Céline D. Alt

Multiparametric Magnetic Resonance Imaging (MRI) and MRI–Transrectal Ultrasound Fusion Biopsy for Index Tumor Detection: Correlation with Radical Prostatectomy Specimen

BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) and MRI fusion targeted biopsy (FTB) detect significant prostate cancer (sPCa) more accurately than conventional biopsies alone. OBJECTIVE To evaluate the detection accuracy of mpMRI and FTB on radical prostatectomy (RP) specimen. DESIGN, SETTING AND PARTICIPANTS From a cohort of 755 men who underwent transperineal MRI and transrectal ultrasound fusion biopsy under general anesthesia between 2012 and 2014, we retrospectively analyzed 120 consecutive patients who had subsequent RP. All received saturation biopsy (SB) in addition to FTB of lesions with Prostate Imaging Reporting and Data System (PI-RADS) score ≥2. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The index lesion was defined as the lesion with extraprostatic extension, the highest Gleason score (GS), or the largest tumor volume (TV) if GS were the same, in order of priority. GS 3+3 and TV ≥1.3ml or GS ≥3+4 and TV ≥0.55ml were considered sPCa. We assessed the detection accuracy by mpMRI and different biopsy approaches and analyzed lesion agreement between mpMRI and RP specimen. RESULTS AND LIMITATIONS Overall, 120 index and 71 nonindex lesions were detected. Overall, 107 (89%) index and 51 (72%) nonindex lesions harbored sPCa. MpMRI detected 110 of 120 (92%) index lesions, FTB (two cores per lesion) alone diagnosed 96 of 120 (80%) index lesions, and SB alone diagnosed 110 of 120 (92%) index lesions. Combined SB and FTB detected 115 of 120 (96%) index foci. FTB performed significantly less accurately compared with mpMRI (p=0.02) and the combination for index lesion detection (p=0.002). Combined FTB and SB detected 97% of all sPCa lesions and was superior to mpMRI (85%), FTB (79%), and SB (88%) alone (p<0.001 each). Spearmans rank correlation coefficient for index lesion agreement between mpMRI and RP was 0.87 (p<0.001). Limitations included the retrospective design, multiple operators, and nonblinding of radiologists. CONCLUSIONS MpMRI identified 92% of index lesions compared with RP histopathology. The combination of FTB and SB was superior to both approaches alone, reliably detecting 97% of sPCa lesions. PATIENT SUMMARY Multiparametric magnetic resonance imaging detects the index lesion accurately in 9 of 10 patients; however, the combined biopsy approach, while missing less significant cancer, comes at the cost of detecting more insignificant cancer.

Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT

PurposeTo compose diagnostic standard operating procedures for both clinical and imaging assessment for vulvar and vaginal cancer, for vaginal sarcoma, and for ovarian cancer.MethodsThe literature was reviewed for diagnosing the above mentioned malignancies in the female pelvis. Special focus herein lies in tumor representation in MRI, followed by the evaluation of CT and PET/CT for this topic.ConclusionMRI is a useful additional diagnostic complement but by no means replaces established methods of gynecologic diagnostics and ultrasound. In fact, MRI is only implemented in the guidelines for vulvar cancer. According to the current literature, CT is still the cross-sectional imaging modality of choice for evaluating ovarian cancer. PET/CT appears to have advantages for staging and follow-up in sarcomas and cancers of the ovaries.ZusammenfassungZielÜbersicht der aktuellen bildgebenden Diagnostik des Vulva- und des Vaginalkarzinoms, des Vaginalsarkoms und des Ovarialkarzinoms.MethodeDurchsicht der Fachliteratur und Erstellung einer Übersicht der Diagnostik weiblicher Beckentumoren mittels MRT und CT sowie PET/CT mit Bildbeispielen unter Einschluss der tumorbezogenen Staging-Kriterien sowie empfohlenen MRT-Sequenzen.SchlussfolgerungDie MRT ist neben der gynäkologischen Untersuchung und dem Ultraschall eine nützliche bildgebende Ergänzung in der Diagnostik. Allerdings ist die MRT bisher nur in den Leitlinien des Vulvakarzinoms verankert. Für die Diagnostik des Ovarialkarzinoms ist die CT weiterhin Schnittbildgebung der Wahl. Die PET/CT scheint vorteilhaft beim Staging und beim Follow-up von Sarkomen und Ovarialkarzinomen zu sein.

