Faculty Bibliography

Purpose To investigate the prevalence of FLCN, BAP1, SDH, and MET mutations in an oncologic cohort and determine the prevalence, clinical features, and imaging features of renal cell carcinoma (RCC) associated with these mutations. Secondarily, to determine the prevalence of encountered benign renal lesions. Materials and Methods From 25 220 patients with cancer who prospectively underwent germline analysis with a panel of more than 70 cancer-predisposing genes from 2015 to 2021, patients with FLCN, BAP1, SDH, or MET mutations were retrospectively identified. Clinical records were reviewed for patient age, sex, race/ethnicity, and renal cancer diagnosis. If RCC was present, baseline CT and MRI examinations were independently assessed by two radiologists. Summary statistics were used to summarize continuous and categorical variables by mutation. Results A total of 79 of 25 220 (0.31%) patients had a germline mutation: FLCN, 17 of 25 220 (0.07%); BAP1, 22 of 25 220 (0.09%); SDH, 39 of 25 220 (0.15%); and MET, one of 25 220 (0.004%). Of these 79 patients, 18 (23%) were diagnosed with RCC (FLCN, four of 17 [24%]; BAP1, four of 22 [18%]; SDH, nine of 39 [23%]; MET, one of one [100%]). Most hereditary RCCs demonstrated ill-defined margins, central nonenhancing area (cystic or necrotic), heterogeneous enhancement, and various other CT and MR radiologic features, overlapping with the radiologic appearance of nonhereditary RCCs. The prevalence of other benign solid renal lesions (other than complex cysts) in patients was up to 11%. Conclusion FLCN, BAP1, SDH, and MET mutations were present in less than 1% of this oncologic cohort. Within the study sample size limits, imaging findings for hereditary RCC overlapped with those of nonhereditary RCC, and the prevalence of other associated benign solid renal lesions (other than complex cysts) was up to 11%. Keywords: Familial Renal Cell Carcinoma, Birt-Hogg-Dubé Syndrome, Carcinoma, Renal Cell, Paragangliomas, Urinary, Kidney © RSNA, 2024.

Reversion mutations that restore wild-type function of the BRCA gene have been described as a key mechanism of resistance to Poly(ADP-ribose) polymerase (PARP) inhibitor therapy in BRCA-associated cancers. Here, we report a case of a patient with metastatic castration-resistant prostate cancer (mCRPC) with a germline BRCA2 mutation who developed acquired resistance to PARP inhibition. Extensive genomic interrogation of cell-free DNA (cfDNA) and tissue at baseline, post-progression, and postmortem revealed ten unique BRCA2 reversion mutations across ten sites. While several of the reversion mutations were private to a specific site, nine out of ten tumors contained at least one mutation, suggesting a powerful clonal selection for reversion mutations in the presence of therapeutic pressure by PARP inhibition. Variable cfDNA shed was seen across tumor sites, emphasizing a potential shortcoming of cfDNA monitoring for PARPi resistance. This report provides a genomic portrait of the temporal and spatial heterogeneity of prostate cancer under the selective pressure of a PARP inhibition and exposes limitations in the current strategies for detection of reversion mutations.

Radiology departments face challenges in delivering timely and accurate imaging reports, especially in high-volume, subspecialized settings. In this retrospective cohort study at a tertiary cancer center, we assessed the efficacy of an Automatic Assignment System (AAS) in improving radiology workflow efficiency by analyzing 232,022 CT examinations over a 12-month period post-implementation and compared it to a historical control period. The AAS was integrated with the hospital-wide scheduling system and set up to automatically prioritize and distribute unreported CT examinations to available radiologists based on upcoming patient appointments, coupled with an email notification system. Following this AAS implementation, despite a 9% rise in CT volume, coupled with a concurrent 8% increase in the number of available radiologists, the mean daily urgent radiology report requests (URR) significantly decreased by 60% (25 ± 12 to 10 ± 5, t = -17.6, p < 0.001), and URR during peak days (95^th quantile) was reduced by 52.2% from 46 to 22 requests. Additionally, the mean turnaround time (TAT) for reporting was significantly reduced by 440 min for patients without immediate appointments and by 86 min for those with same-day appointments. Lastly, patient waiting time sampled in one of the outpatient clinics was not negatively affected. These results demonstrate that AAS can substantially decrease workflow interruptions and improve reporting efficiency.

