Faculty Bibliography
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527
Optimization of Prostate Biopsy: The Role of MRI Targeted Biopsy in Detection, Localization, and Risk Assessment
PURPOSE: Optimization of prostate biopsy requires addressing the shortcomings of standard systematic transrectal ultrasound guided biopsy including false negative rates, incorrect risk stratification, detection of clinically insignificant disease, and the need for repetitive biopsy. MRI is an evolving noninvasive imaging modality that increases the accurate localization of prostate cancer (PCa) at the time of biopsy, thereby enhancing clinical risk assessment, and improving the ability to appropriately counsel patients regarding therapy. The purpose of this review is to 1) summarize the various sequences that comprise a prostate multiparametric MRI exam along with its performance characteristics in cancer detection, localization and reporting standards, 2) evaluate potential applications of MRI targeting in prostate biopsy among men with no previous biopsy, a negative previous biopsy, and those with low stage cancer and 3) describe the techniques of MRI-targeted biopsy and their comparative study outcomes MATERIALS AND METHODS: A bibliographic search covering the period up to October, 2013 was conducted using MEDLINE(R)/PubMed(R). Articles were reviewed and categorized based on which of the three objectives of this review was addressed. Data was extracted, analyzed, and summarized. RESULTS: Mp-MRI consists of anatomic T2-weighted imaging coupled with at least 2 functional imaging techniques and has demonstrated improved PCa detection sensitivity up to 80% in the peripheral zone and 81% in the transition zone. A PCa MRI suspicion score has been developed and is depicted using the Likert or PI-RADS scale for better standardization of MRI interpretation and reporting. Among men with no previous biopsy, MRI increases the frequency of significant cancer detection to 50% in low risk and 71% in high risk patients. In low risk men, the negative predictive valve of a combination of negative MRI with prostate volume parameters is nearly 98%, suggesting a potential role in avoiding a biopsy and reducing overdetection/overtreatment. Among men with previous negative biopsy, 72-87% of cancers detected by MRI guidance are clinically significant. Among men with known low risk cancer, repeat biopsy by MR-targeting demonstrates a high likelihood of confirming low risk disease in low suspicion score lesions and for upgrading in high suspicion score lesions. Techniques of MRI-targeted biopsy include visual estimation TRUS-guided biopsy, software co-registered MRI-US TRUS-guided biopsy, and in-bore MRI-guided biopsy. Although the improvement in accuracy and efficiency of visual estimation biopsy compared to systematic appears limited, both co-registered MRI-US biopsy and in-bore MRI-guided biopsy appears to increase cancer detection rates in conjunction with increasing suspicion score. CONCLUSIONS: Use of MRI for targeting prostate biopsies has potential to reduce the sampling error associate with conventional biopsy by providing better disease localization and sampling. More accurate risk stratification through improved cancer sampling may impact upon therapeutic decision-making. Optimal clinical application of MRI-targeted biopsy remains under investigation.
PMCID:4224958
PMID: 24769030
ISSN: 0022-5347
CID: 931792
A Prospective, Blinded Comparison of Magnetic Resonance (MR) Imaging-Ultrasound Fusion and Visual Estimation in the Performance of MR-targeted Prostate Biopsy: The PROFUS Trial
BACKGROUND: Increasing evidence supports the use of magnetic resonance (MR)-targeted prostate biopsy. The optimal method for such biopsy remains undefined, however. OBJECTIVE: To prospectively compare targeted biopsy outcomes between MR imaging (MRI)-ultrasound fusion and visual targeting. DESIGN, SETTING, AND PARTICIPANTS: From June 2012 to March 2013, prospective targeted biopsy was performed in 125 consecutive men with suspicious regions identified on prebiopsy 3-T MRI consisting of T2-weighted, diffusion-weighted, and dynamic-contrast enhanced sequences. INTERVENTION: Two MRI-ultrasound fusion targeted cores per target were performed by one operator using the ei-Nav|Artemis system. Targets were then blinded, and a second operator took two visually targeted cores and a 12-core biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Biopsy information yield was compared between targeting techniques and to 12-core biopsy. Results were analyzed using the McNemar test. Multivariate analysis was performed using binomial logistic regression. RESULTS AND LIMITATIONS: Among 172 targets, fusion biopsy detected 55 (32.0%) cancers and 35 (20.3%) Gleason sum >/=7 cancers compared with 46 (26.7%) and 26 (15.1%), respectively, using visual targeting (p=0.1374, p=0.0523). Fusion biopsy provided informative nonbenign histology in 77 targets compared with 60 by visual (p=0.0104). Targeted biopsy detected 75.0% of all clinically significant cancers and 86.4% of Gleason sum >/=7 cancers detected on standard biopsy. On multivariate analysis, fusion performed best among smaller targets. The study is limited by lack of comparison with whole-gland specimens and sample size. Furthermore, cancer detection on visual targeting is likely higher than in community settings, where experience with this technique may be limited. CONCLUSIONS: Fusion biopsy was more often histologically informative than visual targeting but did not increase cancer detection. A trend toward increased detection with fusion biopsy was observed across all study subsets, suggesting a need for a larger study size. Fusion targeting improved accuracy for smaller lesions. Its use may reduce the learning curve necessary for visual targeting and improve community adoption of MR-targeted biopsy.
