Impact of qualitative, semi-quantitative, and quantitative analyses of dynamic contrast-enhanced magnet resonance imaging on prostate cancer detection.

Dynamic contrast enhanced imaging (DCE) as an integral part of multiparametric prostate magnet resonance imaging (mpMRI) can be evaluated using qualitative, semi-quantitative, or quantitative assessment methods. Aim of this study is to analyze the clinical benefits of these evaluations of DCE regarding clinically significant prostate cancer (csPCa) detection and grading. 209 DCE data sets of 103 consecutive patients with mpMRI (T2, DWI, and DCE) and subsequent MRI-(in-bore)-biopsy were retrospectively analyzed. Qualitative DCE evaluation according to PI-RADS v2.1, semi-quantitative (curve type; DCE score according to PI-RADS v1), and quantitative Tofts analyses (Ktrans, kep, and ve) as well as PI-RADS v1 and v2.1 overall classification of 209 lesions (92 PCa, 117 benign lesions) were performed. Of each DCE assessment method, cancer detection, discrimination of csPCa, and localization were assessed and compared to histopathology findings. All DCE analyses (p<0.01-0.05), except ve (p = 0.02), showed significantly different results for PCa and benign lesions in the peripheral zone (PZ) with area under the curve (AUC) values of up to 0.92 for PI-RADS v2.1 overall classification. In the transition zone (TZ) only the qualitative DCE evalulation within PI-RADS (v1 and v2.1) could distinguish between PCa and benign lesions (p<0.01; AUC = 0.95). None of the DCE parameters could differentiate csPCa from non-significant (ns) PCa (p ≥ 0.1). Qualitative analysis of DCE within mpMRI according to PI-RADS version 2.1 showed excellent results regarding (cs)PCa detection. Semi-quantitative and quantitative parameters provided no additional improvements. DCE alone wasn't able to discriminate csPCa from nsPCa.

mpMRI of the Prostate (MR-Prostatography): Updated Recommendations of the DRG and BDR on Patient Preparation and Scanning Protocol. / mpMRT der Prostata (MR-Prostatografie): Aktualisierte Empfehlungen der DRG und des BDR zur Vorbereitung und Durchführung.

The Working Group Uroradiology and Urogenital Diagnosis of the German Roentgen Society (DRG) revised and updated the recommendations for preparation and scanning protocol of the multiparametric MRI of the Prostate in a consensus process and harmonized it with the managing board of German Roentgen Society and Professional Association of the German Radiologist (BDR e. V.). These detailed recommendation define the referenced "validated quality standards" of the German S3-Guideline Prostate Cancer and describe in detail the topic 1. anamnestic datas, 2. termination of examinations and preparation of examinations, 3. examination protocol and 4. MRI-(in-bore)-biopsy. KEY POINTS:: · The recommendations for preparation and scanning protocol of the multiparametric MRI of the Prostate were revised and updated in a consensus process and harmonized with the managing board of German Roentgen Society (DRG) and Professional Asssociation of the German Radiologist (BDR).. · Detailed recommendations are given for topic 1. anamnestic datas, 2. termination and preparation of examinations, 3. examination protocoll and 4. MRI-(in-bore)-biopsy.. · These recommendations define the referenced "validated quality standards" of the German S3-Guideline Prostate Cancer.. CITATION FORMAT: · Franiel T, Asbach P, Beyersdorff D et al. mpMRI of the Prostate (MR-Prostatography): Updated Recommendations of the DRG and BDR on Patient Preparation and Examination Protocol. Fortschr Röntgenstr 2021; 193: 763 - 776.

Current Utilization and Acceptance of Multiparametric MRI in the Diagnosis of Prostate Cancer. A Regional Survey.

