Is non-contrast-enhanced magnetic resonance imaging cost-effective for screening of hepatocellular carcinoma?

INTRODUCTION@#Ultrasonography (US) is the current standard of care for imaging surveillance in patients at risk of hepatocellular carcinoma (HCC). Magnetic resonance imaging (MRI) has been explored as an alternative, given the higher sensitivity of MRI, although this comes at a higher cost. We performed a cost-effective analysis comparing US and dual-sequence non-contrast-enhanced MRI (NCEMRI) for HCC surveillance in the local setting.@*METHODS@#Cost-effectiveness analysis of no surveillance, US surveillance and NCEMRI surveillance was performed using Markov modelling and microsimulation. At-risk patient cohort was simulated and followed up for 40 years to estimate the patients' disease status, direct medical costs and effectiveness. Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio were calculated.@*RESULTS@#Exactly 482,000 patients with an average age of 40 years were simulated and followed up for 40 years. The average total costs and QALYs for the three scenarios - no surveillance, US surveillance and NCEMRI surveillance - were SGD 1,193/7.460 QALYs, SGD 8,099/11.195 QALYs and SGD 9,720/11.366 QALYs, respectively.@*CONCLUSION@#Despite NCEMRI having a superior diagnostic accuracy, it is a less cost-effective strategy than US for HCC surveillance in the general at-risk population. Future local cost-effectiveness analyses should include stratifying surveillance methods with a variety of imaging techniques (US, NCEMRI, contrast-enhanced MRI) based on patients' risk profiles.

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.

Can we omit systematic biopsies in patients undergoing MRI fusion-targeted prostate biopsies? / 亚洲男科学杂志(英文版)

Magnetic resonance imaging (MRI)-targeted prostate biopsy is the recommended investigation in men with suspicious lesion(s) on MRI. The role of concurrent systematic in addition to targeted biopsies is currently unclear. Using our prospectively maintained database, we identified men with at least one Prostate Imaging-Reporting and Data System (PI-RADS) ≥3 lesion who underwent targeted and/or systematic biopsies from May 2016 to May 2020. Clinically significant prostate cancer (csPCa) was defined as any Gleason grade group ≥2 cancer. Of 545 patients who underwent MRI fusion-targeted biopsy, 222 (40.7%) were biopsy naïve, 247 (45.3%) had previous prostate biopsy(s), and 76 (13.9%) had known prostate cancer undergoing active surveillance. Prostate cancer was more commonly found in biopsy-naïve men (63.5%) and those on active surveillance (68.4%) compared to those who had previous biopsies (35.2%; both P < 0.001). Systematic biopsies provided an incremental 10.4% detection of csPCa among biopsy-naïve patients, versus an incremental 2.4% among those who had prior negative biopsies. Multivariable regression found age (odds ratio [OR] = 1.03, P = 0.03), prostate-specific antigen (PSA) density ≥0.15 ng ml-2 (OR = 3.24, P < 0.001), prostate health index (PHI) ≥35 (OR = 2.43, P = 0.006), higher PI-RADS score (vs PI-RADS 3; OR = 4.59 for PI-RADS 4, and OR = 9.91 for PI-RADS 5; both P < 0.001) and target lesion volume-to-prostate volume ratio ≥0.10 (OR = 5.26, P = 0.013) were significantly associated with csPCa detection on targeted biopsy. In conclusion, for men undergoing MRI fusion-targeted prostate biopsies, systematic biopsies should not be omitted given its incremental value to targeted biopsies alone. The factors such as PSA density ≥0.15 ng ml-2, PHI ≥35, higher PI-RADS score, and target lesion volume-to-prostate volume ratio ≥0.10 can help identify men at higher risk of csPCa.

