Faculty Bibliography

BACKGROUND AND OBJECTIVE/OBJECTIVE:Staging of bladder cancer (BC) remains a cornerstone of treatment planning, especially in distinguishing non-muscle-invasive BC (NMIBC) from muscle-invasive BC (MIBC). Multiparametric magnetic resonance imaging (mpMRI), together with the Vesical Imaging-Reporting and Data System (VI-RADS) and its neoadjuvant chemotherapy version (nacVI-RADS), has emerged as a noninvasive, standardised tool for local staging and response assessment. Our aim was to provide urologists with a practical, up-to-date overview of bladder mpMRI and its application in diverse clinical settings. METHODS:We conducted a narrative review of the literature, including original studies, meta-analyses, international guidelines, and expert consensus documents, on the role of magnetic resonance imaging (MRI) in the BC diagnostic and therapeutic pathway. KEY FINDINGS AND LIMITATIONS: mpMRI with VI-RADS improves the accuracy of preoperative staging, helps in avoiding repeat transurethral resection of bladder tumour in selected NMIBC cases, and supports decision-making in MIBC in MRI-based pathways. nacVI-RADS allows assessment of treatment responses after systemic therapies, and can potentially guide bladder-sparing approaches. Barriers include variability in access, guideline inconsistency, the reproducibility of interpretation, and limited cost-effectiveness data. However, ongoing multicentre validation efforts and standardised reporting are helping to mitigate these issues. CONCLUSIONS AND CLINICAL IMPLICATIONS/CONCLUSIONS:mpMRI, VI-RADS, and nacVI-RADS represent essential tools for enhancing risk stratification and personalising BC management in clinical urology practice. Their integration into multidisciplinary workflows has the potential to improve outcomes and reduce overtreatment.

Various imaging modalities play key roles throughout the different stages of prostate cancer. Each imaging modality has different strengths and weaknesses and various scoring systems or frameworks are used to interpret their findings. Discordances between imaging modalities or interpretation frameworks, and even with clinicopathological findings are not uncommon. Discordances often lead to challenges in the decision-making process, especially with dynamically changing indications for newer imaging modalities. While more research is needed on harmonizing interpretations across different modalities, multidisciplinary team discussion is key to optimizing management of patients with prostate cancer when such discordances are present. In this comprehensive review, we take a deep dive in to these various discordances seen in clinical practice and explore their clinical implications.

High-quality bladder MRI is essential for reliable detection and characterization of bladder tumors. While the Vesical Imaging Reporting and Data System (VI-RADS) was developed to standardize acquisition, interpretation, and reporting of MRI for bladder cancer staging, no universal scoring system has been established for quality assessment. A systematic review showed that existing efforts for bladder MRI quality assessment have largely relied on study-specific, subjective Likert-type scales, with substantial variability, hindering reproducibility and comparability across studies and institutions. In this paper, we describe a novel bladder MRI scoring system that was developed by the multidisciplinary American College of Radiology VI-RADS Steering Committee, the VI-RADS Quality Score. It provides stratification of quality scores-inadequate, adequate, and optimal-based on signal-to-noise ratio, ability to clearly visualize relevant anatomic landmarks, and assessments of common imaging artifacts, which can guide clinical decision-making. It also emphasizes per-sequence scores in addition to an overall assessment to support targeted MRI protocol optimization. The VI-RADS Quality Score will need to be prospectively validated and will facilitate reproducibility across institutions, build trust in bladder MRI within multidisciplinary teams, and accelerate widespread adoption of bladder MRI for bladder cancer imaging. KEY POINTS: Question While high-quality bladder MRI is essential for evaluating bladder cancer, no universal scoring system is established for quality assessment. Findings A systematic review showed that studies on bladder MRI quality had significant variability. A structured scoring system was developed by the multidisciplinary VI-RADS steering committee. Clinical relevance High-quality bladder MRI is essential for reliable evaluation of bladder cancer. The VI-RADS Steering Committee developed a scoring system for bladder MRI quality assessment. This is expected to facilitate reproducibility and build trust in bladder MRI within multidisciplinary teams.