PURPOSE: To assess the current regional acceptance, valuation, and clinical role of multiparametric MRI (mp-MRI) in prostate cancer diagnostics by patients and physicians. MATERIALS AND METHODS: Of 482 distributed standardized questionnaires, 328 patient and 31 physician questionnaires (urological and general practitioners in and around Düsseldorf) were analyzed over a period of 11 months. Questions were asked concerning general knowledge about prostate cancer, current diagnostic procedures, and knowledge about mp-MRI and MRI-guided biopsy. RESULTS: 70 % of the patients regarded accurate and exact diagnostics of prostate carcinomas as very important and 68 % considered MP-MRI a useful technique. 28 % of the patients with elevated PSA levels and negative transrectal ultrasound-guided biopsy (TRUS-GB) received MP-MRI as a secondary diagnostic. More than half of the patients estimated their overall knowledge about prostate cancer mediocre or worse and wished for more information about MR diagnostics. The majority of physicians (55 %) ordered MP-MRI studies of the prostate and 68 % saw their basic role in secondary diagnostics. CONCLUSION: In this regional assessment mp-MRI of the prostate was considered useful by patients and practitioners. Currently, there still is a considerable discrepancy between recommended and the actual number of conducted MP-MRI studies, particularly in patients after previous negative TRUS-GB, although practitioners already see the benefit in this patient collective. Even though the use of prostate MRI is frequently more established than suggested in the current German S3-guideline, its full potential has not yet been exploited. More comprehensive information about the applications and diagnostic benefits of prostate MRI is needed and desired among patients and physicians. KEY POINTS: · The use of prostate MRI is frequently more established than suggested in the current German S3-guideline (12/2016). · The full potential of mp-MRI of the prostate has not been exploited. · More information about the clinical benefit and potential of prostate MRI is necessary and desired by patients and clinicians. CITATION FORMAT: · Ullrich T, Schimmöller L, Oymanns M et al. Current Utilization and Acceptance of Multiparametric MRI in the Diagnosis of Prostate Cancer. A Regional Survey. Fortschr Röntgenstr 2018; 190: 419 - 426.

Risk Stratification of Equivocal Lesions on Multiparametric Magnetic Resonance Imaging of the Prostate.

PURPOSE: We systematically analyzed the records of patients with PI-RADS™ (Prostate Imaging Reporting and Data System) 3 lesions, which are called equivocal according to PI-RADS version 2, using prostate multiparametric magnetic resonance imaging and magnetic resonance imaging targeted biopsies. Systematic transrectal ultrasound guided biopsies served as the reference standard. MATERIALS AND METHODS: A total of 120 consecutive patients were retrospectively included in the study. In these patients the overall PI-RADS score was 3 after 3 Tesla T2-weighted imaging, diffusion weighted imaging and dynamic contrast enhanced multiparametric magnetic resonance imaging as well as subsequent targeted magnetic resonance imaging/ultrasound fusion guided biopsies plus systematic 12-core transrectal ultrasound guided biopsies. The study end points were the prostate cancer detection rate, the Gleason score distribution, the prostate cancer location and risk stratification by subgroup analyses. RESULTS: Prostate cancer was detected in 13 of 118 patients for a detection rate of 11%, including 5 patients (4.2%) with a Gleason score of 3 + 4 = 7 or greater. Three of the 212 lesions (1.4%) in the transition zone and 6 of the 64 (9.4%) in the peripheral zone were positive for prostate cancer. Multiparametric magnetic resonance imaging revealed patterns of peripheral prostatitis combined with diffuse stromal hyperplasia in 54% of the patients with prostate cancer. Prostate volume was significantly lower in patients with prostate cancer (p = 0.015) but differences in prostate specific antigen levels were not statistically significant (p = 0.87). Prostate specific antigen density was higher in patients with prostate cancer (0.19 vs 0.12 ng/ml/ml). CONCLUSIONS: Low grade prostate cancer (Gleason score 3 + 3 = 6) can develop in patients with an overall PI-RADS score of 3. Prostate cancer with a Gleason score of 3 + 4 = 7 or greater can be detected by multiparametric magnetic resonance imaging with a high degree of certainty. Gleason score 4 + 3 = 7 or greater prostate cancer is unlikely in PI-RADS 3 lesions. Therefore, these patients should primarily undergo followup multiparametric magnetic resonance imaging. In patients with a combination of multiparametric magnetic resonance imaging aspects of extensive prostatitis and diffuse stromal hyperplasia low prostate volume and/or high prostate specific antigen density biopsy might be considered.

Multimodal and sequential treatment improves survival in patients with hepatocellular carcinoma.