BACKGROUND:The diagnostic performance of contrast medium-free biparametric magnetic resonance imaging (bpMRI; combining T2-weighted imaging [T2WI] and diffusion-weighted imaging [DWI]) for evaluating variant-histology urothelial carcinoma (VUC) remains unknown. OBJECTIVE:To compare the diagnostic performance of bpMRI and multiparametric MRI (mpMRI; combining T2WI, DWI, and dynamic contrast-enhanced MRI]) for assessing muscle invasion of VUC. DESIGN, SETTING, AND PARTICIPANTS/METHODS:This multi-institution retrospective analysis included 118 patients with pathologically verified VUC who underwent bladder mpMRI before transurethral bladder tumor resection between 2010 and 2019. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS/METHODS:Three board-certified radiologists separately evaluated two sets of images, set 1 (bpMRI) and set 2 (mpMRI), in accordance with the Vesical Imaging Reporting and Data System (VI-RADS). The histopathology results were utilized as a reference standard. Receiver operating characteristic curve analysis, Z test, and Wald test were used to assess diagnostic abilities. RESULTS AND LIMITATIONS/CONCLUSIONS:Sixty-six (55.9%) and 52 (44.1%) of the 118 patients with VUC included in the analysis (mean age, 71 ± 10 yr; 88 men) had muscle-invasive bladder cancer (MIBC) and non-MIBC, respectively. For the diagnosis of MIBC, the areas under the curve for bpMRI were significantly smaller than those for mpMRI (0.870-0.884 vs 0.902-0.923, p < 0.05). The sensitivity of bpMRI was significantly lower than that of mpMRI for all readers with a VI-RADS cutoff score of 4 (65.2-66.7% vs 77.3-80.3%, p < 0.05). The specificity of bpMRI and mpMRI did not differ significantly for all readers (88.5-90.4 vs 88.5-92.3, p > 0.05). A limitation of the study is the limited sample size because of the rarity of VUC. CONCLUSIONS:In patients with VUC, on applying VI-RADS, the diagnostic results of bpMRI were inferior to those of mpMRI for evaluating muscle invasion. Therefore, mpMRI-based methods are recommended for evaluating muscle invasiveness of VUC. PATIENT SUMMARY/RESULTS:Contrast medium-free biparametric magnetic resonance imaging (bpMRI)-based Vesical Imaging Reporting and Data System (VI-RADS) can accurately diagnose pure urothelial carcinomas, similar to conventional multiparametric magnetic resonance imaging-based VI-RADS. However, bpMRI-based VI-RADS may misdiagnose muscle invasiveness of urothelial carcinoma with variant histology, particularly when its cutoff score is 4.

BACKGROUND & AIMS/UNASSIGNED:The treatment options for systemically progressed hepatocellular carcinoma (HCC) have significantly expanded in recent years. In this study, we aimed to evaluate the potential of Google searches as a reflection of prescription rates for HCC drugs in the United States (US). METHODS/UNASSIGNED:We conducted an in-depth analysis of US prescription data obtained from the IQVIA National Prescription Audit (NPA) and corresponding Google Trends data from January 2017 to December 2022. We focused on drugs used in the first line and second or later treatment lines for HCC, collecting data on their prescriptions and search rates. Search volumes were collected as aggregated search queries for both generic drugs and their respective brand names. RESULTS/UNASSIGNED:During the study period from Q1 2017 to Q4 2022, monthly prescriptions for drugs used in HCC treatment showed an 173% increase (from 1253 to 3422). Conversely online searches increased by 3.5% (from 173 to 179 per 10 million searches). Notably, strong correlations were observed between search interest and prescriptions for newer drugs, which indicates increasing usage, while older drugs with declining usage displayed limited correlation. Our findings suggest a growing role of non-physician professions in managing systemically progressed HCC within the US healthcare system, although oncologists remained primarily responsible for drug prescriptions. CONCLUSIONS/UNASSIGNED:In conclusion, online search monitoring can offer the potential to reflect prescription trends specifically related to the treatment of HCC. This approach provides a swift and accessible means of evaluating the evolving landscape of HCC treatment.

OBJECTIVE/UNASSIGNED:To investigate clinical, pathology, and imaging findings associated with inguinal lymph node (LN) metastases in patients with prostate cancer (PCa). MATERIALS AND METHODS/UNASSIGNED:This was a retrospective single-center study of patients with PCa who underwent imaging and inguinal LN biopsy between 2000 and 2023. We assessed the following aspects on multimodality imaging: inguinal LN morphology; extrainguinal lymphadenopathy; the extent of primary and recurrent tumors; and non-nodal metastases. Imaging, clinical, and pathology features were compared between patients with and without metastatic inguinal LNs. RESULTS/UNASSIGNED:= 0.07-0.37). None of the patients had inguinal LN metastasis in the absence of locally advanced disease with membranous urethra involvement or distant metastasis. CONCLUSION/UNASSIGNED:Several imaging, clinical, and pathology features are associated with inguinal LN metastases in patients with PCa. Isolated metastasis to inguinal LNs is extremely rare and unlikely to occur in the absence of high-risk imaging, clinical, or pathology features.

