Direct MRI-guided In-Bore Targeted Biopsy of the Prostate: A Step-by-Step How To and Lessons Learned.

Multiparametric MRI-the most accurate imaging technique for detection of prostate cancer-has transformed the landscape of prostate cancer diagnosis by enabling targeted biopsies. In a targeted biopsy, tissue samples are obtained from suspicious regions identified at prebiopsy diagnostic MRI. The authors briefly compare the different strategies available for targeting an MRI-visible suspicious lesion, followed by a step-by-step description of the direct MRI-guided in-bore approach and an illustrated review of its application in challenging clinical scenarios. In this technique, direct visualization of the needle, needle guide, and needle trajectory during the procedure provides a precise and versatile strategy to accurately sample suspicious lesions, improving detection of clinically significant cancers. Published under a CC BY 4.0 license Test Your Knowledge questions for this article are available in the supplemental material.

Thickness dependence of piezo-bimorph adaptive mirror bending.

A new generation of adaptive x-ray optics (AXO) is being installed on high-coherent-flux x-ray beamlines worldwide to correct and control the optical wavefront with sub-nm precision. These ultra-smooth mirrors achieve high reflectivities at glancing angles of incidence and can be hundreds of mm long. One type of adaptive x-ray mirror relies on piezoelectric ceramic strips which are segmented into channels and actuated to induce local, longitudinal bending, generating one-dimensional shape changes in the mirror substrate. A recently described mirror model uses a three-layer geometry with parallel actuators on the front and back surfaces of a thicker mirror substrate. By analogy to a solved problem in the thermal actuation of a tri-metal strip, we show that the achievable bending radius varies approximately as the square of the substrate thickness. We provide an analytic solution and simulate bending using a finite-element model.

Real-time machine-learning-driven control system of a deformable mirror for achieving aberration-free X-ray wavefronts.

A neural-network machine learning model is developed to control a bimorph adaptive mirror to achieve and preserve aberration-free coherent X-ray wavefronts at synchrotron radiation and free electron laser beamlines. The controller is trained on a mirror actuator response directly measured at a beamline with a real-time single-shot wavefront sensor, which uses a coded mask and wavelet-transform analysis. The system has been successfully tested on a bimorph deformable mirror at the 28-ID IDEA beamline of the Advanced Photon Source at Argonne National Laboratory. It achieved a response time of a few seconds and maintained desired wavefront shapes (e.g., a spherical wavefront) with sub-wavelength accuracy at 20 keV of X-ray energy. This result is significantly better than what can be obtained using a linear model of the mirror's response. The developed system has not been tailored to a specific mirror and can be applied, in principle, to different kinds of bending mechanisms and actuators.

Off-axis representation of hyperbolic mirror shapes for X-ray beamlines.

Mirror-centered, closed-form expressions for hyperbolic surfaces used in X-ray beamlines have been derived. Hyperbolic mirrors create a virtual focus or source point and can be used to lengthen or shorten the effective focal distance of a compound optical system. The derivations here express off-axis segments of a hyperbolic surface in terms of the real and virtual focal distances and the incident glancing angle at the center of the mirror. Conventional mathematical expressions of hyperbolic shapes describe the surfaces in Cartesian or polar coordinates centered on an axis of symmetry, necessitating cumbersome rotation and translation to mirror-centered coordinates. The representation presented here, with zero slope and the origin at the central point, is most convenient for modeling, metrology, aberration correction, and general surface analysis of off-axis configurations. The direct derivation avoids the need for nested coordinate transforms. A series expansion provides a helpful approximation; the coefficients of the implicit equation are also provided.

Data-driven modeling and control of an X-ray bimorph adaptive mirror.