Background and aims Therapy of hepatocellular carcinoma (HCC) mainly depends on tumor stage and liver function. The aim of this study was to identify additional predictors of overall survival in HCC patients with a particular attention to multimodal therapies. Methods Six hundred and seven consecutive HCC-patients treated in a tertiary center between 1988 and 2011 were retrospectively analyzed. Multivariate analysis was performed by logistic and Cox-regression, overall survival was analyzed by Kaplan Meier statistics. Results In comparison to unimodal therapies, multimodal treatment increased overall survival in BCLC-A patients from 16 to 26 months (p < 0.001), in patients with BCLC-B stage from 9.5 to 16 months (p < 0.001), in BCLC-C patients from 6 to 18 months (p < 0.001), and in stage BCLC-D from 2 to 8 months (not significant). Survival increased throughout all Child Pugh scores, and patients experienced benefits from multimodal therapy irrespective of alfa-fetoprotein levels. Comparing the time span 1988 - 1999 with 2000 - 2011, the rate of multimodal/sequential treatment increased from 12.3 % to 30 % (p < 0.001), and the overall survival of all (treated and non-treated) patients increased from 7 months (1988 - 1999) to 10 months (2000 - 2011, p < 0.001). In multivariate analysis, multimodal treatment was shown to be an independent predictor for overall survival besides elevated alfa-fetoprotein, Child Pugh score, and BCLC stage. Conclusion Multimodal therapies increase overall survival in HCC patients and should be considered in patients with HCC if practicable.

Diagnostic value of CT-localizer and axial low-dose computed tomography for the detection of drug body packing.

OBJECTIVES: The purpose of this study was to assess the diagnostic performance of CT-localizers in the detection of intracorporal containers. METHODS: This study was approved by the research ethics committee of our clinic. From March 2012 to March 2013, 108 subjects were referred to our institute with suspected body packing. The CT-localizer and the axial CT-images were compared by two blinded observers retrospectively. Presence of body packs was assessed in consensus. Sensitivity and specificity, PPV and NPV of the CT-localizer were calculated. RESULTS: Packets were detected in the CT-localizer of 19 suspects. In 28 of 108 cases packs were detected in axial CT-images. Sensitivity of CT-localizer for detection of packs was 0.68, and specificity was 1.00. There were no cases rated as false positive. The PPV was 1.0 and the NPV was 0.89. The omission of the axial CT-images would have led to a mean radiation dose reduction of 1.94 ± 0.5 mSv. CONCLUSIONS: The value of CT-localizers lies in their high PPV. Localizers are limited by low sensitivity, compared to axial CT-images in screening of potential body packers. However, in positive cases their high PPV may possibly allow to omit the complete axial abdominal CT to achieve even lower radiation exposure.

MRI-Guided In-Bore Biopsy: Differences Between Prostate Cancer Detection and Localization in Primary and Secondary Biopsy Settings.

OBJECTIVE: The objective of our study was to evaluate transrectal MRI-guided in-bore biopsy in patients who either were biopsy-naive (primary biopsy) or had undergone at least one previous negative transrectal ultrasound-guided biopsy (secondary biopsy) with regard to cancer detection rate, tumor localization, and lesion size. MATERIALS AND METHODS: In total, 1602 biopsy cores from 297 consecutive patients (mean ± SD, 66.1 ± 7.8 years; median prostate-specific antigen value, 8.2 ng/mL) in primary (n = 160) and secondary (n = 137) prostate biopsy settings were evaluated in this retrospective study. All patients previously underwent prostate MRI (T2-weighted imaging, DWI, dynamic contrast-enhanced imaging) at 3 T. All described lesions were biopsied with MRI-guided in-bore biopsy and were examined histologically. RESULTS: In 148 patients, overall 511 cores were positive for prostate cancer. Clinically significant prostate cancer (any Gleason pattern ≥ 4) was found in 82.4% of patients. The prostate cancer detection rate for patients who underwent primary biopsies was 55.6% and was 43.1% for patients who underwent secondary biopsies. In patients with primary versus secondary biopsies, prostate cancer was located peripherally in 62.9% versus 49.5% (p = 0.04), in the transition zone in 27.4% versus 27.5% (p = 1.0), and in the anterior stroma in 10.3% versus 22.9% (p < 0.01), respectively. The prostate cancer detection rates for patients with smaller prostate volumes (< 30 vs 30-50 vs > 50 mL; p < 0.01) or for patients with larger lesions (> 0.5 vs 0.25-0.5 vs < 0.25 cm(3); p < 0.01) were significantly higher. CONCLUSION: MRI-guided in-bore biopsy led to high detection rates in primary and secondary prostate biopsies. Prostate cancer detection rates were significantly higher for patients with larger lesions and smaller prostate glands. In patients who underwent secondary biopsies, prostate cancer was located in the anterior stroma at a significantly more frequent rate.

