The impact of FDG-PET/CT in the management of patients with vulvar and vaginal cancer.

OBJECTIVES: To evaluate the changes in prognostic impression and patient management following PET/CT in patients with vulvar and vaginal carcinoma; and to compare PET/CT findings with those of conventional imaging modalities. METHODS: We summarized prospectively and retrospectively collected data for 50 consecutive patients from our institution that enrolled in the National Oncologic PET Registry and underwent FDG-PET/CT for a suspected or known primary or recurrent vulvar/vaginal cancer. RESULTS: 54/83 (65%) studies included had a diagnosis of vulvar cancer, and the remaining 29/83 (35%), a diagnosis of vaginal cancer. Following FDG-PET/CT, the physician's prognostic impression changed in 51% of cases. A change in patient management, defined as a change to/from a non-interventional strategy (observation or additional imaging), to/from an interventional strategy (biopsy or treatment), was documented in 36% of studies. The electronic records demonstrated that 95% of the management strategies recorded in the physician questionnaires were implemented as planned. MRI and/or CT were performed within one month of the FDG-PET/CT in 20/83 (24%) and 28/83 (34%) cases, respectively. FDG-PET/CT detected nodes suspicious for metastases on 29/83 (35%) studies performed. MRI and CT detected positive nodes on 6 and 11 studies respectively. Distant metastases were identified in 10 cases imaged with FDG-PET and 5 cases that had additional conventional CT imaging. All suspicious lesions seen on CT were positively identified on PET/CT. In 4 cases, an abnormality identified on PET/CT, was not seen on diagnostic CT. CONCLUSIONS: FDG-PET/CT may play an important role in the management of vulvar and vaginal carcinoma.

Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference.

OBJECTIVES: To evaluate the recommendations for multiparametric prostate MRI (mp-MRI) interpretation introduced in the recently updated Prostate Imaging Reporting and Data System version 2 (PI-RADSv2), and investigate the impact of pathologic tumour volume on prostate cancer (PCa) detectability on mpMRI. METHODS: This was an institutional review board (IRB)-approved, retrospective study of 150 PCa patients who underwent mp-MRI before prostatectomy; 169 tumours ≥0.5-mL (any Gleason Score [GS]) and 37 tumours <0.5-mL (GS ≥4+3) identified on whole-mount pathology maps were located on mp-MRI consisting of T2-weighted imaging (T2WI), diffusion-weighted (DW)-MRI, and dynamic contrast-enhanced (DCE)-MRI. Corresponding PI-RADSv2 scores were assigned on each sequence and combined as recommended by PI-RADSv2. We calculated the proportion of PCa foci on whole-mount pathology correctly identified with PI-RADSv2 (dichotomized scores 1-3 vs. 4-5), stratified by pathologic tumour volume. RESULTS: PI-RADSv2 allowed correct identification of 118/125 (94 %; 95 %CI: 90-99 %) peripheral zone (PZ) and 42/44 (95 %; 95 %CI: 89-100 %) transition zone (TZ) tumours ≥0.5 mL, but only 7/27 (26 %; 95 %CI: 10-42 %) PZ and 2/10 (20 %; 95 %CI: 0-52 %) TZ tumours with a GS ≥4+3, but <0.5 mL. DCE-MRI aided detection of 4/125 PZ tumours ≥0.5 mL and 0/27 PZ tumours <0.5 mL. CONCLUSIONS: PI-RADSv2 correctly identified 94-95 % of PCa foci ≥0.5 mL, but was limited for the assessment of GS ≥4+3 tumours ≤0.5 mL. DCE-MRI offered limited added value to T2WI+DW-MRI. KEY POINTS: • PI-RADSv2 correctly identified 95 % of PCa foci ≥0.5 mL • PI-RADSv2 was limited for the assessment of GS ≥4+3 tumours ≤0.5 mL • DCE-MRI offered limited added value to T2WI+DW-MRI.

Volume-based quantitative FDG PET/CT metrics and their association with optimal debulking and progression-free survival in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery.

