorithm's suitability for clinical translation.

Purpose Defining prostate cancer (PCa) lesion clinical target volumes (CTVs) for multiparametric magnetic resonance imaging (mpMRI) could support focal boosting or treatment to improve outcomes or lower morbidity, necessitating appropriate CTV margins for mpMRI-defined gross tumor volumes (GTVs). This study aimed to identify CTV margins yielding 95% coverage of PCa tumors for prospective cases with high likelihood. Methods and Materials Twenty-five men with biopsy-confirmed clinical stage T1 or T2 PCa underwent pre-prostatectomy mpMRI, yielding T2-weighted, dynamic contrast-enhanced, and apparent diffusion coefficient images. Digitized whole-mount histology was contoured and registered to mpMRI scans (error ≤2 mm). Four observers contoured lesion GTVs on each mpMRI scan. CTVs were defined by isotropic and anisotropic expansion from these GTVs and from multiparametric (unioned) GTVs from 2 to 3 scans. Histologic coverage (proportions of tumor area on co-registered histology inside the CTV, measured for Gleason scores [GSs] ≥6 and ≥7) and prostate sparing (proportions of prostate volume outside the CTV) were measured. Nonparametric histologic-coverage prediction intervals defined minimal margins yielding 95% coverage for prospective cases with 78% to 92% likelihood. Results On analysis of 72 true-positive tumor detections, 95% coverage margins were 9 to 11 mm (GS ≥ 6) and 8 to 10 mm (GS ≥ 7) for single-sequence GTVs and were 8 mm (GS ≥ 6) and 6 mm (GS ≥ 7) for 3-sequence GTVs, yielding CTVs that spared 47% to 81% of prostate tissue for the majority of tumors. Inclusion of T2-weighted contours increased sparing for multiparametric CTVs with 95% coverage margins for GS ≥6, and inclusion of dynamic contrast-enhanced contours increased sparing for GS ≥7. Anisotropic 95% coverage margins increased the sparing proportions to 71% to 86%. Conclusions Multiparametric magnetic resonance imaging–defined GTVs expanded by appropriate margins may support focal boosting or treatment of PCa; however, these margins, accounting for interobserver and intertumoral variability, may preclude highly conformal CTVs. Multiparametric GTVs and anisotropic margins may reduce the required margins and improve prostate sparing.

Three-dimensional (3D) prostate image segmentation is useful for cancer diagnosis and therapy guidance, but can be time-consuming to perform manually and involves varying levels of difficulty and interoperator variability within the prostatic base, midgland (MG), and apex. In this study, the authors measured accuracy and interobserver variability in the segmentation of the prostate on T2-weighted endorectal magnetic resonance (MR) imaging within the whole gland (WG), and separately within the apex, midgland, and base regions.The authors collected MR images from 42 prostate cancer patients. Prostate border delineation was performed manually by one observer on all images and by two other observers on a subset of ten images. The authors used complementary boundary-, region-, and volume-based metrics [mean absolute distance (MAD), Dice similarity coefficient (DSC), recall rate, precision rate, and volume difference (ΔV)] to elucidate the different types of segmentation errors that they observed. Evaluation for expert manual and semiautomatic segmentation approaches was carried out. Compared to manual segmentation, the authors' semiautomatic approach reduces the necessary user interaction by only requiring an indication of the anteroposterior orientation of the prostate and the selection of prostate center points on the apex, base, and midgland slices. Based on these inputs, the algorithm identifies candidate prostate boundary points using learned boundary appearance characteristics and performs regularization based on learned prostate shape information.The semiautomated algorithm required an average of 30 s of user interaction time (measured for nine operators) for each 3D prostate segmentation. The authors compared the segmentations from this method to manual segmentations in a single-operator (mean whole gland MAD = 2.0 mm, DSC = 82%, recall = 77%, precision = 88%, and ΔV = - 4.6 cm(3)) and multioperator study (mean whole gland MAD = 2.2 mm, DSC = 77%, recall = 72%, precision = 86%, and ΔV = - 4.0 cm(3)). These results compared favorably with observed differences between manual segmentations and a simultaneous truth and performance level estimation reference for this data set (whole gland differences as high as MAD = 3.1 mm, DSC = 78%, recall = 66%, precision = 77%, and ΔV = 15.5 cm(3)). The authors found that overall, midgland segmentation was more accurate and repeatable than the segmentation of the apex and base, with the base posing the greatest challenge.The main conclusions of this study were that (1) the semiautomated approach reduced interobserver segmentation variability; (2) the segmentation accuracy of the semiautomated approach, as well as the accuracies of recently published methods from other groups, were within the range of observed expert variability in manual prostate segmentation; and (3) further efforts in the development of computer-assisted segmentation would be most productive if focused on improvement of segmentation accuracy and reduction of variability within the prostatic apex and base.