BACKGROUND:Neoadjuvant chemotherapy (NAC) before radical cystectomy is standard of care in patients with muscle-invasive bladder cancer (MIBC). Response assessment after NAC is important but suboptimal using CT. We assessed MRI without vs. with intravenous contrast (biparametric [BP] vs. multiparametric [MP]) for identifying residual disease on cystectomy and explored its prognostic role. METHODS:Consecutive MIBC patients that underwent NAC, MRI, and cystectomy between January 2000-November 2022 were identified. Two radiologists reviewed BP-MRI (T2 + DWI) and MP-MRI (T2 + DWI + DCE) for residual tumor. Diagnostic performances were compared using receiver operating characteristic curve analysis. Kaplan-Meier curves and Cox proportional-hazards models were used to evaluate association with disease-free survival (DFS). RESULTS:61 patients (36 men and 25 women; median age 65 years, interquartile range 59-72) were included. After NAC, no residual disease was detected on pathology in 19 (31.1%) patients. BP-MRI was more accurate than MP-MRI for detecting residual disease after NAC: area under the curve = 0.75 (95% confidence interval (CI), 0.62-0.85) vs. 0.58 (95% CI, 0.45-0.70; p = 0.043). Sensitivity were identical (65.1%; 95% CI, 49.1-79.0) but specificity was higher in BP-MRI compared with MP-MRI for determining residual disease: 77.8% (95% CI, 52.4-93.6) vs. 38.9% (95% CI, 17.3-64.3), respectively. Positive BP-MRI and residual disease on pathology were both associated with worse DFS: hazard ratio (HR) = 4.01 (95% CI, 1.70-9.46; p = 0.002) and HR = 5.13 (95% CI, 2.66-17.13; p = 0.008), respectively. Concordance between MRI and pathology results was significantly associated with DFS. Concordant positive (MRI+/pathology+) patients showed worse DFS than concordant negative (MRI-/pathology-) patients (HR = 8.75, 95% CI, 2.02-37.82; p = 0.004) and compared to the discordant group (MRI+/pathology- or MRI-/pathology+) with HR = 3.48 (95% CI, 1.39-8.71; p = 0.014). CONCLUSION/CONCLUSIONS:BP-MRI was more accurate than MP-MRI for identifying residual disease after NAC. A negative BP-MRI was associated with better outcomes, providing complementary information to pathological assessment of cystectomy specimens.

PURPOSE/OBJECTIVE:Ovarian-Adnexal Reporting and Data System (O-RADS) MRI uses a 5-point scale to establish malignancy risk in sonographically-indeterminate adnexal masses. The management of O-RADS MRI score 4 lesions is challenging, as the prevalence of malignancy is widely variable (5-90%). We assessed imaging features that may sub-stratify O-RADS MRI 4 lesions into malignant and benign subgroups. METHOD/METHODS:Retrospective single-institution study of women with O-RADS MRI score of 4 adnexal masses between April 2021-August 2022. Imaging findings were assessed independently by 2 radiologists according to the O-RADS lexicon white paper. MRI and clinical findingswere compared between malignant and benign adnexal masses, and inter-reader agreement was calculated. RESULTS:Seventy-four women (median age 52 years, IQR 36-61) were included. On pathology, 41 (55.4%) adnexal masses were malignant. Patients with malignant masses were younger (p = 0.02) with higher CA-125 levels (p = 0.03). Size of solid tissue was greater in malignant masses (p = 0.01-0.04). Papillary projections and larger solid portion were more common in malignant lesions; irregular septations and predominantly solid composition were more frequent in benign lesions (p < 0.01). Solid tissue of malignant lesions was more often hyperintense on T2-weighted and diffusion-weighted imaging (p ≤ 0.03). Other imaging findings were not significantly different (p = 0.09-0.77). Inter-reader agreement was excellent-good for most features (ICC = 0. 662-0.950; k = 0. 650-0.860). CONCLUSION/CONCLUSIONS:Various MRI and clinical features differed between malignant and benign O-RADS MRI score 4 adnexal masses. O-RADS MRI 4 lesions may be sub-stratified (high vs low risk) based on solid tissue characteristics and CA-125 levels.

In a retrospective single-center study, the authors assessed the efficacy of an automated imaging examination assignment system for enhancing the diversity of subspecialty examinations reported by oncologic imaging fellows. The study aimed to mitigate traditional biases of manual case selection and ensure equitable exposure to various case types. Methods included evaluating the proportion of "uncommon" to "common" cases reported by fellows before and after system implementation and measuring the weekly Shannon Diversity Index to determine case distribution equity. The proportion of reported uncommon cases more than doubled from 8.6% to 17.7% in total, at the cost of a concurrent 9.0% decrease in common cases from 91.3% to 82.3%. The weekly Shannon Diversity Index per fellow increased significantly from 0.66 (95% CI: 0.65, 0.67) to 0.74 (95% CI: 0.72, 0.75; P < .001), confirming a more balanced case distribution among fellows after introduction of the automatic assignment. © RSNA, 2023 Keywords: Computer Applications, Education, Fellows, Informatics, MRI, Oncologic Imaging.