OBJECTIVE: Our aim was to evaluate the associations between quantitative (18)F-fluorodeoxyglucose positron-emission tomography (FDG-PET) uptake metrics, optimal debulking (OD) and progression-free survival (PFS) in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery. METHODS: Fifty-five patients with recurrent ovarian cancer underwent FDG-PET/CT within 90 days prior to surgery. Standardized uptake values (SUVmax), metabolically active tumour volumes (MTV), and total lesion glycolysis (TLG) were measured on PET. Exact logistic regression, Kaplan-Meier curves and the log-rank test were used to assess associations between imaging metrics, OD and PFS. RESULTS: MTV (p = 0.0025) and TLG (p = 0.0043) were associated with OD; however, there was no significant association between SUVmax and debulking status (p = 0.83). Patients with an MTV above 7.52 mL and/or a TLG above 35.94 g had significantly shorter PFS (p = 0.0191 for MTV and p = 0.0069 for TLG). SUVmax was not significantly related to PFS (p = 0.10). PFS estimates at 3.5 years after surgery were 0.42 for patients with an MTV ≤ 7.52 mL and 0.19 for patients with an MTV > 7.52 mL; 0.46 for patients with a TLG ≤ 35.94 g and 0.15 for patients with a TLG > 35.94 g. CONCLUSION: FDG-PET metrics that reflect metabolic tumour burden are associated with optimal secondary cytoreductive surgery and progression-free survival in patients with recurrent ovarian cancer. KEY POINTS: • Both TLG and MTV were associated with optimal tumour debulking. • There was no significant association between SUVmax and tumour debulking status. • Patients with higher MTV and/or TLG had significantly shorter PFS. • SUVmax was not significantly related to PFS.

Combined PET/MR: The Real Work Has Just Started. Summary Report of the Third International Workshop on PET/MR Imaging; February 17-21, 2014, Tübingen, Germany.

This paper summarises the proceedings and discussions at the third annual workshop held in Tübingen, Germany, dedicated to the advancement of the technical, scientific and clinical applications of combined PET/MRI systems in humans. Two days of basic scientific and technical instructions with "hands-on" tutorials were followed by 3 days of invited presentations from active researchers in this and associated fields augmented by round-table discussions and dialogue boards with specific themes. These included the use of PET/MRI in paediatric oncology and in adult neurology, oncology and cardiology, the development of multi-parametric analyses, and efforts to standardise PET/MRI examinations to allow pooling of data for evaluating the technology. A poll taken on the final day demonstrated that over 50 % of those present felt that while PET/MRI technology underwent an inevitable slump after its much-anticipated initial launch, it was now entering a period of slow, progressive development, with new key applications emerging. In particular, researchers are focusing on exploiting the complementary nature of the physiological (PET) and biochemical (MRI/MRS) data within the morphological framework (MRI) that these devices can provide. Much of the discussion was summed up on the final day when one speaker commented on the state of PET/MRI: "the real work has just started".

Volume and landmark analysis: comparison of MRI measurements obtained with an endorectal coil and with a phased-array coil.

AIM: To compare prostate volumes and distances between anatomical landmarks on MRI images obtained with a phased-array coil (PAC) only and with a PAC and an endorectal coil (ERC). MATERIALS AND METHODS: Informed consent was waived for this Health Insurance Portability and Accountability Act-compliant study. Fifty-nine men underwent PAC-MRI and ERC-MRI at 1.5 (n = 3) or 3 T (n = 56). On MRI images, two radiologists independently measured prostate volume and distances between the anterior rectal wall (ARW) and symphysis pubis at the level of the verumontanum; ARW and symphysis pubis at the level of the mid-symphysis pubis; and bladder neck and mid-symphysis pubis. Differences between measurements from PAC-MRI and ERC-MRI were assessed with the Wilcoxon RANK SUM test. Inter-reader agreement was assessed using the concordance correlation coefficient (CCC). RESULTS: Differences in prostate volume between PAC-MRI and ERC-MRI [median: -0.75 mm(3) (p = 0.10) and median: -0.84 mm(3) (p = 0.06) for readers 1 and 2, respectively] were not significant. For readers 1 and 2, median differences between distances were as follows: -10.20 and -12.75 mm, respectively, ARW to symphysis pubis at the level of the verumontanum; -6.60 and -6.08 mm, respectively, ARW to symphysis pubis at the level of the mid-symphysis pubis; -3 and -3 mm respectively, bladder neck to mid-symphysis pubis. All differences in distance were significant for both readers (p ≤ 0.0005). Distances were larger on PAC-MRI (p ≤ 0.0005). Inter-reader agreement regarding prostate volume was almost perfect on PAC-MRI (CCC: 0.99; 95% CI: 0.98-1.00) and ERC-MRI (CCC: 0.99; 95% CI: 0.99-1.00); inter-reader agreement for distance measurements varied (CCCs: 0.54-0.86). CONCLUSION: Measurements of distances between anatomical landmarks differed significantly between ERC-MRI and PAC-MRI, although prostate volume measurements did not.