Evaluation of non-contrast magnetic resonance imaging as an imaging surveillance tool for hepatocellular carcinoma in at-risk patients

INTRODUCTION@#This study aimed to evaluate the potential of non-contrast-enhanced magnetic resonance (MR) imaging as an imaging surveillance tool for detection of hepatocellular carcinoma (HCC) in at-risk patients and to compare the performance of non-contrast MR imaging with ultrasonography (US) as a screening modality for the same.@*METHODS@#In this retrospective study, patients diagnosed with HCC between 1 January 2010 and 31 December 2015 were selected from our institution's cancer registry. Patients who underwent MR imaging and had US performed within three months of the MR imaging were included. For each MR imaging, two non-contrast MR imaging sequences - T2-weighted fat-saturated (T2-W FS) sequence and diffusion-weighted imaging (DWI) - were reviewed for the presence of suspicious lesions. A non-contrast MR image was considered positive if the lesion was seen on both sequences. The performance of non-contrast MR imaging was compared to that of hepatobiliary US for the detection of HCC.@*RESULTS@#A total of 73 patients with 108 HCCs were evaluated. Sensitivity of non-contrast MR imaging for the detection of HCC using T2-W FS and DWI was 93.2%, which was significantly higher than that of US, which was 79.5% (p = 0.02). In a subgroup of 55 patients with imaging features of liver cirrhosis, the sensitivity of non-contrast MR imaging was 90.9%, which was also significantly higher than that of US, which was 74.5% (p = 0.02).@*CONCLUSION@#Our pilot study showed that non-contrast MR imaging, using a combination of T2-W FS and DWI, is a potential alternative to US as a screening tool for surveillance of patients at risk for HCC.

Safety of a rapid outpatient hydration protocol for patients with renal impairment requiring intravenous iodinated contrast media for computed tomography

INTRODUCTION@#Patients receiving intravenous iodinated contrast media for computed tomography (CT) are predisposed to contrast-induced nephropathy. Chronic kidney disease is an important risk factor, and hydration is the mainstay of prevention. While inpatients can undergo intravenous hydration, limited knowledge exists regarding regimens for outpatients. We employed a rapid outpatient hydration protocol to reduce postponement of imaging appointments for patients with suboptimal estimated glomerular filtration rate (eGFR).@*METHODS@#From June 2015, we amended our CT preparation protocol to mandate rapid hydration (oral, intravenous or both) for patients with an eGFR of 30-60 mL/min/1.73 m@*RESULTS@#226 outpatients received the hydration protocol, which correlated with a 95% reduction in postponement of imaging appointments. No complications of fluid overload from hydration were encountered. A significant association was observed between age and decrease in eGFR, but this was not significant when stratified by drop in eGFR category. No statistical significance was found between decrease in eGFR and gender or race. Higher baseline eGFR was less likely to be associated with decrease in eGFR after imaging. Type of hydration was not related to a drop in eGFR category for patients with an eGFR of 45-59 mL/min/1.73 m@*CONCLUSION@#We defined a shorter hydration regimen that is safe to use in the outpatient setting.

Multiparametric MRI in Active Surveillance of Prostate Cancer: An Overview and a Practical Approach

MRI has become important for the detection of prostate cancer. MRI-guided biopsy is superior to conventional systematic biopsy in patients suspected with prostate cancer. MRI is also increasingly used for monitoring patients with low-risk prostate cancer during active surveillance. It improves patient selection for active surveillance at diagnosis, although its role during follow-up is unclear. We aim to review existing evidence and propose a practical approach for incorporating MRI into active surveillance protocols.

Multiparametric MRI in Active Surveillance of Prostate Cancer: An Overview and a Practical Approach

MRI has become important for the detection of prostate cancer. MRI-guided biopsy is superior to conventional systematic biopsy in patients suspected with prostate cancer. MRI is also increasingly used for monitoring patients with low-risk prostate cancer during active surveillance. It improves patient selection for active surveillance at diagnosis, although its role during follow-up is unclear. We aim to review existing evidence and propose a practical approach for incorporating MRI into active surveillance protocols.