Post-radiotherapy erectile dysfunction (ED) can significantly impact the quality of life of patients with prostate cancer (PCa). Critical anatomical structures, such as the neurovascular bundle (NVB), internal pudendal arteries (IPA), penile bulb, and corporal tissues track in close proximity to the prostate, making them susceptible to radiation-related damage. This study aimed to evaluate the anatomical patterns of these structures and their relationship with the prostate, and to provide comprehensive illustrative examples on MRI. Consecutive patients with PCa who underwent MRI-linear accelerator (LINAC)-based stereotactic body radiotherapy (SBRT) in January-December 2024 were included. NVB patterns were classified into 3 categories: (1) "classical" with discrete NVB elements, (2) "adherent", dispersed and adherent to prostatic capsule, and (3) "absent". The smallest distance between the IPA and the prostate capsule and membranous urethral length (MUL), serving as a surrogate for distance between corporal tissue and prostatic apex, were also measured. These MRI findings were compared between prostate volumes >40 and <40 ml and between MRI/pathological features of the dominant intraprostatic lesion. A total of 160 men (median age 70 years, interquartile range [IQR] 64-76) were included. The most common NVB pattern was "classic" (80.0-85.0%), followed by the "adherent" NVB pattern (13.8-18.1%). The median smallest distance between the IPA and prostate was 2.3 cm (IQR 1.8-2.8 cm), with 3.1-3.8% less than 1.0 cm. The median MUL was 1.5 cm (IQR, 1.2-1.8 cm), with 2.5% of patients less than 1.0 cm. No significant association was found between these MRI features and prostate volume or other variables (p = 0.09-0.99). In conclusion, most PCa patients demonstrated favorable anatomy for potential dose sparing of critical structures. Comprehensive MRI illustrations are provided to help radiation oncologists recognize the location, trajectory, and relationship of these structures, facilitating their contouring and ultimately aiding in achieving meaningful dose reductions to these erectile function structures.

OBJECTIVE:To develop a tool for the clinical hybrid imaging workflow which combines morphologic and functional measurements. And to quantify the number of clicks saved per positron emission tomography/computed tomography (PET/CT) interpretation. METHODS:A tool was developed where a volume of interest (VOI) is automatically created around line distance measurements. VOI statistics for both PET and CT component, and line distances are generated and displayed. Usage data for the first two months after introduction of the tool was analyzed. RESULTS:Eleven radiologists and nuclear medicine physicians used the tool in 364 PET/CTs. In 19% of examinations, the novel tool was the only tool that needed to be used. The novel combined tool was used 1001 times, whereas the traditional spherical VOI had been placed 1131 times. The usage ratio of new to traditional tool differed significantly between examinations with ≤ 6 annotations (ratio 1.0) versus > 6 annotations (ratio 0.63, p = 0.030). The average number of saved clicks per PET/CT was estimated at 16.5. CONCLUSION/CONCLUSIONS:A novel combined measurement tool for hybrid imaging was implemented and saved on average 16.5 clicks per examination. These improvements contribute to a smoother workflow and demonstrate the positive impact of thoughtful software design in medical practice.

Prostate-specific membrane antigen (PSMA) PET is a powerful tool for prostate cancer staging and restaging, providing higher sensitivity and specificity than conventional imaging. The recognition of interpretive pitfalls led to the development of various scoring systems and frameworks, which in turn created challenges for consistent interpretation. The Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) version 2 classification integrates the five-point PRIMARY score for assessing local disease, the molecular imaging TNM stage for disease extent, and the PSMA expression score to assess eligibility for PSMA-targeted radioligand therapy. The PSMA Reporting and Data System (PSMA-RADS) classifies PSMA PET/CT findings on the basis of the likelihood of presence of prostate cancer. For assessing therapy response, PSMA PET Progression (PPP) criteria focus on new lesions and clinical or biochemical progression, whereas Response Evaluation Criteria in PSMA PET/CT (RECIP 1.0) assess new lesions and changes in total PSMA-positive total tumor volume. The European Association of Nuclear Medicine (EANM) E-PSMA guideline and EANM-Society of Nuclear Medicine and Molecular Imaging procedure guidelines provide standardized reporting recommendations, incorporating elements from existing systems such as PROMISE, PSMA-RADS, and PPP. Nevertheless, such systems can be essential for optimizing prostate cancer management and facilitating communication among imaging professionals, clinicians, and patients. This article outlines these systems and discusses potential strengths and weaknesses.