PMID: 24262102
ISSN: 0302-2838
CID: 666702
Gleason Score 3 + 4=7 Prostate Cancer With Minimal Quantity of Gleason Pattern 4 on Needle Biopsy Is Associated With Low-risk Tumor in Radical Prostatectomy Specimen
A modified Gleason grading system as proposed in the 2005 International Society of Urological Pathology (ISUP) consensus meeting is the current grading system for prostate cancer. With this modified ISUP Gleason grading system, many Gleason score (GS) 6 cancers by the old grading system are upgraded to GS7 cancers on biopsy diagnosis even with minimal quantity (
PMID: 24832163
ISSN: 0147-5185
CID: 996472
Renal masses measuring under 2cm: Pathologic outcomes and associations with MRI features
PURPOSE: To evaluate pathologic outcomes and associations with MRI features in small renal masses measuring up to 20mm METHODS: 86 patients (61+/-13 years; 45M/41F) with 92 renal masses measuring up to 20mm that underwent MRI prior to tissue diagnosis were included. Two radiologists independently evaluated all masses for microscopic lipid, hemorrhage, T2-hyperintensity, T2-homogeneity, cystic/necrotic areas, hypervascularity, enhancement homogeneity, circumscribed margins, and predominantly exophytic location. These MRI features, as well as patient age, gender, and history of RCC, were compared with pathologic findings using Fisher's exact test, unpaired t-test, and multivariate logistic regression. RESULTS: 26.1% (24/92) of masses under 2cm were benign, only 32.6% (30/92) were clear-cell RCC, and only 7.6% (7/92) were high-grade. Among 16 masses measuring up to 1cm, only 12.5% (2/16) were clear-cell RCC, and none was high-grade. Within the entire cohort, no MRI or clinical feature showed a significant difference between benign and malignant lesions (p>/=0.053). However, for both readers, clear-cell RCC exhibited a significantly higher frequency of T2-hyperintensity, cystic/necrotic areas, and hypervascularity, and a significantly lower frequency of hemorrhage, T2-homogeneity, and enhancement homogeneity (p<0.001-0.036). Hypervascularity was a significant independent predictor of clear-cell RCC for both readers (p=0.002-0.007), as was T2-hyperintensity for reader 2 (p=0.007). CONCLUSION: A substantial fraction of small renal masses were benign, and when malignant, largely exhibited indolent pathologic characteristics, particularly when measuring under 1cm Although small benign and malignant masses could not be differentiated on MRI, hypervascularity showed a significant independent association with clear-cell RCC in comparison with other lesions.