Adaptive X-ray mirrors are being adopted on high-coherent-flux synchrotron and X-ray free-electron laser beamlines where dynamic phase control and aberration compensation are necessary to preserve wavefront quality from source to sample, yet challenging to achieve. Additional difficulties arise from the inability to continuously probe the wavefront in this context, which demands methods of control that require little to no feedback. In this work, a data-driven approach to the control of adaptive X-ray optics with piezo-bimorph actuators is demonstrated. This approach approximates the non-linear system dynamics with a discrete-time model using random mirror shapes and interferometric measurements as training data. For mirrors of this type, prior states and voltage inputs affect the shape-change trajectory, and therefore must be included in the model. Without the need for assumed physical models of the mirror's behavior, the generality of the neural network structure accommodates drift, creep and hysteresis, and enables a control algorithm that achieves shape control and stability below 2 nm RMS. Using a prototype mirror and ex situ metrology, it is shown that the accuracy of our trained model enables open-loop shape control across a diverse set of states and that the control algorithm achieves shape error magnitudes that fall within diffraction-limited performance.

Sensitivity of multiparametric MRI and targeted biopsy for detection of adverse pathologies (Cribriform gleason pattern 4 and intraductal carcinoma): Correlation of detected and missed prostate cancer foci with whole mount histopathology.

PURPOSE: Accurate preoperative detection of prostate cancer (PCa) exhibiting "cribriform" morphology (intraductal carcinoma [IDC-P] or cribriform Gleason pattern 4 [CrP4]) is important as it is independently associated with a variety of adverse clinical outcomes. The sensitivity of multiparametric magnetic resonance imaging (mpMRI) in the detection of PCa exhibiting "cribriform" morphology remains controversial. MATERIALS AND METHODS: A total of 117 eligible men with prospectively reported mpMRI who underwent in-bore MRI targeted biopsy followed by whole-mount radical prostatectomy (RP) were analyzed for lesion-level imaging-pathology correlation. RESULTS: Of the 206 PCa foci at RP (117 index and 89 non-index), 74% (152/206) were detected by mpMRI. Of the 54 tumors missed by mpMRI, most were non-index (98%, 53/54), grade group (GG) 1 (68%, 37/54) or GG 2 (26%, 14/54), with a median size of 1.0 cm (range, 0.7-1.5 cm), and non-cribriform morphology (96%, 52/54). Cribriform morphology was detected in 26% (53/206) of all tumors, and although targeted biopsies identified 96% (51/53) of these cancers, the cribriform component was depicted in only 45% (24/53). Of these, mpMRI detected all (100%, 44/44) index and 78% (7/9) of the non-index tumors. At univariable analysis, tumor size greater than 5 mm, % pattern 4 > 5%, cribriform morphology, zone (transition versus peripheral zone), and region (apex versus mid/base) were significantly associated with tumor visibility at mpMRI. At multivariable analysis, only tumor size, presence of any pattern 4, and peripheral zone remained significant predictors for visibility by mpMRI. CONCLUSION: At a lesion level, mpMRI offers high sensitivity for the detection of cribriform morphologies, however, the cribriform component is frequently missed by targeted biopsies. The MRI visibility is significantly associated with larger tumor size, presence of Gleason pattern 4, and peripheral zone location.

Analytic descriptions of parabolic X-ray mirrors.

On X-ray beamlines and telescopes, glancing-incidence mirrors with parabolic profiles are used to collimate, focus, and collect light. Here, analytic descriptions for paraboloidal, plane-parabolic, and parabolic cylindrical mirrors in several congruent geometries that are commonly used in fabrication, metrology, and modeling are provided. The exact expressions are derived directly from Fermat's principle, without coordinate transformations, in several mirror-centered coordinate systems, including one with the surface tangent to the central point of intersection. Coefficients for a sixth-order polynomial series approximation are calculated for that coordinate system.

Derivation of closed-form ellipsoidal X-ray mirror shapes from Fermat's principle.