Comparison of patient comfort between MR-guided in-bore and MRI/ultrasound fusion-guided prostate biopsies within a prospective randomized trial.

PURPOSE: The objective of this study was to compare patient comfort between MR-guided in-bore prostate biopsy (IB-GB) and MRI/ultrasound fusion-guided prostate biopsy (FUS-GB) with additional systematic 12-core transrectal ultrasound (TRUS)-guided biopsy within a prospective randomized trial. METHODS: Two hundred and ten consecutive patients were randomly assigned in a 1:1 ratio to receive either IB-GB and prior intrarectal instillation of a 2% lidocaine gel (n = 106) or FUS-GB plus additional systematic 12-core TRUS-guided biopsy and prior application of a periprostatic nerve block (PPNB) with 2% mepivacaine (n = 104). The maximal procedural pain (MPP) on a 0-10 visual analog scale and the operating room time were recorded for each biopsy session. RESULTS: Baseline characteristics and mean number of targeted biopsy cores (5.6 ± 0.8 vs 5.4 ± 1.2 for IB-GB and FUS-GB, respectively; p = 0.278) were similar in both study arms. In relation to the IB-GB arm, the total number of biopsy cores in the FUS-GB arm, including the systematic 12-core TRUS-guided biopsy, was significantly higher (17.4 ± 1.2; p < 0.001). Patients with IB-GB had significantly higher MPP scores (2.95 ± 2.15) compared with subjects with FUS-GB (1.95 ± 1.56; p < 0.001). FUS-GB required significantly less time (28.22 ± 11.61 min) in comparison with IB-GB (42.09 ± 11.37 min; p < 0.001). CONCLUSIONS: The PPNB can easily be administered just prior to performing FUS-GB. Thus, patients have significantly lower pain levels in comparison with IB-GB, which is usually done with intrarectal anesthetic gels. Although the addition of a systematic 12-core TRUS-guided biopsy significantly increases the number of biopsy cores, FUS-GB still requires significantly less time in comparison with IB-GB.

Prospective randomized trial comparing magnetic resonance imaging (MRI)-guided in-bore biopsy to MRI-ultrasound fusion and transrectal ultrasound-guided prostate biopsy in patients with prior negative biopsies.

BACKGROUND: A significant proportion of prostate cancers (PCas) are missed by conventional transrectal ultrasound-guided biopsy (TRUS-GB). It remains unclear whether the combined approach using targeted magnetic resonance imaging (MRI)-ultrasound fusion-guided biopsy (FUS-GB) and systematic TRUS-GB is superior to targeted MRI-guided in-bore biopsy (IB-GB) for PCa detection. OBJECTIVE: To compare PCa detection between IB-GB alone and FUS-GB + TRUS-GB in patients with at least one negative TRUS-GB and prostate-specific antigen ≥4 ng/ml. DESIGN, SETTING, AND PARTICIPANTS: Patients were prospectively randomized after multiparametric prostate MRI to IB-GB (arm A) or FUS-GB + TRUS-GB (arm B) from November 2011 to July 2014. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The study was powered at 80% to demonstrate an overall PCa detection rate of ≥60% in arm B compared to 40% in arm A. Secondary endpoints were the distribution of highest Gleason scores, the rate of detection of significant PCa (Gleason ≥7), the number of biopsy cores to detect one (significant) PCa, the positivity rate for biopsy cores, and tumor involvement per biopsy core. RESULTS AND LIMITATIONS: The study was halted after interim analysis because the primary endpoint was not met. The trial enrolled 267 patients, of whom 210 were analyzed (106 randomized to arm A and 104 to arm B). PCa detection was 37% in arm A and 39% in arm B (95% confidence interval for difference, -16% to 11%; p=0.7). Detection rates for significant PCa (29% vs 32%; p=0.7) and the highest percentage tumor involvement per biopsy core (48% vs 42%; p=0.4) were similar between the arms. The mean number of cores was 5.6 versus 17 (p<0.001). A limitation is the limited number of patients because of early cessation of accrual. CONCLUSIONS: This trial failed to identify an important improvement in detection rate for the combined biopsy approach over MRI-targeted biopsy alone. A prospective comparison between MRI-targeted biopsy alone and systematic TRUS-GB is justified. PATIENT SUMMARY: Our randomized study showed similar prostate cancer detection rates between targeted prostate biopsy guided by magnetic resonance imaging and the combination of targeted biopsy and systematic transrectal ultrasound-guided prostate biopsy. An important improvement in detection rates using the combined biopsy approach can be excluded.

