Use of Imaging and Biopsy in Prostate Cancer Diagnosis:A Survey From the Asian Prostate Imaging Working Group

Objective@#To elucidate the use of radiological studies, including nuclear medicine, and biopsy for the diagnosis and staging of prostate cancer (PCA) in clinical practice and understand the current status of PCA in Asian countries via an international survey. @*Materials and Methods@#The Asian Prostate Imaging Working Group designed a survey questionnaire with four domains focused on prostate magnetic resonance imaging (MRI), other prostate imaging, prostate biopsy, and PCA backgrounds. The questionnaire was sent to 111 members of professional affiliations in Korea, Japan, Singapore, and Taiwan who were representatives of their working hospitals, and their responses were analyzed. @*Results@#This survey had a response rate of 97.3% (108/111). The rates of using 3T scanners, antispasmodic agents, laxative drugs, and prostate imaging-reporting and data system reporting for prostate MRI were 21.6%−78.9%, 22.2%−84.2%, 2.3%−26.3%, and 59.5%−100%, respectively. Respondents reported using the highest b-values of 800−2000 sec/mm2 and fields of view of 9−30 cm. The prostate MRI examinations per month ranged from 1 to 600, and they were most commonly indicated for biopsy-naïve patients suspected of PCA in Japan and Singapore and staging of proven PCA in Korea and Taiwan.The most commonly used radiotracers for prostate positron emission tomography are prostate-specific membrane antigen in Singapore and fluorodeoxyglucose in three other countries. The most common timing for prostate MRI was before biopsy (29.9%). Prostate-targeted biopsies were performed in 63.8% of hospitals, usually by MRI-ultrasound fusion approach. The most common presentation was localized PCA in all four countries, and it was usually treated with radical prostatectomy. @*Conclusion@#This survey showed the diverse technical details and the availability of imaging and biopsy in the evaluation of PCA. This suggests the need for an educational program for Asian radiologists to promote standardized evidence-based imaging approaches for the diagnosis and staging of PCA.

Imaging Patterns of Bacillus Calmette–Guérin-Related Granulomatous Prostatitis Based on Multiparametric MRI

Objective@#To categorize multiparametric MRI features of Bacillus Calmette–Guérin (BCG)-related granulomatous prostatitis (GP) and discover potential manifestations for its differential diagnosis from prostate cancer. @*Materials and Methods@#The cases of BCG-related GP in 24 male (mean age ± standard deviation, 66.0 ± 9.4 years; range, 50–88 years) pathologically confirmed between January 2011 and April 2019 were retrospectively reviewed. All patients underwent intravesical BCG therapy followed by a MRI scan. Additional follow-up MRI scans, including diffusion-weighted imaging (DWI), were performed in 19 patients. The BCG-related GP cases were categorized into three: A, B, or C. The lesions with diffusion restriction and homogeneous enhancement were classified as type A. The lesions with diffusion restriction and a poorly enhancing component were classified as type B. A low signal intensity on high b-value DWI (b = 1000 s/mm2 ) was considered characteristic of type C. Two radiologists independently interpreted the MRI scans before making a consensus about the types. @*Results@#The median lesion size was 22 mm with the interquartile range (IQR) of 18–26 mm as measured using the initial MRI scans. The lesion types were A, B, and C in 7, 15, and 2 patients, respectively. Cohen’s kappa value for the inter-reader agreement for the interpretation of the lesion types was 0.837. On the last follow-up MRI scans of 19 patients, the size decreased (median, 5.8 mm; IQR, 3.4–8.5 mm), and the type changed from A or B to C in 11 patients. The lesions resolved in four patients. In five patients who underwent prostatectomy, caseous necrosis on histopathology matched with the non-enhancing components of type B lesions and the entire type C lesions. @*Conclusion@#BCG-related GP demonstrated three imaging patterns on multiparametric MRI. Contrast-enhanced T1-weighted imaging and DWI may play a role in its differential diagnosis from prostate cancer.