Ellipsoidal and plane-elliptical surfaces are widely used as reflective, point-to-point focusing elements in many optical systems, including X-ray optics. Here the classical optical path function approach of Fermat is applied to derive a closed-form expression for these surfaces that are uniquely described by the object and image distances and the angle of incidence at a point on a mirror surface. A compact description facilitates design, modeling, fabrication, and testing to arbitrary accuracy. Congruent surfaces in two useful coordinate systems - a system centered on the ellipsoid's axes of symmetry and a mirror-centered or `vertex' system with the surface tangent to the xy plane at the mirror's center - are presented. Expressions for the local slope and radii of curvature are derived from the result, and the first several terms of the Maclauren series expansion are provided about the mirror center.

Diaboloidal mirrors: algebraic solution and surface shape approximations.

A new type of optical element that can focus a cylindrical wave to a point focus (or vice versa) is analytically described. Such waves are, for example, produced in a beamline where light is collimated in one direction and then doubly focused by a single optic. A classical example in X-ray optics is the collimated two-crystal monochromator, with toroidal mirror refocusing. The element here replaces the toroid, and in such a system provides completely aberration free, point-to-point imaging of rays from the on-axis source point. We present an analytic solution for the mirror shape in its laboratory coordinate system with zero slope at the centre, and approximate solutions, based on bending an oblique circular cone and a bent right circular cylinder, that may facilitate fabrication and metrology.

Simulations of applications using diaboloid mirrors.

The diaboloid is a reflecting surface that converts a spherical wave to a cylindrical wave. This complex surface may find application in new Advanced Light Source bending-magnet beamlines or in other beamlines that now use toroidal optics for astigmatic focusing. Here, the numerical implementation of diaboloid mirrors is described, and the benefit of this mirror in beamlines exploiting diffraction-limited storage rings is studied by ray tracing. The use of diaboloids becomes especially interesting for the new low-emittance storage rings because the reduction of aberration becomes essential for such small sources. The validity of the toroidal and other mirror surfaces approximating the diaboloid, and the effect of the mirror magnification, are discussed.

Gleason Grade Group Concordance between Preoperative Targeted Biopsy and Radical Prostatectomy Histopathologic Analysis: A Comparison Between In-Bore MRI-guided and MRI-Transrectal US Fusion Prostate Biopsies.

Purpose: To determine and compare rates of grade group (GG) discrepancies between different targeted biopsy techniques (in-bore vs fusion) after propensity score weighting using whole-mount radical prostatectomy (RP) histopathologic analysis as the reference standard. Materials and Methods: This retrospective study evaluated men who underwent targeted (fusion or in-bore) biopsy between April 2017 and January 2019 followed by prostatectomy. The primary endpoint of the study was a change in GG from biopsy to RP at a patient level. For downgrade and upgrade analysis, men with biopsy GG1 (downgrade not possible) and GG5 (upgrade not possible) were excluded, respectively. GG upgrade, downgrade, and concordance rates of each targeting approach were compared using propensity score weighting and logistic regression with inverse probability of treatment weighting. Significance level was set at .05. Index lesion GG on RP specimen served as the reference standard. Results: A total of 191 men (90 in the in-bore [mean age, 63 years ± 7 (standard deviation)] and 101 in the fusion biopsy group [mean age, 65 years ± 7]) were eligible and included. Fewer GG upgrades were noted in the in-bore biopsy group (14%; 12 of 85) compared with the fusion plus systematic biopsy group (30%; 28 of 93) (P = .012). The incidence of GG downgrade in the in-bore group (25%; 21 of 84) was higher than in the fusion group (17%; 16 of 93); however, the difference was not statistically significant (P = .2). Of the 77 men misclassified by both biopsy techniques, the majority (56%, n = 43) had a change in GG of 2 to 3 or 3 to 2. Conclusion: Superior sampling accuracy with MRI-guided in-bore biopsies offers a lower incidence of GG upgrades compared with MRI-transrectal US fusion biopsies upon RP.Keywords: Biopsy/Needle Aspiration, MR-Imaging, Oncology, Pathology, Prostate Supplemental material is available for this article.© RSNA, 2021.

Final 5-Year Outcomes of the Multicenter Randomized Sham-Controlled Trial of a Water Vapor Thermal Therapy for Treatment of Moderate to Severe Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia.