Role of endorectal prostate MRI in patients with initial suspicion of prostate cancer.

PURPOSE: To evaluate the role of conventional endorectal prostate MRI in patients with initial suspicion of prostate cancer. MATERIALS AND METHODS: Ethics board approval was received for this retrospective study of 87 men who underwent 1.5-Tesla conventional prostate MRI with a combination of endorectal and body phased-array coils for suspected prostate cancer before their first systematic 12-core TRUS-guided biopsy. Three radiologists independently analyzed the images, dividing the prostate into 12 regions corresponding to the biopsy scheme and scoring each region for the presence of prostate cancer on a 5-point scale. Results were analyzed by prostate region. ROC analysis was done and descriptive statistics were calculated. The negative predictive value, specificity, sensitivity and positive predictive value were calculated using dichotomized scores (benign tissue = scores of 1 and 2; malignant tissues = scores of 3, 4, and 5). RESULTS: Biopsy revealed cancer in 47/87 patients (26 low-grade [Gleason score 6]; 21 high-grade [Gleason score ≥ 3 + 4]), and 184/1044 cores (77 low-grade and 107 high-grade) with a median of 3 positive cores per cancer patient (range 1 - 12). The areas under ROC curves were 0.65 - 0.67 for cancer detection by region overall and 0.75 - 0.76 for the detection of high-grade cancer by region. Statistic figures for the detection of all cancers/high-grade cancers by region were as follows: negative predictive value, 87.4 - 88.2 %/92.6 - 93.1 %; specificity, 72.3 - 79.4 %/71.5 - 79.8 %; sensitivity, 49.5 - 54.8 %/62.6 - 69.2 %; and positive predictive value, 29.3 - 34.0 %/29.4 - 34.7 %. CONCLUSION: In patients with suspected prostate cancer, negative MRI findings indicate the absence of high-grade prostate cancer on subsequent TRUS-guided 12-core biopsy with high probability. However, agreement between conventional 1.5-T endorectal prostate MRI and systematic 12-core TRUS-guided biopsy for the detection of prostate cancer appears to be moderate.

Acute effects of pelvic irradiation on the adult uterus revealed by dynamic contrast-enhanced MRI.

OBJECTIVE: Pelvic radiation therapy (RT) can influence fertility in female rectal cancer survivors. Data regarding its effects on the adult uterus are scant. This study aims to evaluate the uterus before and after RT, using dynamic contrast-enhanced MRI. METHODS: Eligible patients (n=10) received RT for rectal cancer, had an intact uterus and underwent dynamic contrast-enhanced MRI before and after RT. Seven patients were pre-menopausal. RESULTS: Patients received pelvic RT (median, 50.2 Gy) with concurrent 5-fluorouracil. Five patients were treated with intensity modulated RT (IMRT) and five with a three-field technique. The median D95 of the uterus was 30 Gy; D05 was 48 Gy; and V95 was 97%. The median cervical D95 was 45 Gy; D05, 50 Gy; and V95, 100%. Cervical dose was higher with IMRT than with three-field plans (p≤0.038). On T2 MRI, the junctional zone was visible in nine patients before and in one after RT (p=0.001). Median cervical length (2.3 vs 3.0 cm) and endometrial thickness (2.6 vs 5.9 mm) were reduced after RT (p≤0.008). In pre-menopausal patients, the volume transfer constant, K(trans), (0.069 vs 0.195, p=0.006) and the extracellular extravascular volume fraction, V(e), (0.217 vs 0.520, p=0.053) decreased. CONCLUSION: Pelvic RT significantly affected uterine anatomy and perfusion. Cervical dose was higher with IMRT than three-field plans, but no attempt was made to constrain the dose. ADVANCES IN KNOWLEDGE: Pelvic RT significantly affects the adult uterus. These findings are crucial to understand the potential consequences of RT on fertility, and they lay the groundwork for further prospective studies.