CT-Based Fagotti Scoring System for Non-Invasive Prediction of Cytoreduction Surgery Outcome in Patients with Advanced Ovarian Cancer

Objective@#To construct a CT-based Fagotti scoring system by analyzing the correlations between laparoscopic findings and CT features in patients with advanced ovarian cancer. @*Materials and Methods@#This retrospective cohort study included patients diagnosed with stage III/IV ovarian cancer who underwent diagnostic laparoscopy and debulking surgery between January 2010 and June 2018. Two radiologists independently reviewed preoperative CT scans and assessed ten CT features known as predictors of suboptimal cytoreduction. Correlation analysis between ten CT features and seven laparoscopic parameters based on the Fagotti scoring system was performed using Spearman’s correlation. Variable selection and model construction were performed by logistic regression with the least absolute shrinkage and selection operator method using a predictive index value (PIV) ≥ 8 as an indicator of suboptimal cytoreduction. The final CT-based scoring system was internally validated using 5-fold cross-validation. @*Results@#A total of 157 patients (median age, 56 years; range, 27–79 years) were evaluated. Among 120 (76.4%) patients with a PIV ≥ 8, 105 patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the optimal cytoreduction rate was 90.5% (95 of 105). Among 37 (23.6%) patients with PIV < 8, 29 patients underwent primary debulking surgery, and the optimal cytoreduction rate was 93.1% (27 of 29). CT features showing significant correlations with PIV ≥ 8 were mesenteric involvement, gastro-transverse mesocolon-splenic space involvement, diaphragmatic involvement, and para-aortic lymphadenopathy. The area under the receiver operating curve of the final model for prediction of PIV ≥ 8 was 0.72 (95% confidence interval: 0.62–0.82). @*Conclusion@#Central tumor burden and upper abdominal spread features on preoperative CT were identified as distinct predictive factors for high PIV on diagnostic laparoscopy. The CT-based PIV prediction model might be useful for patient stratification before cytoreduction surgery for advanced ovarian cancer.

Imaging of Scrotal Tumors

Ultrasonography is effective for imaging superficial organs, such as the scrotum. Using a highfrequency transducer, ultrasonography can identify the location and characteristics of scrotal lesions with high accuracy. The primary role of ultrasound (US) in the evaluation of a scrotal mass is to determine if it is intratesticular or extratesticular. Additional clinical information and other imaging options may be needed to diagnose benign tumors and pseudo-tumors. MRI is an effective problem-solving tool in cases with nondiagnostic US findings. CT is helpful for staging testicular cancer and localizing undescended testis. This review covers the imaging features of testicular and extratesticular tumors.

CT-Based Fagotti Scoring System for Non-Invasive Prediction of Cytoreduction Surgery Outcome in Patients with Advanced Ovarian Cancer

Objective@#To construct a CT-based Fagotti scoring system by analyzing the correlations between laparoscopic findings and CT features in patients with advanced ovarian cancer. @*Materials and Methods@#This retrospective cohort study included patients diagnosed with stage III/IV ovarian cancer who underwent diagnostic laparoscopy and debulking surgery between January 2010 and June 2018. Two radiologists independently reviewed preoperative CT scans and assessed ten CT features known as predictors of suboptimal cytoreduction. Correlation analysis between ten CT features and seven laparoscopic parameters based on the Fagotti scoring system was performed using Spearman’s correlation. Variable selection and model construction were performed by logistic regression with the least absolute shrinkage and selection operator method using a predictive index value (PIV) ≥ 8 as an indicator of suboptimal cytoreduction. The final CT-based scoring system was internally validated using 5-fold cross-validation. @*Results@#A total of 157 patients (median age, 56 years; range, 27–79 years) were evaluated. Among 120 (76.4%) patients with a PIV ≥ 8, 105 patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the optimal cytoreduction rate was 90.5% (95 of 105). Among 37 (23.6%) patients with PIV < 8, 29 patients underwent primary debulking surgery, and the optimal cytoreduction rate was 93.1% (27 of 29). CT features showing significant correlations with PIV ≥ 8 were mesenteric involvement, gastro-transverse mesocolon-splenic space involvement, diaphragmatic involvement, and para-aortic lymphadenopathy. The area under the receiver operating curve of the final model for prediction of PIV ≥ 8 was 0.72 (95% confidence interval: 0.62–0.82). @*Conclusion@#Central tumor burden and upper abdominal spread features on preoperative CT were identified as distinct predictive factors for high PIV on diagnostic laparoscopy. The CT-based PIV prediction model might be useful for patient stratification before cytoreduction surgery for advanced ovarian cancer.

Imaging of Scrotal Tumors

Ultrasonography is effective for imaging superficial organs, such as the scrotum. Using a highfrequency transducer, ultrasonography can identify the location and characteristics of scrotal lesions with high accuracy. The primary role of ultrasound (US) in the evaluation of a scrotal mass is to determine if it is intratesticular or extratesticular. Additional clinical information and other imaging options may be needed to diagnose benign tumors and pseudo-tumors. MRI is an effective problem-solving tool in cases with nondiagnostic US findings. CT is helpful for staging testicular cancer and localizing undescended testis. This review covers the imaging features of testicular and extratesticular tumors.