Severe liver fibrosis caused by Schistosoma mansoni: management and treatment with a transjugular intrahepatic portosystemic shunt.

Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis--a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa--is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.

Smaller caliber renal arteries are a novel feature of uromodulin-associated kidney disease.

Hyperuricemia is very common in industrialized countries and known to promote vascular smooth muscle cell proliferation. Juvenile hyperuricemia is a hallmark of uromodulin-associated kidney disease characterized by progressive interstitial renal fibrosis leading to end-stage renal disease within decades. Here we describe a member of a Polish-German family with a history of familial background of chronic kidney disease, hyperuricemia, and gout. This patient had hypertension because of bilateral small renal arteries, hyperuricemia, and chronic kidney disease. Clinical and molecular studies were subsequently performed in 39 family members, which included a physical examination, Duplex ultrasound of the kidneys, laboratory tests for renal function, and urine analysis. In eight family members contrast-enhanced renal artery imaging by computed tomography-angiography or magnetic resonance imaging was conducted and showed that bilateral non-arteriosclerotic small caliber renal arteries were associated with hyperuricemia and chronic kidney disease. Of the 26 family members who underwent genotyping, 11 possessed the P236R mutation (c.707C>G) of the uromodulin gene. All family members with a small caliber renal artery carried the uromodulin P236R mutation. Statistical analysis showed a strong correlation between reduced renal artery lumen and decreased estimated glomerular filtration rate. Thus, bilateral small caliber renal arteries are a new clinical phenotype associated with an uromodulin mutation.

TACE plus sorafenib for the treatment of hepatocellular carcinoma: results of the multicenter, phase II SOCRATES trial.

PURPOSE: The present multicenter phase II trial investigated the combination of TACE and sorafenib for the treatment of HCC. PATIENTS AND METHODS: Eligibility criteria included histologically confirmed, unresectable HCC beyond Milan criteria, no extrahepatic spread, Child-Pugh score ≤ 8 and ECOG PS 0-2. Patients had received no prior therapy for HCC. Sorafenib was given at a dose of 400 mg/bid (interrupted only around TACE). TACE with lipiodol, 50 mg doxorubicin and polyvinyl alcohol (PVA) particles was repeated q6w as long as there was no overall disease progression. Tumor assessment by MRI was performed q6w according to EASL criteria. The primary endpoint was time to progression (TTP). RESULTS: Patients (n = 43) received a mean of 2.6 ± 2.2 TACE interventions (range 0-10). Median TTP was 16.4 months (95 % CI 10.7-∞). Median overall survival (OS) was 20.1 months (95 % CI 17.6-28.2). Disease control rate according to EASL criteria was 74.4 % (7 % complete responses [CRs] + 41.8 % partial responses [PRs] + 25.6 % stable diseases [SDs]). Four patients (9 %) became amenable to either radiofrequency ablation or liver transplantation; 5 (12 %) patients died during the trial. Overall, there were 360 AEs, including 56 grade 3/4 AEs and 39 SAEs. CONCLUSIONS: Combination treatment of TACE and sorafenib in the present trial was tolerable and associated with an interesting response rate, TTP and OS. Combination therapies will probably close gaps in the present mono therapy driven treatment guidelines for locally advanced HCC.

MR-sequences for prostate cancer diagnostics: validation based on the PI-RADS scoring system and targeted MR-guided in-bore biopsy.