PURPOSE/UNASSIGNED:Stomal complications after ileal conduit urinary diversion are challenging and can negatively affect quality of life after radical cystectomy. Parastomal hernias (PHs) develop in up to half of patients; 30% to 75% are symptomatic, and up to one-third require surgical repair. Recurrence rates after local tissue repair are high, and relocation of the stoma requires closure of the original defect, placing both sites at risk for hernias. MATERIALS AND METHODS/UNASSIGNED:The primary aim of this randomized phase 3 trial was to test whether prophylactic placement of a parastomal mesh at ileal conduit formation reduced radiographic PH (rPH) rate compared with standard techniques without mesh; final rPH assessment was at 24 months. Ultrapro semiabsorbable mesh was placed in a sublay position dorsal to rectus muscle and anterior to posterior rectus sheath. RESULTS/UNASSIGNED:= .2). CONCLUSIONS/UNASSIGNED:We were unable to identify a clinical benefit to prophylactic parastomal mesh placement. Based on these findings, mesh at the time of conduit creation should not be used to avoid PH formation.

BACKGROUND:Potential rural-urban differences in prostate cancer care are understudied, particularly regarding the utilization of advanced diagnostic tests. Herein we examined variations in Positron Emission Tomography (PET) utilization for prostate cancer care, including diagnosis, staging and treatment planning, across residential regions in the United States. METHODS:Patients newly diagnosed with prostate cancer between 2019 and 2021 and post-diagnostic PETs were identified using full Medicare claims data. PET use was assessed in all newly diagnosed patients, though indications vary by risk. Patients' counties were categorized as metro, urban, or rural, from most to least urbanized. Regional PET utilization was further examined at the level of hospital referral regions. A multivariable logistic regression model was performed to assess the impact of rurality on PET imaging. A secondary analysis included an interaction term for race to explore the effect of residence on PET imaging by racial group. RESULTS:Overall, 495 865 patients were included in the analysis: 393 861 (79.4%) lived in metro, 56 698 (11.4%) in urban and 39 707 (8.0%) in rural counties. Patients in metro counties underwent PET imaging more often (8.4%) than patients in urban (7.3%) or rural counties (7.2%), p < 0.0001. At a level of hospital referral region, PET utilization rates ranged from 2.2 to 20.8%. PET imaging was more commonly performed in White compared to Black or Hispanic patients. Rural patients were less likely to undergo PET imaging compared to metro patients (odds ratio [OR] 0.87, 95% Confidence interval [CI]: 0.82-0.92 p < 0.0001). Rural Black (OR 0.69, 95%CI 0.57-0.83, p < 0.0001) and rural White patients (OR 0.89, 95%CI 0.83-0.94 p < 0.0001) were less likely to obtain PET imaging compared to their metro counterparts, p-interaction < 0.0001. CONCLUSION/CONCLUSIONS:Rural patients were less likely to undergo PET imaging than metro patients. The effect of rurality was most pronounced among Black patients. Our findings underscore the need for strategies to support equitable use of PET imaging.

Liquid biopsy helps detect cells and cell-derived metabolites, proteins, nucleic acids, and vesicles that are shed into body fluids by tumors. This diagnostic test requires only approximately 10 mL of blood or urine. It has received considerable attention as a minimally invasive tool for whole-body tumor interrogation for use in patients with cancer. It poses an attractive and potentially cost-effective alternative to invasive tissue sampling through tissue biopsies, especially serial assessments, such as for treatment response evaluation and mutations that occur during cancer treatment. Cell-free and circulating tumor DNA are the most frequently tested liquid biopsy analytes, and have shown promise for cancer screening, assessment of residual disease after treatment, and clinical outcome prediction and prognostication. Whereas liquid biopsy is less sensitive than imaging in early tumor stages, it is more specific and may help detect treatment response earlier than the Response Evaluation Criteria in Solid Tumors, or RECIST. Aimed primarily at radiologists, this review article provides an update on recent developments in the use of liquid biopsy, including findings from landmark clinical trials and U.S. regulatory approvals as companion diagnostic tests for clinical use, particularly in four malignancies: lymphoma, breast cancer, prostate cancer, and melanoma. Finally, current challenges for the clinical implementation of liquid biopsy are discussed.