PURPOSE: We present final 5-year outcomes of the multicenter randomized sham-controlled trial of a water vapor therapy (Rezum™) for treatment of moderate to severe lower urinary tract symptoms due to benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 197 subjects >50 years of age with International Prostate Symptom Score ≥13, maximum flow rate ≤15 ml/second and prostate volume 30 to 80 cc were randomized and followed for 5 years. From the control arm of 61 subjects, a subset of 53 subjects requalified and after 3 months received treatment as part of the crossover group and were also followed for 5 years. The total number of vapor treatments to each lobe of the prostate was determined by length of prostatic urethra and included middle lobe treatment per physician discretion. RESULTS: Significant improvement of lower urinary tract symptoms was observed at <3 months post-thermal therapy, remaining durable through 5 years in the treatment group (International Prostate Symptom Score reduced 48%, quality of life increased 45%, maximum flow rate improved 44%, Benign Prostatic Hyperplasia Impact Index decreased 48%). Surgical re-treatment rate was 4.4% with no reports of device or procedure related sexual dysfunction or sustained de novo erectile dysfunction. Results within the crossover group were similar through 5 years. CONCLUSIONS: Minimally invasive treatment with water vapor thermal therapy provides significant and durable symptom relief as well as flow rate improvements through 5 years, with low surgical re-treatment rates and without impacting sexual function. It is a versatile therapy, providing successful treatment to obstructive lateral and middle lobes.

Pseudo-gray-scale halftone gratings for shearing and Hartmann wavefront sensors.

Now in use on x-ray beamlines worldwide, shearing interferometry and Hartmann wavefront sensing provide effective feedback for measuring and optimizing high-quality beams. Conventionally, both approaches spatially modulate the beam properties (amplitude or phase) using two-tone, binary patterns, leading to deleterious diffraction effects that must be mitigated. In shearing, the presence of multiple diffraction orders affects measurement near boundaries. In Hartmann, diffraction limits the measurement point density. We demonstrate that the use of pseudo-gray-scale halftone patterns in the diffracting elements can improve the performance of both techniques.

Binary Amplitude Reflection Gratings for X-ray Shearing and Hartmann Wavefront Sensors.

New, high-coherent-flux X-ray beamlines at synchrotron and free-electron laser light sources rely on wavefront sensors to achieve and maintain optimal alignment under dynamic operating conditions. This includes feedback to adaptive X-ray optics. We describe the design and modeling of a new class of binary-amplitude reflective gratings for shearing interferometry and Hartmann wavefront sensing. Compact arrays of deeply etched gratings illuminated at glancing incidence can withstand higher power densities than transmission membranes and can be designed to operate across a broad range of photon energies with a fixed grating-to-detector distance. Coherent wave-propagation is used to study the energy bandwidth of individual elements in an array and to set the design parameters. We observe that shearing operates well over a ±10% bandwidth, while Hartmann can be extended to ±30% or more, in our configuration. We apply this methodology to the design of a wavefront sensor for a soft X-ray beamline operating from 230 eV to 1400 eV and model shearing and Hartmann tests in the presence of varying wavefront aberration types and magnitudes.

Impact of the Number of Cores on the Prostate Cancer Detection Rate in Men Undergoing in-Bore Magnetic Resonance Imaging-Guided Targeted Biopsies.