Role of endorectal prostate MRI in patients with initial suspicion of prostate cancer.

PURPOSE: To evaluate the role of conventional endorectal prostate MRI in patients with initial suspicion of prostate cancer. MATERIALS AND METHODS: Ethics board approval was received for this retrospective study of 87 men who underwent 1.5-Tesla conventional prostate MRI with a combination of endorectal and body phased-array coils for suspected prostate cancer before their first systematic 12-core TRUS-guided biopsy. Three radiologists independently analyzed the images, dividing the prostate into 12 regions corresponding to the biopsy scheme and scoring each region for the presence of prostate cancer on a 5-point scale. Results were analyzed by prostate region. ROC analysis was done and descriptive statistics were calculated. The negative predictive value, specificity, sensitivity and positive predictive value were calculated using dichotomized scores (benign tissue = scores of 1 and 2; malignant tissues = scores of 3, 4, and 5). RESULTS: Biopsy revealed cancer in 47/87 patients (26 low-grade [Gleason score 6]; 21 high-grade [Gleason score ≥ 3 + 4]), and 184/1044 cores (77 low-grade and 107 high-grade) with a median of 3 positive cores per cancer patient (range 1 ­ 12). The areas under ROC curves were 0.65 ­ 0.67 for cancer detection by region overall and 0.75 ­ 0.76 for the detection of high-grade cancer by region. Statistic figures for the detection of all cancers/high-grade cancers by region were as follows: negative predictive value, 87.4 ­ 88.2 %/92.6 ­ 93.1 %; specificity, 72.3 ­ 79.4 %/71.5 ­ 79.8 %; sensitivity, 49.5 ­ 54.8 %/62.6 ­ 69.2 %; and positive predictive value, 29.3 ­ 34.0 %/29.4 ­ 34.7 %. CONCLUSION: In patients with suspected prostate cancer, negative MRI findings indicate the absence of high-grade prostate cancer on subsequent TRUS-guided 12-core biopsy with high probability. However, agreement between conventional 1.5-T endorectal prostate MRI and systematic 12-core TRUS-guided biopsy for the detection of prostate cancer appears to be moderate.

Prospective evaluation of MRI, ¹¹C-acetate PET/CT and contrast-enhanced CT for staging of bladder cancer.

PURPOSE: To prospectively evaluate the diagnostic performance of magnetic resonance imaging (MRI), (11)C-acetate positron emission tomography/computed tomography (PET/CT) and contrast-enhanced CT for bladder cancer staging, using whole-mount pathologic review of radical cystectomy and pelvic lymph node specimens as the reference standard. MATERIALS AND METHODS: The institutional review board approved this prospective study, which was compliant with the Health Insurance Portability and Accountability Act. Written informed consent was obtained from 16 patients with histologically confirmed bladder cancer who underwent MRI, (11)C-acetate PET/CT and contrast-enhanced CT before radical cystectomy and pelvic lymph node dissection. Before imaging 4/16 patients had received intravesical Bacillus Calmette-Guérin treatment, 6 had received systemic chemotherapy, 3 had received both and 3 had received neither. Measures of diagnostic performance including accuracy, sensitivity and specificity were estimated separately for each imaging modality. RESULTS: MRI correctly staged 56% of patients (9/16), overstaged 38% (6/16) and understaged 6% (1/16). CT correctly staged 50% of patients (8/16), overstaged 44% (7/16) and understaged 6% (1/16). In 9 patients, (11)C-acetate PET/CT showed uptake within the bladder wall; the uptake was true-positive in 7 patients and false-positive in 2 patients. Of the remaining 7 patients, 5 had true-negative and 2 had false-negative PET/CT results for cancer in the bladder wall. For all modalities, staging accuracy was reduced in patients with a history of prior intravesical and/or systemic chemotherapy. CONCLUSION: In staging bladder cancer, MRI, (11)C-acetate PET/CT and CT displayed similar levels of accuracy. For all modalities, a history of intravesical and/or systemic chemotherapy affected staging accuracy.

