Faculty Bibliography

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.

PURPOSE/OBJECTIVE:To explore pragmatic approaches integrating MRI and PSMA-PET/CT for evaluating extraprostatic extension (EPE) of prostate cancer (PCa). METHODS:>12). Diagnostic performance was tested with receiver operating characteristic (ROC) curves and compared using DeLong and McNemar tests. RESULTS:>12 among which 87.5% (7/8) were corrected upgraded and had pathological EPE. CONCLUSION/CONCLUSIONS:Several pragmatic approaches were explored for integrating MRI and PSMA-PET/CT to assess EPE in PCa. Combining morphological information from MRI and PSMA expression on PET/CT demonstrated good diagnostic performance and may be a simple pragmatic integrated method that can be used.

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 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.

OBJECTIVES/OBJECTIVE:Prostate-specific membrane antigen (PSMA)-PET/CT has become integral to management of prostate cancer; however, PSMA-avid rib lesions pose a diagnostic challenge. This study investigated clinicopathological and imaging findings that predict metastatic etiology of PSMA-avid rib lesions. MATERIALS AND METHODS/METHODS:), miPSMA score), CT features (sclerotic, lucent, fracture, no correlate), other sites of metastases, and primary tumor findings. A composite reference standard for rib lesion etiology (metastatic vs non-metastatic) based on histopathology, serial imaging, and clinical assessment was used. RESULTS:, miPSMA), more commonly involved multiple ribs, and were more often sclerotic (p < 0.01); lucency/fractures were only seen in benign lesions. CONCLUSION/CONCLUSIONS:Several imaging and clinicopathological factors differed between PSMA-avid metastatic and benign lesions. Isolated rib lesions without other sites of metastasis are almost always benign. Careful assessment of CT features can help diagnose benign lesions. KEY POINTS/CONCLUSIONS:Question While prostate-specific membrane antigen (PSMA)-PET/CT has become integral to the management of prostate cancer, PSMA-avid rib lesions pose a diagnostic challenge. Findings Approximately a quarter of patients who had PSMA-avid rib lesions were metastatic. However, only 2.1% of them had isolated rib metastasis (without PSMA-avid metastases elsewhere). Clinical relevance Isolated PSMA-avid rib lesions are almost always benign when there is no evidence of metastatic disease elsewhere. Scrutinizing CT features can help diagnose benign PSMA-avid lesions with greater certainty.

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.

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.

OBJECTIVES/OBJECTIVE:An increasing number of patients with prostate cancer (PCa) undergo assessment with magnetic resonance imaging (MRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT). This offers comprehensive multimodality staging but can lead to discrepancies. The objective was to assess the rates and types of discordance between MRI and PSMA-PET/CT for primary PCa assessment. MATERIALS AND METHODS/METHODS:Consecutive men diagnosed with intermediate and high-risk PCa who underwent MRI and PSMA-PET/CT in 2021-2023 were retrospectively included. MRI and PSMA-PET/CT were interpreted using PI-RADS v2.1 and PRIMARY scores. Discordances between the two imaging modalities were categorized as "minor" (larger or additional lesion seen on one modality) or "major" (positive on only one modality or different index lesions between MRI and PSMA-PET/CT) and reconciled using radical prostatectomy or biopsy specimens. RESULTS:Three hundred and nine men (median age 69 years, interquartile range (IQR) 64-75) were included. Most had Gleason Grade Group ≥ 3 PCa (70.9% (219/309)). Median PSA was 9.0 ng/mL (IQR 5.6-13.6). MRI and PSMA-PET/CT were concordant in 157/309 (50.8%) and discordant in 152/309 (49.1%) patients; with 39/152 (25.7%) major and 113/152 (74.3%) minor discordances. Of 27 patients with lesions only seen on MRI, 85.2% (23/27) were clinically significant PCa (csPCa). Of 23 patients with lesions only seen on PSMA-PET/CT, 78.3% (18/23) were csPCa. Altogether, lesions seen on only one modality were csPCa in 80.0% (36/45). CONCLUSION/CONCLUSIONS:MRI and PSMA-PET/CT were discordant in half of patients for primary PCa evaluation, with major discrepancies seen in roughly one out of eight patients. KEY POINTS/CONCLUSIONS:Question While both MRI and PSMA-PET/CT can be used for primary tumor assessment, the discordances between them are not well established. Findings MRI and PSMA-PET/CT were discordant in about half of the patients. Most prostate lesions seen on only one modality were significant cancer. Clinical relevance MRI and PSMA-PET/CT are often discordant for assessing the primary prostate tumor. Using both modalities for primary prostate tumor evaluation can provide complementary information that may substantially impact treatment planning.