Adam J. Jung

Does local recurrence of prostate cancer after radiation therapy occur at the site of primary tumor? Results of a longitudinal MRI and MRSI study

PURPOSE To determine if local recurrence of prostate cancer after radiation therapy occurs at the same site as the primary tumor before treatment, using longitudinal magnetic resonance (MR) imaging and MR spectroscopic imaging to assess dominant tumor location. METHODS AND MATERIALS This retrospective study was HIPAA compliant and approved by our Committee on Human Research. We identified all patients in our institutional prostate cancer database (1996 onward) who underwent endorectal MR imaging and MR spectroscopic imaging before radiotherapy for biopsy-proven prostate cancer and again at least 2 years after radiotherapy (n = 124). Two radiologists recorded the presence, location, and size of unequivocal dominant tumor on pre- and postradiotherapy scans. Recurrent tumor was considered to be at the same location as the baseline tumor if at least 50% of the tumor location overlapped. Clinical and biopsy data were collected from all patients. RESULTS Nine patients had unequivocal dominant tumor on both pre- and postradiotherapy imaging, with mean pre- and postradiotherapy dominant tumor diameters of 1.8 cm (range, 1-2.2) and 1.9 cm (range, 1.4-2.6), respectively. The median follow-up interval was 7.3 years (range, 2.7-10.8). Dominant recurrent tumor was at the same location as dominant baseline tumor in 8 of 9 patients (89%). CONCLUSIONS Local recurrence of prostate cancer after radiation usually occurs at the same site as the dominant primary tumor at baseline, suggesting supplementary focal therapy aimed at enhancing local tumor control would be a rational addition to management.

Imaging of nontraumatic adrenal hemorrhage.

OBJECTIVE The purpose of this pictorial essay is to review the imaging findings of acute, chronic, and tumor-related nontraumatic adrenal hemorrhage. CONCLUSION Rapid development or evolution of a nonenhancing adrenal mass or masses with an adreniform shape or high T1 signal intensity on MR images of a patient under stress or with a bleeding diathesis, including anticoagulant use, suggests acute adrenal hemorrhage. Chronic hemorrhage appears as a thin-walled pseudocyst or atrophy. Imaging findings that may indicate underlying tumor include intralesional calcification, enhancement, and hypermetabolic activity on PET images.

Role of endorectal MR imaging and MR spectroscopic imaging in defining treatable intraprostatic tumor foci in prostate cancer: Quantitative analysis of imaging contour compared to whole-mount histopathology

PURPOSE To investigate the role of endorectal MR imaging and MR spectroscopic imaging in defining the contour of treatable intraprostatic tumor foci in prostate cancer, since targeted therapy requires accurate target volume definition. MATERIALS AND METHODS We retrospectively identified 20 patients with prostate cancer who underwent endorectal MR imaging and MR spectroscopic imaging prior to radical prostatectomy and subsequent creation of detailed histopathological tumor maps from whole-mount step sections. Two experienced radiologists independently reviewed all MR images and electronically contoured all suspected treatable (≥0.5 cm(3)) tumor foci. Deformable co-registration in MATLAB was used to calculate the margin of error between imaging and histopathological contours at both capsular and non-capsular surfaces and the treatment margin required to ensure at least 95% tumor coverage. RESULTS Histopathology showed 17 treatable tumor foci in 16 patients, of which 8 were correctly identified by both readers and an additional 2 were correctly identified by reader 2. For all correctly identified lesions, both readers accurately identified that tumor contacted the prostatic capsule, with no error in contour identification. On the non-capsular border, the median distance between the imaging and histopathological contour was 1.4mm (range, 0-12). Expanding the contour by 5mm at the non-capsular margin included 95% of tumor volume not initially covered within the MR contour. CONCLUSIONS Endorectal MR imaging and MR spectroscopic imaging can be used to accurately contour treatable intraprostatic tumor foci; adequate tumor coverage is achieved by expanding the treatment contour at the non-capsular margin by 5mm.

Imaging Prostate Cancer

This article reviews the anatomy of the prostate gland, magnetic resonance (MR) imaging techniques, and the role MR imaging in the setting of prostate cancer. Sequences discussed include T2-weighted MR imaging, proton ((1)H) MR spectroscopic imaging, diffusion-weighted MR imaging, and dynamic contrast-enhanced MR imaging. MR imaging can be applied as an adjuvant tool to establish the diagnosis, localize, determine the extent, and estimate the aggressiveness of prostate cancers. The role of transrectal ultrasonography, computed tomography, and radionuclide scans is also briefly discussed.

Tumor fistulization associated with targeted therapy: computed tomographic findings and clinical consequences.