Immunoglobulin G4-Related Disease of the Ovary Mimicking Bilateral Ovarian Malignancies

Immunoglobulin G4-related disease (IgG4-RD) is a fibro-inflammatory condition characterized by several pathological features that can theoretically involve all organs. Ovarian involvement in IgG4-RD has been reported by two studies only. Herein, we report a pathologically confirmed case of ovarian involvement of IgG4-RD, which mimicked bilateral ovarian malignancies on computed tomography and magnetic resonance imaging.

Effects of Altered Calcium Metabolism on Cardiac Parameters in Primary Aldosteronism

BACKGROUND: Increasing evidence supports interplay between aldosterone and parathyroid hormone (PTH), which may aggravate cardiovascular complications in various heart diseases. Negative structural cardiovascular remodeling by primary aldosteronism (PA) is also suspected to be associated with changes in calcium levels. However, to date, few clinical studies have examined how changes in calcium and PTH levels influence cardiovascular outcomes in PA patients. Therefore, we investigated the impact of altered calcium homeostasis caused by excessive aldosterone on cardiovascular parameters in patients with PA. METHODS: Forty-two patients (mean age 48.8±10.9 years; 1:1, male:female) whose plasma aldosterone concentration/plasma renin activity ratio was more than 30 were selected among those who had visited Severance Hospital from 2010 to 2014. All patients underwent adrenal venous sampling with complete access to both adrenal veins. RESULTS: The prevalence of unilateral adrenal adenoma (54.8%) was similar to that of bilateral adrenal hyperplasia. Mean serum corrected calcium level was 8.9±0.3 mg/dL (range, 8.3 to 9.9). The corrected calcium level had a negative linear correlation with left ventricular end-diastolic diameter (LVEDD, ρ=−0.424, P=0.031). Moreover, multivariable regression analysis showed that the corrected calcium level was marginally associated with the LVEDD and corrected QT (QTc) interval (β=−0.366, P=0.068 and β=−0.252, P=0.070, respectively). CONCLUSION: Aldosterone-mediated hypercalciuria and subsequent hypocalcemia may be partly involved in the development of cardiac remodeling as well as a prolonged QTc interval, in subjects with PA, thereby triggering deleterious effects on target organs additively.

Prostate Imaging-Reporting and Data System Version 2: Beyond Prostate Cancer Detection

The main purpose of Prostate Imaging-Reporting and Data System Version 2 (PI-RADSv2) is to effectively detect clinically significant prostate cancers (csPCa) using multiparametric magnetic resonance imaging. Since the first introduction of PI-RADSv2, researchers have validated its diagnostic performance in identifying csPCa, and these promising data have influenced biopsy and treatment schemes. However, in this article, we focused on the potential of PI-RADSv2 in relation to various aspects of PCa such as Gleason score, tumor volume, extraprostatic extension, lymph node metastasis, and postoperative biochemical recurrence, beyond prostate cancer detection.

Cardiac Dysfunction in Association with Increased Inflammatory Markers in Primary Aldosteronism

BACKGROUND: Oxidative stress in primary aldosteronism (PA) is thought to worsen aldosterone-induced damage by activating proinflammatory processes. Therefore, we investigated whether inflammatory markers associated with oxidative stress is increased with negative impacts on heart function as evaluated by echocardiography in patients with PA. METHODS: Thirty-two subjects (mean age, 50.3±11.0 years; 14 males, 18 females) whose aldosterone-renin ratio was more than 30 among patients who visited Severance Hospital since 2010 were enrolled. Interleukin-1β (IL-1β), IL-6, IL-8, monocyte chemoattractant protein 1, tumor necrosis factor α (TNF-α), and matrix metalloproteinase 2 (MMP-2), and MMP-9 were measured. All patients underwent adrenal venous sampling with complete access to both adrenal veins. RESULTS: Only MMP-2 level was significantly higher in the aldosterone-producing adenoma (APA) group than in the bilateral adrenal hyperplasia (BAH). Patients with APA had significantly higher left ventricular (LV) mass and A velocity, compared to those with BAH. IL-1β was positively correlated with left atrial volume index. Both TNF-α and MMP-2 also had positive linear correlation with A velocity. Furthermore, MMP-9 showed a positive correlation with LV mass, whereas it was negatively correlated with LV end-systolic diameter. CONCLUSION: These results suggest the possibility that some of inflammatory markers related to oxidative stress may be involved in developing diastolic dysfunction accompanied by LV hypertrophy in PA. Further investigations are needed to clarify the role of oxidative stress in the course of cardiac remodeling.