Accuracy of ultrasonography-guided fine needle aspiration cytology and significance of non-diagnostic cytology in the preoperative detection of thyroid malignancy

INTRODUCTION@#Thyroid fine-needle aspiration cytology (FNAC) is an established investigation for the preoperative evaluation of thyroid nodules and is often done under ultrasonography guidance. While its accuracy has been widely reported, there is little evidence in the literature on the approach to non-diagnostic cytology results. In our study, we aimed to determine the diagnostic performance of ultrasonography-guided thyroid FNAC for the preoperative diagnosis of thyroid cancer at our institution and evaluate the significance of a non-diagnostic thyroid FNAC.@*METHODS@#We retrospectively reviewed the thyroid ultrasonography studies and medical records of all patients who underwent both thyroid FNAC and subsequent thyroid surgery at our institution from 2011 to 2013. FNAC results were correlated with the final histological diagnosis from surgery and the ultrasonography studies were reviewed for suspicious sonographic features.@*RESULTS@#FNAC predicted malignancy with sensitivity, specificity, positive predictive value, negative predictive value, false positive rate, false negative rate and total accuracy of 90.7%, 53.6%, 43.3%, 93.7%, 46.4%, 9.3% and 64.1%, respectively. We found that only one of 26 nodules with non-diagnostic FNAC results was proven malignant on a second FNAC and subsequent thyroidectomy.@*CONCLUSION@#The accuracy of ultrasonography-guided FNAC at our institution was comparable to that reported in the literature. There appears to be very low probability of malignancy in sonographically benign nodules with initial non-diagnostic FNAC results.

A practical and adaptive approach to lung cancer screening: a review of international evidence and position on CT lung cancer screening in the Singaporean population by the College of Radiologists Singapore

Lung cancer is the leading cause of cancer-related death around the world, being the top cause of cancer-related deaths among men and the second most common cause of cancer-related deaths among women in Singapore. Currently, no screening programme for lung cancer exists in Singapore. Since there is mounting evidence indicating a different epidemiology of lung cancer in Asian countries, including Singapore, compared to the rest of the world, a unique and adaptive approach must be taken for a screening programme to be successful at reducing mortality while maintaining cost-effectiveness and a favourable risk-benefit ratio. This review article promotes the use of low-dose computed tomography of the chest and explores the radiological challenges and future directions.

Water as neutral oral contrast agent in abdominopelvic CT: comparing effectiveness with Gastrografin in the same patient

Introduction: Positive oral contrast is no longer deemed necessary for abdominopelvic computed tomography (CT) scans. Studies have shown water to be an equally effective oral contrast agent. However, to our knowledge no study has compared effectiveness between gastrografin and water in the same patient, which will provide a more objective evaluation of the two oral contrast agents. We aim to make a head-to-head comparison of water as neutral oral contrast (OC) against gastrografin as positive OC for abdominopelvic CT scans in the same patient. Methods: A retrospective review of 206 abdominopelvic CT scans of 103 patients was performed. The scans were reviewed in consensus by two blinded radiologists. The ability to visualise each abdominopelvic organ, contrastassociated artefacts and small bowel wall delineation, was qualitatively scored on a 5-point scale. Each patient had two sets of scores, one with water and another with gastrografin as OC. Paired scores from the two OCs were evaluated by Wilcoxon signed rank test to determine any significant difference in performance between the two OCs for visualisation of abdominopelvic anatomy on CT. Results: There was significantly better delineation of duodenal wall (p<0.001) and overall visualisation of the duodenum (p=0.011) using water as OC compared to gastrografin. No statistically significant differences were demonstrated between water and gastrografin for visualisation of the rest of the abdominopelvic organs, walldelineation of the rest small bowel and contrast-associated artefacts. Conclusions: Water can be used in place of gastrografin as oral contrast in abdominopelvic CT without compromising visualization of abdominopelvic organs.