Purpose: To describe the computed tomographic (CT) appearances and clinical consequences of tumor fistulization as a complication of targeted therapy for cancer. Methods: The committee on human research approved this Health Insurance Portability and Accountability Act-compliant study and waived written informed consent. Based on the records of the senior author and our multidisciplinary Tumor Boards, we retrospectively identified 4 patients (1 man and 3 women with a mean age of 55.25 years; range, 47 to 64 years) who developed tumor fistulization while being treated with targeted therapy consisting of sunitinib (n = 2); bevacizumab (n = 1); and XL184, an investigational c-Met inhibitor (n = 1). All available clinical, imaging, and histopathological records were reviewed, with particular emphasis on treatment administered, CT findings, and clinical course. Results: All 4 patients developed fistulae from large metastatic deposits in the abdomen (mean size before treatment, 10.55 cm; range, 7.4-13.4 cm) to the gastrointestinal tract, and one patient also developed fistulae from a lung metastasis of undetermined size to the bronchial tree. All fistulae manifested as the appearance of air within a pre-existing tumor mass. At the time of fistula detection, disease at other sites in the 4 patients showed signs of regression (n = 1), progression (n = 2), or stability (n = 1). Currently, one patient is alive without evidence of disease, and the 3 other patients are deceased. Conclusions: Targeted therapy can be associated with tumor fistulization to the gastrointestinal tract or tracheobronchial tree; familiarity with the CT findings should facilitate the diagnosis of this complication, which seems to be of variable and patient-specific prognostic significance.

Clinical utility of endorectal MRI-guided prostate biopsy: Preliminary experience

To investigate the potential clinical utility of endorectal MRI‐guided biopsy in patients with known or suspected prostate cancer.

Endorectal MRI and MR spectroscopic imaging of prostate cancer: developing selection criteria for MR-guided focal therapy.

To investigate criteria that can identify dominant treatable prostate cancer foci with high certainty at endorectal magnetic resonance imaging (MRI) and MR spectroscopic (MRS) imaging, and thus facilitate selection of patients who are radiological candidates for MR‐guided focal therapy.

Local staging of prostate cancer: comparative accuracy of T2-weighted endorectal MR imaging and transrectal ultrasound.

OBJECTIVE The objective of this study was to compare the accuracy of T2-weighted magnetic resonance (MR) imaging and transrectal ultrasound (TRUS) for staging of prostate cancer. MATERIAL AND METHODS A total of 101 men with biopsy-proven prostate cancer undergoing both T2-weighted endorectal MR imaging and B-mode TRUS for local tumor staging prior to radical prostatectomy were retrospectively identified. Three MR readers rated the likelihood of locally advanced disease using a 5-point scale. An ultrasound reader performed the same rating. Staging accuracy was compared using receiver operating characteristic curves. RESULTS Staging accuracy was not significantly different between MR imaging (A(z) = 0.69-0.70) and TRUS (A(z) = 0.81, P>.05). CONCLUSIONS T2-weighted MR imaging demonstrates comparable accuracy to B-mode TRUS for depicting locally invasive prostate cancer.

Imaging late complications of cholecystectomy

OBJECTIVE To review the imaging findings in late complications of cholecystectomy. CONCLUSIONS Late postcholecystectomy complications include papillary stenosis, choledocholithiasis, biliary stricture, remnant gallbladder, and dropped gallstones. Such complications can cause substantial morbidity, and knowledge of the imaging appearances can facilitate expeditious diagnosis and treatment.

Multiparametric Magnetic Resonance Imaging Approaches in Focal Prostate Cancer Therapy

This chapter reviews the role of Magnetic Resonance (MR) imaging in prostate cancer with emphasis on functional imaging techniques and roles in focal therapy. Multiparametric MR imaging sequences applied for prostate cancer imaging include T2-weighted MR, proton MR spectroscopic imaging, diffusion-weighted imaging, dynamic contrast-enhanced MR, and quantitative T2-weighted imaging. These techniques provide information on independent characteristics of normal and cancerous prostate tissue, including normal/abnormal ductal morphology, concentrations of metabolites relevant to prostate cancer, water diffusion rates which are affected by cellularity, blood flow rates and volumes and therefore vascularity, and quantitative morphology, respectively. The information provided by these independent MR imaging methods can be used to determine the presence and location of prostate cancers with high sensitivity and specificity. Prostate MRI can be applied to diagnosing prostate cancer, predicting organ-confined prostate cancer, localization of intra-glandular prostate cancer, and estimation of intra-glandular prostate cancer volume. It has been applied to MR directed transrectal ultrasound-guided biopsy, direct MR-guided biopsy, MR-transrectal ultrasound fusion biopsy, and MR-guided focal therapy. The chapter describes what is known about the potential for combining these imaging techniques to improve selection, guidance, and subsequent monitoring of the effectiveness of focal therapy.