PMID: 24882784
ISSN: 0720-048x
CID: 1030572
Pilot study of a novel tool for input-free automated identification of transition zone prostate tumors using T2- and diffusion-weighted signal and textural features
PURPOSE: To present results of a pilot study to develop software that identifies regions suspicious for prostate transition zone (TZ) tumor, free of user input. MATERIALS AND METHODS: Eight patients with TZ tumors were used to develop the model by training a Naive Bayes classifier to detect tumors based on selection of most accurate predictors among various signal and textural features on T2-weighted imaging (T2WI) and apparent diffusion coefficient (ADC) maps. Features tested as inputs were: average signal, signal standard deviation, energy, contrast, correlation, homogeneity and entropy (all defined on T2WI); and average ADC. A forward selection scheme was used on the remaining 20% of training set supervoxels to identify important inputs. The trained model was tested on a different set of ten patients, half with TZ tumors. RESULTS: In training cases, the software tiled the TZ with 4 x 4-voxel "supervoxels," 80% of which were used to train the classifier. Each of 100 iterations selected T2WI energy and average ADC, which therefore were deemed the optimal model input. The two-feature model was applied blindly to the separate set of test patients, again without operator input of suspicious foci. The software correctly predicted presence or absence of TZ tumor in all test patients. Furthermore, locations of predicted tumors corresponded spatially with locations of biopsies that had confirmed their presence. CONCLUSION: Preliminary findings suggest that this tool has potential to accurately predict TZ tumor presence and location, without operator input.J. Magn. Reson. Imaging 2013; (c) 2013 Wiley Periodicals, Inc.
PMID: 24924512
ISSN: 1053-1807
CID: 1033862
Comparison of MRI pulse sequences for prediction of size of hepatocellular carcinoma at explant evaluation
OBJECTIVE. The purpose of this study was to retrospectively compare the size of hepatocellular carcinoma (HCC) on images obtained using different MRI pulse sequences with the tumor size determined at pathologic evaluation of liver explant specimens. MATERIALS AND METHODS. Ninety-two patients with HCC who underwent contrast-enhanced liver MRI within 90 days before liver transplant were included. A single pathologist measured the dominant HCC in each case. In different sessions, two abdominal radiologists (readers 1 and 2) aware only of the location of the dominant HCC independently measured lesion size on images obtained using the following sequences: T2-weighted imaging; b-500 diffusion-weighted imaging; and arterial, portal venous, and equilibrium phases of contrast enhancement. Size measurements on MR images were compared with explant measurements by use of Pearson correlation coefficients, paired t tests, and Bland-Altman plots. RESULTS. Correlation with pathologic findings was highest for reader 1 for portal venous (r = 0.890) and equilibrium (r = 0.828) phase images and for reader 2 for arterial, portal venous, and equilibrium phase images (r = 0.842-0.860). Absolute error relative to pathologic size was lowest for reader 1 using portal venous (4.3 mm) and for reader 2 using portal venous and arterial phase images (both 4.7 mm). Systematic error for both readers was lowest with portal venous and equilibrium phase images (reader 1, systematic under-measurement of 0.5 mm in both sequences; reader 2, systematic over-measurement of 0.1 mm with portal venous phase images and systematic under-measurement of 1.1 mm with equilibrium phase images). Sequences in which reader 1 made systematic over-measurements were diffusion-weighted images, arterial phase images, and T2-weighted images (by 3.5, 2.9, and 1.6 mm). Reader 2 made systematic over-measurements using arterial phase and T2-weighted images (by 1.5 and 0.4 mm). CONCLUSION. The data suggest the arterial phase may be suboptimal for measuring HCC at MRI. Portal venous phase acquisition warrants further investigation as a potential standard approach for such measurements.
PMID: 25055263
ISSN: 0361-803x
CID: 1076082
Comparison of blood pool and extracellular gadolinium chelate for functional MR evaluation of vascular thoracic outlet syndrome
OBJECTIVE: To compare performance of single-injection blood pool agent (gadofosveset trisodium, BPA) against dual-injection extracellular contrast (gadopentetate dimeglumine, ECA) for MRA/MRV in assessment of suspected vascular TOS. MATERIALS AND METHODS: Thirty-one patients referred for vascular TOS evaluation were assessed with BPA (n=18) or ECA (n=13) MRA/MRV in arm abduction and adduction. Images were retrospectively assessed for: image quality (1=non-diagnostic, 5=excellent), vessel contrast (1=same signal as muscle, 4=much brighter than muscle) and vascular pathology by two independent readers, with a separate experienced reader providing reference assessment of vascular pathology. RESULTS: Median image quality was diagnostic or better (score >/=3) for ECA and BPA at all time points, with BPA image quality superior at abduction late (BPA 4.5, ECA 4, p=0.042) and ECA image quality superior at adduction-early (BPA 4.5; ECA 4.0, p=0.018). High qualitative vessel contrast (mean score >/=3) was observed at all time points with both BPA and ECA, with superior BPA vessel contrast at abduction-late (BPA 3.97+/-0.12; ECA 3.73+/-0.26, p=0.007) and ECA at adduction-early (BPA 3.42+/-0.52; ECA 3.96+/-0.14, p<0.001). Readers readily identified arterial and venous pathology with BPA, similar to ECA examinations. CONCLUSION: Single-injection BPA MRA/MRV for TOS evaluation demonstrated diagnostic image quality and high vessel contrast, similar to dual-injection ECA imaging, enabling identification of fixed and functional arterial and venous pathology.