Simplified Zero Ischemia in Robot Assisted Partial Nephrectomy: Initial Yonsei Experience

PURPOSE: To evaluate the safety and feasibility of a simplified zero ischemia technique using kidney donor computed tomographic (CT) angiography and conventional laparoscopic bulldog clamps. MATERIALS AND METHODS: We conducted a review of seven robot-assisted partial nephrectomies (RAPNs) performed by a single surgeon from January 2012 to May 2012. Using a simplified protocol of 3-dimentional reconstruction, tertiary arterial branches supplying the tumor were selectively clamped prior to resection. We used conventional laparoscopic bulldog clamps instead of microsurgical vessel clamps. The patients' demographic information, perioperative outcomes, pathologic outcomes and pre- and postoperative renal functions up to 3 months follow-up were analyzed. RESULTS: RAPN were successfully performed for seven complex renal hilar tumors. There were no significant differences in the total operation time, estimated blood loss or postoperative outcomes compared with published literature on standard RAPN. Negative surgical margins were reported in all cases. CONCLUSIONS: We presented a simplified-zero ischemia technique using kidney Donor CT angiography and conventional laparoscopic bulldog clamps. We have also demonstrated its safety and feasibility in patients with complex renal hilar tumors. This modified technique can be easily adopted by most surgeons who are currently performing RAPN.

Differential Diagnosis of Complex Renal Cysts Based on Lesion Size along with the Bosniak Renal Cyst Classification

PURPOSE: To identify size criteria for complex cystic renal masses that can distinguish renal cell carcinoma from benign cysts supplementing the Bosniak classification. MATERIALS AND METHODS: We reviewed the records of 97 patients who underwent surgery for complex cystic renal masses from January 2001 to April 2010. The pathological results were compared with the lesion sizes measured by preoperative computed tomography and other radiological features (contrast enhancement, irregularities of cyst walls and septa, and calcification) were also obtained for categorization according to the Bosniak renal cyst classification. RESULTS: Malignancy was significantly associated with cyst size (>2 cm), male gender, and younger patient age (<50 years). According to the Bosniak classification, there was no category I cyst, and all 8 category II cysts were benign. However, 3 of 18 (17%) category IIF cysts, 21 of 39 (54%) category III cysts, and 29 of 32 (90%) category IV cysts were malignant. All category IIF cysts were benign in patients older than 50 years of age. CONCLUSION: Many complex cystic renal masses smaller than 2 cm were benign. We suggest that lesion size should be taken into account when formulating treatment plans for complex cystic renal masses.

Round Ligament Varicosities During Pregnancy: Case Report

There are various causes of a painful palpable mass in the groin during pregnancy. The differential diagnoses of an inguinal mass include hernia, lymphadenopathy, mesothelial cyst, cystic lymphangioma, neoplasms (lipoma, leiomyoma and sarcoma), endometriosis, embryonic remnants and round ligament varicosities. Among them, round ligament varicosities can be easily misdiagnosed as an inguinal hernia in a pregnant woman. These lesions should be managed conservatively because they resolve spontaneously during the postpartum period. Ultrasonography can help make the diagnosis of round ligament varicosities and so prevent unnecessary surgical intervention and the associated morbidity. Herein we report on a case of round ligament varicosities that presented during pregnancy and this condition was readily diagnosed via Doppler sonography.

Spontaneous Treatment of Renal Artery Pseudoaneurysm after Partial Nephrectomy: A Case Report

A partial nephrectomy is being used increasingly for the removal of renal cell carcinomas. A renal artery pseudoaneurysm (RAP) is a rare, potentially life threatening complication after a partial nephrectomy. This paper presents a case of spontaneous thrombosis of RAP after a partial nephrectomy. The presented case is believed to be the largest in diameter (59 mm) among the reported cases of spontaneous treatment of RAP by complete thrombosis.

Prospective Evaluation of the Accuracy of MDCT Angiography for Living Kidney Donor