To describe a new syndrome of tight orbit and intractable glaucoma with a poor visual prognosis.A retrospective observational case series of six patients seen at two centres between 2001 and 2007 assessing intraocular pressure (IOP), best-corrected visual acuity and visual field.Three men and three women, ranging in age at diagnosis from 14 to 53 years, demonstrated similar orbital features and progressive visual field loss despite intensive management with medication and laser and operative surgery. Highest IOPs ranged from 30 to 50 mmHg. Trabeculectomy and/or glaucoma drainage devices were attempted in five patients but all failed. One patient underwent orbital decompression with achievement of IOP control. Final IOP at last follow-up was variable; only two patients achieved IOP in the normal range, with the rest ranging from 25 to 40 mmHg. All patients had advanced visual field loss.Tight orbit syndrome presents a serious clinical challenge. Despite maximum medical therapy and surgical intervention IOP is difficult to control, resulting in progressive visual field loss.

Purpose Microwave (MW) thermal ablation permits large, uniform burn volumes through synergistic placement of multiple probes; however, proper MW thermal induction requires that the probes be parallel. The stability and reliability of the ellipsoidal ablation volume shape to non-parallel MW probe placement is unknown, yet it is critical to determine when needle repositioning is required. The impact of non-parallelity on multi-probe MW ablation volume is evaluated in an in vivo porcine liver model. Materials and Methods Animal ethics approval was obtained to perform hepatic ablations in pigs under general anesthesia. Two MW probes were inserted under 3D US guidance in parallel, 5°, 10°, and 15° diverging orientations with all tips separated by 1.5cm. Ten minute ablations were performed at 45W. The pig was sacrificed and the liver harvested post-ablation. The harvested liver was imaged with MRI to assess ablation shape prior to histopathological fixation, which causes deformation and volume loss. The ablation volume cross-section was analyzed at both the probe tip and feed point. Results A total of eight ablations were performed on two pigs. Post-ablation hepatic MRI demonstrated excellent histological detail in T1 weighting, where the well marginated hemorrhagic zone separated the coagulation zone from the normal parenchyma. The periphery of the coagulation zone was used for all measurements. The ablation volumes were more lobulated and less spherical as the probe alignment moved from parallel to 5o obliquity. Decoupling of the multi-probe synergistic energy was most evident at 10o divergence, with two lobes within the ablation volume encircling each probe. These effects were largest at the probe tip as compared to the focal point. The ablation length along the probe axis was not substantially affected. Quantative comparisons are within the Table. Conclusion For multiple MW probes, the expected ablation volume shape is not reliable for insertions of ≥5° obliquity, so care should be taken to ensure parallel insertion. Table 1

volume is critical in treatment planning. Whether by expert guidelines, retrograde urethrography, bony landmark, ultrasound, or CT-based planning, there is discordant anatomic information regarding the distance between apex and the bulb, also known as the genitourinary diaphragm (GUD) or membranous urethra length (MUL). In this study, we use MRI with endorectal coil in a large series of patients to better characterize the MUL in radiation therapy planning. Materials/Methods: Patients with early stage, clinically localized prostate cancer (Gleason 6 and 7, cT1c-cT2b, PSA 85% interobserver agreement within 2 mm measurement. There was no association between MUL and patient age, T-stage, Gleason score, patient height, weight, or NCCN risk group. Conclusions: Although there remains variability, the median MUL, or GUD length, is 15 mm. This report likely represents the largest evaluation of the pre-treatment MUL in men with prostate cancer treated with external beam radiation. Our data challenges traditional guidelines between the apex and bulb from smaller series and adds to critical anatomic information of male urethral length and prostate apex anatomy. Prostate MRI with endorectal coil produces a reliable MUL and should be used to optimize target volume delineation at the prostate apex. Author Disclosure: N.K. Taunk: None. O. Akin: None. X. Pei: None. M. Zelefsky: None.