PURPOSE: This study evaluated the accuracy of MR sequences [T2-, diffusion-weighted, and dynamic contrast-enhanced (T2WI, DWI, and DCE) imaging] at 3T, based on the European Society of Urogenital Radiology (ESUR) scoring system [Prostate Imaging Reporting and Data System (PI-RADS)] using MR-guided in-bore prostate biopsies as reference standard. METHODS: In 235 consecutive patients [aged 65.7 ± 7.9 years; median prostate-specific antigen (PSA) 8 ng/ml] with multiparametric prostate MRI (mp-MRI), 566 lesions were scored according to PI-RADS. Histology of all lesions was obtained by targeted MR-guided in-bore biopsy. RESULTS: In 200 lesions, biopsy revealed prostate cancer (PCa). The area under the curve (AUC) for cancer detection was 0.70 (T2WI), 0.80 (DWI), and 0.74 (DCE). A combination of T2WI + DWI, T2WI + DCE, and DWI + DCE achieved an AUC of 0.81, 0.78, and 0.79. A summed PI-RADS score of T2WI + DWI + DCE achieved an AUC of 0.81. For higher grade PCa (primary Gleason pattern ≥ 4), the AUC was 0.85 for T2WI + DWI, 0.84 for T2WI + DCE, 0.86 for DWI + DCE, and 0.87 for T2WI + DWI + DCE. The AUC for T2WI + DWI + DCE for transitional-zone PCa was 0.73, and for the peripheral zone 0.88. Regarding higher-grade PCa, AUC for transitional-zone PCa was 0.88, and for peripheral zone 0.96. CONCLUSION: The combination of T2WI + DWI + DCE achieved the highest test accuracy, especially in patients with higher-grade PCa. The use of ≤2 MR sequences led to lower AUC in higher-grade and peripheral-zone cancers. KEY POINTS: • T2WI + DWI + DCE achieved the highest accuracy in patients with higher grade PCa • T2WI + DWI + DCE was more accurate for peripheral- than for transitional-zone PCa • DCE increased PCa detection accuracy in the peripheral zone • DWI was the leading sequence in the transitional zone.

Prospective evaluation of magnetic resonance imaging guided in-bore prostate biopsy versus systematic transrectal ultrasound guided prostate biopsy in biopsy naïve men with elevated prostate specific antigen.

PURPOSE: Magnetic resonance imaging guided biopsy is increasingly performed to diagnose prostate cancer. However, there is a lack of well controlled, prospective trials to support this treatment method. We prospectively compared magnetic resonance imaging guided in-bore biopsy with standard systematic transrectal ultrasound guided biopsy in biopsy naïve men with increased prostate specific antigen. MATERIALS AND METHODS: We performed a prospective study in 132 biopsy naïve men with increased prostate specific antigen (greater than 4 ng/ml). After 3 Tesla functional multiparametric magnetic resonance imaging patients were referred for magnetic resonance imaging guided in-bore biopsy of prostate lesions (maximum 3) followed by standard systematic transrectal ultrasound guided biopsy (12 cores). We analyzed the detection rates of prostate cancer and significant prostate cancer (greater than 5 mm total cancer length or any Gleason pattern greater than 3). RESULTS: A total of 128 patients with a mean ± SD age of 66.1 ± 8.1 years met all study requirements. Median prostate specific antigen was 6.7 ng/ml (IQR 5.1-9.0). Transrectal ultrasound and magnetic resonance imaging guided biopsies provided the same 53.1% detection rate, including 79.4% and 85.3%, respectively, for significant prostate cancer. Magnetic resonance imaging and transrectal ultrasound guided biopsies missed 7.8% and 9.4% of clinically significant prostate cancers, respectively. Magnetic resonance imaging biopsy required significantly fewer cores and revealed a higher percent of cancer involvement per biopsy core (each p <0.01). Combining the 2 methods provided a 60.9% detection rate with an 82.1% rate for significant prostate cancer. CONCLUSIONS: Magnetic resonance imaging guided in-bore and systematic transrectal ultrasound guided biopsies achieved equally high detection rates in biopsy naïve patients with increased prostate specific antigen. Magnetic resonance imaging guided in-bore biopsies required significantly fewer cores and revealed a significantly higher percent of cancer involvement per biopsy core.

Feasibility of diffusional kurtosis tensor imaging in prostate MRI for the assessment of prostate cancer: preliminary results.