PURPOSE: In donor nephrectomy, it is important to understand the exact anatomy of the blood vessels during minimally invasive surgery. We prospectively analyzed the accuracy of the vessel structures obtained by use of 64-row multi-detector computed tomography (MDCT) angiography compared with the actual vessel structure observed during surgery. MATERIALS AND METHODS: We analyzed 238 patients who underwent donor nephrectomy from July 2007 to August 2010. Before the operation, MDCT angiography was performed, and after the operation, the surgeons themselves wrote the protocol. The ipsilateral artery, the number of veins, the association with the run of the hilar vessel, and other vascular anomalies in computed tomography (CT) angiography and in the donor protocol were summarized. RESULTS: Among 238 patients, nephrectomy was performed on the left side in 199 patients. The accuracy of MDCT for the artery and the vein was 93.3% and 92.4%, respectively. Accuracy did not differ significantly on the left and right sides (artery: p=0.124; vein: p=0.174). In 199 patients, the CT findings for the lumbar vein were compared with the surgical findings. The overall accuracy was shown to be 84.9%, and the accuracy of the group drained to the inferior vena cava (54%) was significantly different (p<0.01) from that of the group drained to the renal vein (98.6%). Thus, it may be necessary to pay close attention to the interpretation of the findings for the lumbar vein. CONCLUSIONS: MDCT angiography is important for understanding the exact anatomy of blood vessels before minimally invasive surgery. We showed that 64-channel MDCT has high accuracy in the main vessel and hilar vessels. However, close attention to the interpretation of the CT findings for the lumbar vein may be required.

Comparison of Two Local Anesthesia Injection Methods During a Transrectal Ultrasonography-guided Prostate Biopsy

PURPOSE: To compare the effectiveness of 2 injection methods of lidocaine during a transrectal ultrasound (TRUS)-guided prostate biopsy for pain control and complication rates. MATERIALS AND METHODS: We retrospectively evaluated patients who underwent a TRUS-guided prostate biopsy from March 2005 to March 2006. One hundred patients were categorized into two groups based on injection method. For group 1, 10 mL of 1% lidocaine was injected bilaterally at the junction of the seminal vesicle and prostate and for group 2, into Denonvilliers' fascia. Pain scores using a visual analog scale (VAS) as well as immediate and delayed complication rates were evaluated. RESULTS: The mean VAS score showed no significant differences between the groups (group 1, 3.4+/-1.78; group 2, 2.8+/-1.3; p = 0.062). The difference in delayed complication rates and incidence of hematuria, hemospermia, and blood via the rectum was not significant between groups. However, two patients in group 1 complained of symptoms immediately after local anesthesia; one of tinnitus and the other of mild dizziness. CONCLUSION: There were no significant differences between pain control and complication rates between the 2 lidocaine injection methods. However, injection into Denonvilliers' fascia is thought to have less potential risk.

Idiopathic Retroperitoneal Fibrosis Associated with Hashimoto's Thyroiditis in an Old-aged Man

Idiopathic retroperitoneal fibrosis (IRPF) is a rare disease characterized by a retroperitoneal inflammatory proliferative fibrosing process. Hashimoto's thyroiditis is the most common inflammatory condition of the thyroid gland; and is a frequently-occurring autoimmune disorder manifesting predominantly in middle-aged women. We report a rare association of IRPF with Hashimoto's thyroiditis in a 67-year-old man demonstrating good response to steroid therapy.

Robot-Assisted Laparoscopic Radical Prostatectomy: Four Cases

The role of the da Vinci(TM) robot is being defined in minimally invasive urologic surgery. Robot-assisted laparoscopic radical prostatectomy (rLRP) has emerged as a feasible treatment option for patients with organ-confined prostate cancer. We performed the first four rLRPs on four prostate cancer patients in the Republic of Korea. This is a report of its techniques and outcomes. In all four cases, the surgery was successfully completed with a mean operative time of 392.5 minutes. The mean estimated blood loss was 312.5mL, and catheterization lasted 14 to 21 days. There were no major intraoperative or postoperative complications. The mean hospital stay was 11 days. The rLRP is a safe and feasible approach. It will become one of the standard options for the management of localized prostate cancer.

Inflammatory Myofibroblastic Tumor of Kidney / 대한비뇨기과학회지

Inflammatory myofibroblastic tumor (IMT) is a very rare benign mass lesion. Inflammatory myofibroblastic tumor of genitourinary tract most frequently involves the urinary bladder. Renal inflammatory myofibroblastic tumor is rare. Renal inflammatory myofibroblastic tumor usually remain asymtomatic until the tumor occurs obstructive uropathy. We experienced a case of right renal inflammatory myofibroblastic tumor.

Recurrent Urinary Tract Obstruction Due to Long-Coiled Transplant Ureter and Extrinsic Ureteric Compression / 대한이식학회지

Urinary tract complications, manifesting as leakage or obstruction, generally occur in 3.0~13% of renal recipients. Most complications occur at the ureterovesical anastomosis and are secondary to technical causes and ureteric ischemia. Ultrasound and computed tomographic images are described in a recipient who underwent oversea deceased donor renal transplantation and presented with recurrent ureteral obstruction and hydronephrosis secondary to combination of unusually located transplant kidney, long-coiled ureter, ureteric compression and ischemia of the transplant ureter.