Reproducibility and clinical correlations of post-treatment changes on CT of prostate cancer bone metastases treated with chemotherapy.

OBJECTIVES: The objective of this study was to determine whether, in patients with prostate cancer (PCa) bone metastases receiving chemotherapy, early post-treatment changes on CT are reproducible and associated with clinical outcomes. METHODS: Blinded to outcomes, two radiologists with 1 year and 5 years of experience independently reviewed CTs obtained before and 3 months after chemotherapy initiation in 38 patients with bone metastases from castration-resistant PCa, recording the size, matrix and attenuation of ≤5 lesions; presence of new lesions, extraosseous components, periosteal reactions and cortical thickening; and overall CT assessment (improved, no change or worse). Kappa statistics were used to assess inter-reader agreement; the Kruskal-Wallis test and Cox regression model were used to evaluate associations. RESULTS: Inter-reader agreement was low/fair for size change (concordance correlation coefficient=0.013), overall assessment and extraosseous involvement (κ=0.3), moderate for periosteal reaction and cortical thickening (κ=0.4-0.5), and substantial for CT attenuation (κ=0.7). Most metastases were blastic (Reader 1, 58%; Reader 2, 67%) or mixed lytic-blastic (Reader 1, 42%; Reader 2, 34%). No individual CT features correlated with survival. Readers 1 and 2 called the disease improved in 26% and 5% of patients, unchanged in 11% and 21%, and worse in 63% and 74%, respectively, with 64% interreader agreement. Overall CT assessment did not correlate with percentage change in prostate-specific antigen level. For the more experienced reader (Reader 2), patients with improved or unchanged disease had significantly longer median survival (p=0.036). CONCLUSIONS: In PCa bone metastases, interreader agreement is low in overall CT post-treatment assessment and varies widely for individual CT features. Improved or stable disease identified by an experienced reader is statistically associated with longer survival.

Integrated diagnostics: proceedings from the 9th biennial symposium of the International Society for Strategic Studies in Radiology.

The International Society for Strategic Studies in Radiology held its 9th biennial meeting in August 2011. The focus of the programme was integrated diagnostics and massive computing. Participants discussed the opportunities, challenges, and consequences for the discipline of radiology that will likely arise from the integration of diagnostic technologies. Diagnostic technologies are increasing in scope, including advanced imaging techniques, new molecular imaging agents, and sophisticated point-of-use devices. Advanced information technology (IT), which is increasingly influencing the practice of medicine, will aid clinical communication and the development of "population images" that represent the phenotype of particular diseases, which will aid the development of diagnostic algorithms. Integrated diagnostics offer increased operational efficiency and benefits to patients through quicker and more accurate diagnoses. As physicians with the most expertise in IT, radiologists are well placed to take the lead in introducing IT solutions and cloud computing to promote integrated diagnostics. To achieve this, radiologists must adapt to include quantitative data on biomarkers in their reports. Radiologists must also increase their role as participating physicians, collaborating with other medical specialties, not only to avoid being sidelined by other specialties but also to better prepare as leaders in the selection and sequence of diagnostic procedures. Key Points • New diagnostic technologies are yielding unprecedented amounts of diagnostic information.• Advanced IT/cloud computing will aid integration and analysis of diagnostic data.• Better diagnostic algorithms will lead to faster diagnosis and more rapid treatment.

Prostate cancer imaging.

As prostate cancer is a biologically heterogeneous disease for which a variety of treatment options are available, the major objective of prostate cancer imaging is to achieve more precise disease characterization. Magnetic resonance imaging (MRI) may enhance the staging of prostate cancer compared with clinical evaluation, transrectal ultrasound, or computed tomography (CT), and allows concurrent evaluation of prostatic, periprostatic, and pelvic anatomy. In clinical practice, the fusion of MRI or dynamic contrast-enhanced MRI (DCE-MRI) with MR spectroscopic imaging (MRSI) is improving the evaluation of cancer location, size, and extent, while providing an indication of tumor aggressiveness. Pretreatment knowledge of these prognostic variables is essential for achieving minimally invasive, patient-specific therapy.

Measuring tumor response and shape change on CT: esophageal cancer as a paradigm.