PURPOSE: To assess the feasibility of full diffusional kurtosis tensor imaging (DKI) in prostate MRI in clinical routine. Histopathological correlation was achieved by targeted biopsy. MATERIALS AND METHODS: Thirty-one men were prospectively included in the study. Twenty-one were referred to our hospital with increased prostate specific antigen (PSA) values (>4ng/ml) and suspicion of prostate cancer. The other 10 men were volunteers without any history of prostate disease. DKI applying diffusion gradients in 20 different spatial directions with four b-values (0, 300, 600, 1000s/mm(2)) was performed additionally to standard functional prostate MRI. Region of interest (ROI)-based measurements were performed in all histopathologically verified lesions of every patient, as well as in the peripheral zone, and the central gland of each volunteer. RESULTS: DKI showed a substantially better fit to the diffusion-weighted signal than the monoexponential apparent diffusion coefficient (ADC). Altogether, 29 lesions were biopsied in 14 different patients with the following results: Gleason score 3+3=6 (n=1), 3+4=7 (n=7), 4+3=7 (n=6), 4+4=8 (n=1), and 4+5=9 (n=2), and prostatitis (n=12). Values of axial (Kax) and mean kurtosis (Kmean) were significantly different in the tumor (Kax 1.78±0.39, Kmean 1.84±0.43) compared with the normal peripheral zone (Kax 1.09±0.12, Kmean 1.16±0.13; p<0.001) or the central gland (Kax 1.40±0.12, Kmean 1.44±0.17; p=0.01 respectively). There was a minor correlation between axial kurtosis (r=0.19) and the Gleason score. CONCLUSION: Full DKI is feasible to utilize in a routine clinical setting. Although there is some overlap some DKI parameters can significantly distinguish prostate cancer from the central gland or the normal peripheral zone. Nevertheless, the additional value of DKI compared with conventional monoexponential ADC calculation remains questionable and requires further research.

Prognostic value of a cell-cycle progression score in men with prostate cancer managed with active surveillance after MRI-guided prostate biopsy--a pilot study.

BACKGROUND/AIM: Initial inaccurate staging is a common problem associated with active surveillance (AS) for patients detected by transrectal ultrasound-guided prostate biopsy (TRUS-GB). Subsequently, repeated biopsies are necessary to monitor such patients. Thus, in addition to the already established clinicopathological criteria, there is a considerable demand for new, objective decision criteria to more accurately select AS candidates. Recently, a novel RNA expression signature derived from 31 cell-cycle progression (CCP) genes has been shown to be a strong predictor of outcome in patients after radical prostatectomy or radiotherapy. This is a qualitative pilot study to evaluate the prognostic value of the CCP-score (CCP-S) for the first time in men managed with AS after MRI-guided prostate biopsy (MRI-GB). PATIENTS AND METHODS: Nine patients previously diagnosed with prostate cancer during an ongoing, prospective trial assessing MRI-GB with additional TRUS-GB and were subsequently managed with AS. CCP-S were retrospectively derived from biopsy specimens. The CCP-S is defined as the expression level of 31 CCP genes, normalized to 15 housekeeping genes, and is clinically validated in a range between -1.3 and 4.7. To assess the estimated 10-year mortality risk (without curative treatment), the CCP-S from each patient was combined with the individual CAPRA (Cancer of the Prostate Risk Assessment) score (CAPRA-S). RESULTS: Median patient age was 72 (range=58-77) years. Mean pre-biopsy PSA level was 6.33±1.94 (range 4.23-9.97) ng/ml. Eight cases had Gleason score 6 (3+3) and one cancer had Gleason score 7 (3+4). Median CCP-S was -0.9 (range=-1.5 to 0.0). Combining CCP-S with CAPRA-S [CAPRA-S: 1 (n=4), 2 (n=4), 3 (n=1)] the estimated 10-year mortality risk was not calculable for three patients because their CCP-S [CCP-S -1.4 (n=2) and -1.5 (n=1)] was outside the validated range. For the other 6 patients the estimated 10-year mortality ranged from 1.0-3.0%. CONCLUSION: The CCP-S confirms accurate staging of AS patients detected by MRI-based biopsy strategies and may significantly reduce inaccurate staging of AS patients and subsequent unnecessary re-biopsies. The CCP score may help to more accurately select for active surveillance candidates.

Diffusion kurtosis imaging of the human kidney: a feasibility study.

PURPOSE: To assess the feasibility and to optimize imaging parameters of diffusion kurtosis imaging (DKI) in human kidneys. METHODS: The kidneys of ten healthy volunteers were examined on a clinical 3T MR scanner. For DKI, respiratory triggered EPI sequences were acquired in the coronal plane (3 b-values: 0, 300, 600s/mm(2), 30 diffusion directions). A goodness of fit analysis was performed and the influence of the signal-to-noise ratio (SNR) on the DKI results was evaluated. Region-of-interest (ROI) measurements were performed to determine apparent diffusion coefficient (ADC), fractional anisotropy (FA) and mean kurtosis (MK) of the cortex and the medulla of the kidneys. Intra-observer and inter-observer reproducibility using Bland-Altman plots as well as subjective image quality of DKI were examined and ADC, FA, and MK parameters were compared. RESULTS: The DKI model fitted better to the experimental data (r=0.99) with p<0.05 than the common mono-exponential ADC model (r=0.96). Calculation of reliable kurtosis parameters in human kidneys requires a minimum SNR of 8.31 on b=0s/mm(2) images. Corticomedullary differentiation was possible on FA and MK maps. ADC, FA and MK revealed significant differences in medulla (ADC=2.82 × 10(-3)mm(2)/s±0.25, FA=0.42±0. 05, MK=0.78±0.07) and cortex (ADC=3.60 × 10(-3)mm(2)/s±0.28, FA=0.18±0.04, MK=0.94±0.07) with p<0.001. CONCLUSION: Our initial results indicate the feasibility of DKI in the human kidney presuming an adequate SNR. Future studies in patients with kidney diseases are required to determine the value of DKI for functional kidney imaging.