OBJECTIVE: To determine the incremental detection rate of clinically significant prostate cancer (csPCa) provided by sequential cores during in-bore magnetic resonance imaging (MRI)-guided prostate biopsies. METHODS: Single-center, retrospective interpretation of prospectively acquired data in men without previous diagnosis of csPCa who underwent in-bore MRI-guided prostate biopsy between May 2017 and December 2019. Endpoints included detection of csPCa (grade group [GG] ≥ 2) and rate of GG upgrade provided by additional cores. Descriptive statistics presented as mean and standard deviation for the continuous variables, and frequency and percentage for the categorical variables. RESULTS: Four hundred and forty-three men with 747 lesions met eligibility criteria. Clinically significant prostate cancer was detected in 43.1% (322/747) of the biopsied lesions and GG 2 PCa or greater was identified by the first core in 78.3% (252/322) of them. On a per-core basis, cores 2, 3, 4, and 5 found new csPCa in 6% (42/744), 4% (26/719), 1% (2/137), and 0% (0/11) of the cases. Core biopsy 2, 3, 4, and 5 resulted in GG upgrade in 12% (91/744), 7% (49/719), 7% (9/137), and 0% (0/11) of the lesions, respectively. Each additional core was associated with a mean increase of 5 minutes in the duration of the biopsy. CONCLUSIONS: In men undergoing in-bore MRI-guided prostate biopsies, 3 targeted cores per lesion provide an optimal trade-off between detection of clinically significant tumors and biopsy duration.

Reflective binary amplitude grating for soft x-ray shearing and Hartmann wavefront sensing.

We demonstrate a reflective wavefront sensor grating suitable for the characterization of high-quality x-ray beamlines and optical systems with high power densities. Operating at glancing incidence angles, the optical element is deeply etched with a two-level pattern of shearing interferometry gratings and Hartmann wavefront sensor grids. Transverse features block unwanted light, enabling binary amplitude in reflection with high pattern contrast. We present surface characterization and soft x-ray reflectometry of a prototype grating array to demonstrate function prior to wavefront measurement applications. A simulation of device performance is shown.

Compensation of heat load deformations using adaptive optics for the ALS upgrade: a wave optics study.

A realistic wave optics simulation method has been developed to study how wavefront distortions originating from heat load deformations can be corrected using adaptive X-ray optics. Several planned soft X-ray and tender X-ray insertion-device beamlines in the Advanced Light Source upgrade rely on a common design principle. A flat, first mirror intercepts the white beam; vertical focusing is provided by a variable-line-space monochromator; and horizontal focusing comes from a single, pre-figured, adaptive mirror. A variety of scenarios to cope with thermal distortion in the first mirror are studied by finite-element analysis. The degradation of the intensity distribution at the focal plane is analyzed and the adaptive optics that correct it is modeled. The range of correctable wavefront errors across the operating range of the beamlines is reported in terms of mirror curvature and spatial frequencies. The software developed is a one-dimensional wavefront propagation package made available in the OASYS suite, an adaptable, customizable and efficient beamline modeling platform.

Adaptive shape control of wavefront-preserving X-ray mirrors with active cooling and heating.

This article describes the development and testing of a novel, water-cooled, active optic mirror system (called "REAL: Resistive Element Adjustable Length") that combines cooling with applied auxiliary heating, tailored to the spatial distribution of the thermal load generated by the incident beam. This technique is theoretically capable of sub-nanometer surface figure error control even at high power density. Tests conducted in an optical metrology laboratory and at synchrotron X-ray beamlines showed the ability to maintain the mirror profile to the level needed for the next generation storage rings and FEL mirrors.

Extreme ultraviolet microscope characterization using photomask surface roughness.

We demonstrate a method for characterizing the field-dependent aberrations of a full-field synchrotron-based extreme ultraviolet microscope. The statistical uniformity of the inherent, atomic-scale roughness of readily-available photomask blanks enables a self-calibrating computational procedure using images acquired under standard operation. We characterize the aberrations across a 30-um field-of-view, demonstrating a minimum aberration magnitude of smaller than [Formula: see text] averaged over the center 5-um area, with a measurement accuracy better than [Formula: see text]. The measured field variation of aberrations is consistent with system geometry and agrees with prior characterizations of the same system. In certain cases, it may be possible to additionally recover the illumination wavefront from the same images. Our method is general and is easily applied to coherent imaging systems with steerable illumination without requiring invasive hardware or custom test objects; hence, it provides substantial benefits when characterizing microscopes and high-resolution imaging systems in situ.