BACKGROUND: Accurate response assessment is essential for evaluating new cancer treatments. We evaluated the impact of Response Evaluation Criteria in Solid Tumors (RECIST), World Health Organization (WHO) criteria and tumor shape on response assessment in patients with metastatic esophageal cancer. PATIENTS AND METHODS: In 19 patients with metastatic esophageal cancer in a phase II trial of bryostatin-1 and paclitaxel, response was retrospectively assessed for 89 lesions with RECIST and WHO criteria on baseline and serial follow-up CT scans. The eccentricity factor (EF) was introduced for measuring the degree to which tumor shape diverges from a perfect sphere [EF = radical1-(LPD/MD)(2), where LPD is the largest perpendicular diameter and MD is the maximal diameter]. RESULTS: The disagreement rate in best overall response categorization between RECIST (unidimensional) and WHO (bidimensional) criteria was 26.3%. Change in eccentricity was significantly greater (P < 0.01) for patients with disagreement (mean 0.31, range 0-0.91). When the short axis was used for unidimensional lymph node measurement, disagreement between WHO and RECIST lessened. CONCLUSIONS: Response assessment by WHO and RECIST differs substantially. Greater change in eccentricity is associated with greater discordance between WHO and RECIST. The discordance between WHO and RECIST may impact on how effective a therapy is judged to be.

New horizons in genitourinary oncologic imaging.

In the management of prostate cancer, combined anatomic and metabolic imaging is already in clinical use. In daily clinical practice, fusion of magnetic resonance imaging and magnetic resonance spectroscopic imaging is improving the evaluation of cancer location, size, and extent and is simultaneously providing assessment of tumor aggressiveness. Pretreatment knowledge of these prognostic variables is essential if minimally invasive, patient-specific cancer therapy is to be achieved. This report discusses the changes that are occurring in oncologic imaging and in genitourinary oncologic imaging in particular. It presents an overview of the applications of magnetic resonance imaging and magnetic resonance spectroscopic imaging for prostate cancer that is intended to illustrate the evolution of state-of-the-art imaging in a clinical setting. It also provides a short review of molecular imaging probes from the field of ongoing prostate cancer research. It concludes with a broader discussion of the nature of molecular imaging and the benefits it offers for cancer research and clinical care, which include noninvasive, in vivo imaging of specific cellular and molecular processes, nearly simultaneous monitoring of multiple molecular events, real-time imaging of the trafficking and targeting of cells, optimal patient-specific adjustment of drug and gene therapy, and assessment of disease progression at a molecular pathologic level.

MR imaging and MR spectroscopic imaging in the pre-treatment evaluation of prostate cancer.

Magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H MRSI) are emerging as the most sensitive tools for the non-invasive, anatomic and metabolic evaluation of prostate cancer. This article reviews the current applications of MRI and 1H MRSI in clinical practice and discusses the promise of these modalities for improving prostate cancer management. MRI demonstrates zonal anatomy with excellent contrast resolution and can reveal tumours in areas not routinely sampled on biopsy and not palpable on digital rectal examination. In addition, MR images allow assessment of local extent (including extracapsular extension and seminal vesicle invasion) and thus can assist in local staging while providing surgeons and radiation therapists with a visual road-map for treatment planning. The addition of 1H MRSI to MRI can improve prostate cancer detection and assessment of tumour volume; it also contributes indirectly to improved local staging. In addition, 1H MRSI metabolic and volumetric data correlate with pathological Gleason grade and thus may offer a non-invasive means to better predict prostate cancer aggressiveness. Combined MRI/1H MRSI is currently of greatest value for high-risk patients. With greater understanding of the relationship between spectroscopic data and tumour biology, it may become possible to use MRI/1H MRSI to achieve more precise stratification of patients in clinical trials, to monitor the progress of patients who select watchful waiting or minimally aggressive cancer therapies, and to guide and assess emerging local prostate cancer therapies.

Localized prostate cancer: effect of hormone deprivation therapy measured by using combined three-dimensional 1H MR spectroscopy and MR imaging: clinicopathologic case-controlled study.