Increased signal intensity of prostate lesions on high b-value diffusion-weighted images as a predictive sign of malignancy.

OBJECTIVES: The evaluation of lesions detected in prostate magnetic resonance imaging (MRI) with increased signal intensity (SI) on high b-value diffusion-weighted images as a sign of malignancy. METHODS: One hundred and three consecutive patients with prostate MRI examination and MRI-guided in-bore biopsy were retrospectively included in the study. MRI-guided in-bore biopsy histologically confirmed prostate cancer in 50 patients (n = 92 lesions). The other 53 patients (n = 122 lesions) had negative bioptical results. RESULTS: In patients with histologically confirmed prostate cancer, 46 of the 92 lesions had visually increased SI on the high b-value images compared with the peripheral zone (SI = +27 ± 16%) or the central gland (SI = +37 ± 19%, P < 0.001 respectively). In patients with a negative biopsy, ten of the 122 lesions had visually increased SI (compared with the peripheral zone, SI = +29 ± 18%, and with the central gland, SI = +41 ± 15%, P < 0.001 respectively). Neither the apparent diffusion coefficient (ADC) values nor the Gleason Score of lesions with increased SI were significantly different from lesions without increased SI. CONCLUSIONS: Visually increased SI on the high b-value images of diffusion-weighted imaging using standard b-values is a sign of malignancy but can occasionally also be a feature of benign lesions. However, it does not indicate more aggressive tumours. KEY POINTS: • Diffusion weighted magnetic resonance imaging is increasingly used to diagnose prostatic cancer • Reduced signal intensity (SI) on apparent diffusion coefficient (ADC) mapping is characteristic • Prostatic tumours usually exhibit increased SI on high b-value images • But benign lesions can also yield increased SI on high b-value images.

Functional evaluation of transplanted kidneys using arterial spin labeling MRI.

PURPOSE: To investigate non-contrast-enhanced arterial spin labeling (ASL) MRI for functional assessment of transplanted kidneys at 1.5 Tesla (T) and 3T. MATERIALS AND METHODS: This study was approved by the local ethics committee, and written informed consent was obtained from all participants. Ninety eight renal allograft recipients (mean age, 51.5 ± 14.6 years) were prospectively included in this study. ASL MRI was performed at 1.5T (n = 65) and 3T (n = 33) using a single-slice flow-sensitive alternating inversion recovery true-fast imaging with steady-state precession (FAIR True-FISP) sequence in the paracoronal plane. ASL perfusion was regional analyzed for the renal cortex on parameter maps. ASL was compared between patients with good or moderate allograft function (Group a; estimated glomerular filtration rate [eGFR] > 30 mL/min/1.73 m(2)) and patients with heavily impaired allograft function (Group b; eGFR ≤ 30 mL/min/1.73 m(2)) and correlated to renal function as determined by eGFR. RESULTS: ASL perfusion and eGFR were comparable at 1.5T (246.9 ± 66.8 mL/100 g/min and 41.9 ± 22.7 mL/min/1.73 m(2)) and 3T (236.5 ± 102.3 mL/100 g/min and 35.9 ± 22.9 mL/min/1.73 m(2)). ASL perfusion was significantly higher in group a (282.7 ± 60.8 mL/100 g/min) as compared to group b (178.2 ± 63.3 mL/100 g/min) (P < 0.0001). ASL perfusion values exhibited a significant correlation with renal function as determined by eGFR (r = 0.59; P < 0.0001). CONCLUSION: Cortical ASL perfusion values differ between patients with good or moderate allograft function and poor allograft function and correlate significantly with allograft function. Our results highlight the potential of ASL MRI for functional evaluation of renal allografts.