PMID: 24840478
ISSN: 0720-048x
CID: 1003652
How "consistent" is "consistent"? A clinician-based assessment of the reliability of expressions used by radiologists to communicate diagnostic confidence
AIM: To evaluate the degree of variability in clinicians' interpretation of expressions used by radiologists to communicate their level of diagnostic confidence within radiological reports. MATERIALS AND METHODS: Clinicians were solicited to complete a prospective survey asking them to select the approximate perceived level of certainty, expressed as a percentage, associated with 20 expressions used by radiologists to communicate their level of diagnostic confidence within radiological reports. The median and inter-decile range (IDR) were computed for each expression, with a smaller IDR indicating greater reproducibility. Clinicians were also asked questions regarding their attitudes about radiologists' communication of diagnostic confidence. RESULTS: Forty-nine surveys were completed. Median confidence associated with the expressions ranged from 10-90%. Reproducibility of the expressions was variable, as IDR ranged from 15-53%, although a median IDR of 40% indicated overall poor reproducibility. Expressions with relatively higher reproducibility included "most likely", "likely", and "unlikely" (IDR 15-20%), whereas expressions with relatively lower reproducibility included "compatible with", "suspicious for", "possibly," and "can be seen in the setting of" (IDR >/=45%). Only 20% of clinicians agreed or strongly agreed that radiologists consistently use such expressions within their reports. Fifty-five percent of clinicians preferred that diagnostic confidence be communicated as a percentage rather than as a textual expression. CONCLUSION: There was poor reproducibility in clinicians' interpretations of many expressions used by radiologists to communicate their level of diagnostic confidence. Use of percentages to convey diagnostic confidence within reports may mitigate this source of ambiguity in radiologists' communication with clinicians.
PMID: 24836524
ISSN: 0009-9260
CID: 1032492
Guest Editorial: The Figley Fellowship-A Window for Junior Radiologists Into the Inner Workings of the AJR [Editorial]
PMID: 24951189
ISSN: 0361-803x
CID: 1050762
Journal of the American College of Radiology : JACR. 2014:11(5):496-500.DOI: 10.1016/j.jacr.2013.09.015
Adoption of an Integrated Radiology Reading Room Within a Urologic Oncology Clinic: Initial Experience in Facilitating Clinician Consultations
PURPOSE: The authors describe their initial experience in implementing an integrated radiology reading room within a urologic oncology clinic, including the frequency and nature of clinician consultations and the perceived impact on patient management by clinicians. METHODS: A radiology reading room was established within an office-based urologic oncology clinic in proximity to the surgeon's work area. A radiologist was present in this reading room for a 3-hour shift each day. The frequency and nature of consultations during these shifts were recorded. Also, the clinic's staff completed a survey assessing perceptions of the impact of the integrated reading room on patient management. RESULTS: One hundred two consultations occurred during 57 included dates (average, 1.8 consultations per shift): 52% for review of external cases brought in by patients on discs, 43% for review of internal cases, and 5% for direct review by the radiologist of imaging with patients. The maximum number of consultations during a single shift was 8. All of the clinic's urologists indicated that >90% of consultations benefited patient care. The clinicians indicated tendencies to view consultations as affecting management in the majority of cases, to be more likely to seek consultation for outside imaging when the radiologist was on site, and to be less likely to repeat outside imaging when the radiologist was on site. CONCLUSIONS: The integrated reading room within the clinic has potential to improve the quality of care, for instance by facilitating increased review of outside imaging studies and thereby potentially reducing duplicate ordering and by enabling occasional direct image review with patients by radiologists.
PMID: 24485593
ISSN: 1546-1440
CID: 801322