PURPOSE: To determine the accuracy of combined magnetic resonance (MR) imaging and three-dimensional (3D) proton MR spectroscopic imaging in localizing prostate cancer to a sextant of the gland in patients receiving hormone deprivation therapy. MATERIALS AND METHODS: Combined MR imaging/3D MR spectroscopic imaging examinations were performed in 16 hormone-treated patients and 48 nontreated matched control patients before radical prostatectomy and step-section histopathologic analysis. At MR imaging, cancer presence within the peripheral zone was assessed on a per sextant basis by two readers. At 3D MR spectroscopic imaging, cancer was identified by using (choline plus creatine)-to-citrate ratios at cutoff values of 2 and 3 SDs above mean normal peripheral zone values. Data were compared by using receiver operating characteristic analysis. RESULTS: There was no significant difference in the ability of combined MR imaging/3D MR spectroscopic imaging to localize prostate cancer in treated versus control patients. For MR imaging alone, the sensitivity and specificity were 91% and 48% (reader 1) and 75% and 60% (reader 2) in treated patients versus 79% and 60% (reader 1) and 84% and 43% (reader 2) in control patients. For 3D MR spectroscopic imaging alone (>3 SDs cutoff), higher specificity (treated, 80%; controls, 73%) but lower sensitivity (treated, 56%; controls, 53%) was attained. In treated patients, high sensitivity or specificity (up to 92%) was achieved when either or both modalities indicated cancer. CONCLUSION: When performed within 4 months after initiating hormone deprivation therapy, combined MR imaging/3D MR spectroscopic imaging had the same accuracy in localizing prostate cancer as in nontreated patients.

Shared patient analysis: a method to assess the clinical benefits of patient referrals.

BACKGROUND: Referral to specialized physicians or institutions often is deemed necessary in clinical medicine, but no method exists to assess the clinical benefit of such referrals. OBJECTIVES: To describe a method, which is shared patient analysis, to measure the expected improvement in clinical management associated with referrals and to apply that method in the field of abdominal and pelvic oncological radiology. SUBJECTS: All patients referred, during a 4-year period, to surgical oncologists at four academic centers (the referral providers, or RPs) with radiographs performed before referral at a community site (the initial providers, or IPs). Patients (n = 396) for whom both the IP interpretation and a final diagnosis was available were eligible. All IP and RP readings were placed in random order and presented to surgical oncologists, who then recommended a treatment course. MEASUREMENTS: Diagnostic accuracy of the IP and RP readings and the proportion of patients who were assigned to an appropriate treatment by the oncologist were determined. RESULTS: When the indication for imaging was primary diagnosis or staging, the kappa for presence of cancer was 0.70. When the indication was cancer follow-up, the kappa for presence of recurrent/progressing cancer was 0.66. There were disagreements between the IP and RP radiologists over the interpretation of 162 films, with the RP radiologists being correct in 153 (94%). Had the patients been treated using IP readings, there would have been 19 more inappropriate surgeries and 19 more admissions (both P <0.05) than if the oncologists had based their recommendations on RP readings. CONCLUSIONS: The technique of shared patient analysis permits assessment of the clinical benefits associated with referrals.

Magnetic resonance imaging in the evaluation of congenital anomalies of the external genitalia.

OBJECTIVES: To assess the value of magnetic resonance imaging (MRI) in the anatomic evaluation and management planning of complex congenital genitourinary anomalies. METHODS: Multiplanar T(1) and T(2)-weighted MR images were obtained in 6 pediatric patients with congenital genitourinary anomalies, including aphallia, diphallia, ectopic scrotum, and epispadias. The imaging studies were read by experienced radiologists and discussed with the urologic surgeons in a multidisciplinary conference. RESULTS: Each congenital anomaly was demonstrated in detail by MRI. The MR images of penile agenesis showed hypoplastic corpora cavernosa and a vestigial bulb. In patients with penile duplication, MRI was able to delineate the course of each corporal body and the varying degree of thickness of the tunica albuginea. For the patient with scrotal ectopia, detailed MR images excluded both the possibility of urethral and corporal duplications and the presence of viable testes in the ectopic scrotum. In the case of epispadias, MRI illustrated the precise spatial relationship between the erectile bodies and urethra. Additionally, MRI identified related aberrant pelvic organs and provided images of the external genital structures. CONCLUSIONS: MRI, by rendering excellent anatomic interpretation of complex genital anomalies and associated abnormal pelvic tissues, assists surgeons in conceptualizing the anomalous structures and contributes to their formulation of management approaches.