Improved detection of anterior fibromuscular stroma and transition zone prostate cancer using biparametric and multiparametric MRI with MRI-targeted biopsy and MRI-US fusion guidance.

Background:The objective of this study was to analyze the potential of prostate magnetic resonance imaging (MRI) and MRI/transrectal ultrasound-fusion biopsies to detect and to characterize significant prostate cancer (sPC) in the anterior fibromuscular stroma (AFMS) and in the transition zone (TZ) of the prostate and to assess the accuracy of multiparametric MRI (mpMRI) and biparametric MRI (bpMRI) (T2w and diffusion-weighted imaging (DWI)).Methods:Seven hundred and fifty-five consecutive patients underwent prebiopsy 3 T mpMRI and transperineal biopsy between October 2012 and September 2014. MRI images were analyzed using PIRADS (Prostate Imaging-Reporting and Data System). All patients had systematic biopsies (SBs, median n=24) as reference test and targeted biopsies (TBs) with rigid software registration in case of MRI-suspicious lesions. Detection rates of SBs and TBs were assessed for all PC and sPC patients defined by Gleason score (GS)⩾3+4 and GS⩾4+3. For PC, which were not concordantly detected by TBs and SBs, prostatectomy specimens were assessed. We further compared bpMRI with mpMRI.Results:One hundred and ninety-one patients harbored 194 lesions in AFMS and TZ on mpMRI. Patient-based analysis detected no difference in the detection of all PC for SBs vs TBs in the overall cohort, but in the repeat-biopsy population TBs performed significantly better compared with SBs (P=0.004 for GS⩾3+4 and P=0.022 for GS⩾4+3, respectively). Nine GS⩾4+3 sPCs were overlooked by SBs, whereas TBs missed two sPC in men undergoing primary biopsy. The combination of SBs and TBs provided optimal local staging. Non-inferiority analysis showed no relevant difference of bpMRI to mpMRI in sPC detection.Conclusions:MRI-targeted biopsies detected significantly more anteriorly located sPC compared with SBs in the repeat-biopsy setting. The more cost-efficient bpMRI was statistically not inferior to mpMRI in sPC detection in TZ/AFMS.

Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT@@@Bildgebung weiblicher Beckentumoren unter Berücksichtigung von MRT, CT und PET/CT: Teil 1: Part 1

AimThe goal of this article is to provide an overview of diagnostic standard operating procedures for both clinical and imaging assessment of cervical and endometrial carcinoma, sarcoma of the uterus, and primary pelvic non-Hodgkin’s lymphoma.MethodsThe literature was reviewed for methods used to diagnose malignancies in the female pelvis with a special focus on the role of MRI as the imaging method of choice. Furthermore, CT findings and staging criteria for the mentioned malignancies are also provided.ConclusionWhereas ultrasound still remains the imaging modality of choice in clinical practice for the early diagnosis of female pelvic malignancies, MRI is more frequently recognized as a diagnostic tool for its accuracy in tumor identification. MRI also plays a crucial role in the 3D pretreatment planning for brachytherapy especially in cervical cancer. In the future, PET/CT might achieve an important role for staging lymph nodes or distant metastases as well as tumor recurrence.ZielÜberblick über den aktuellen Stand der bildgebenden Diagnostik des Zervix- und des Endometriumkarzinoms, des Uterussarkoms und des primären Non-Hodgkin-Lymphoms des Beckens.MethodikDurchsicht der Fachliteratur und Erstellung einer Übersicht der Diagnostik weiblicher Beckentumoren mittels MRT und CT sowie PET/CT mit Bildbeispielen unter Einschluss der tumorbezogenen Staging-Kriterien sowie empfohlenen MRT-Sequenzen.SchlussfolgerungIm klinischen Alltag ist der Ultraschall für die Primärdiagnostik weiblicher Beckentumoren bildgebendes Verfahren der Wahl, wobei die MRT durch den hohen Weichteilkontrast einen zunehmenden Stellenwert als bildgebendes Verfahren zur Tumordetektion besitzt. Auch für die prätherapeutische 3D-Bestrahlungsplanung insbesondere des Zervixkarzinomes spielt die MRT eine wichtige Rolle. Die PET/CT erscheint zunehmend relevanter im Lymphknotenstaging sowie in der Detektion von Fernmetastasen und in der Rezidivdiagnostik.

Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for Advanced Risk Modeling of Prostate Cancer—Patient-tailored Risk Stratification Can Reduce Unnecessary Biopsies

BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) is gaining widespread acceptance in prostate cancer (PC) diagnosis and improves significant PC (sPC; Gleason score≥3+4) detection. Decision making based on European Randomised Study of Screening for PC (ERSPC) risk-calculator (RC) parameters may overcome prostate-specific antigen (PSA) limitations. OBJECTIVE We added pre-biopsy mpMRI to ERSPC-RC parameters and developed risk models (RMs) to predict individual sPC risk for biopsy-naïve men and men after previous biopsy. DESIGN, SETTING, AND PARTICIPANTS We retrospectively analyzed clinical parameters of 1159 men who underwent mpMRI prior to MRI/transrectal ultrasound fusion biopsy between 2012 and 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariate regression analyses were used to determine significant sPC predictors for RM development. The prediction performance was compared with ERSPC-RCs, RCs refitted on our cohort, Prostate Imaging Reporting and Data System (PI-RADS) v1.0, and ERSPC-RC plus PI-RADSv1.0 using receiver-operating characteristics (ROCs). Discrimination and calibration of the RM, as well as net decision and reduction curve analyses were evaluated based on resampling methods. RESULTS AND LIMITATIONS PSA, prostate volume, digital-rectal examination, and PI-RADS were significant sPC predictors and included in the RMs together with age. The ROC area under the curve of the RM for biopsy-naïve men was comparable with ERSPC-RC3 plus PI-RADSv1.0 (0.83 vs 0.84) but larger compared with ERSPC-RC3 (0.81), refitted RC3 (0.80), and PI-RADS (0.76). For postbiopsy men, the novel RMs discrimination (0.81) was higher, compared with PI-RADS (0.78), ERSPC-RC4 (0.66), refitted RC4 (0.76), and ERSPC-RC4 plus PI-RADSv1.0 (0.78). Both RM benefits exceeded those of ERSPC-RCs and PI-RADS in the decision regarding which patient to receive biopsy and enabled the highest reduction rate of unnecessary biopsies. Limitations include a monocentric design and a lack of PI-RADSv2.0. CONCLUSIONS The novel RMs, incorporating clinical parameters and PI-RADS, performed significantly better compared with RMs without PI-RADS and provided measurable benefit in making the decision to biopsy men at a suspicion of PC. For biopsy-naïve patients, both our RM and ERSPC-RC3 plus PI-RADSv1.0 exceeded the prediction performance compared with clinical parameters alone. PATIENT SUMMARY Combined risk models including clinical and imaging parameters predict clinically relevant prostate cancer significantly better than clinical risk calculators and multiparametric magnetic resonance imaging alone. The risk models demonstrate a benefit in making a decision about which patient needs a biopsy and concurrently help avoid unnecessary biopsies.

The Impact of Magnetic Resonance Imaging on Prediction of Extraprostatic Extension and Prostatectomy Outcome in Patients with Low-, Intermediate- and High-Risk Prostate Cancer: Try to Find a Standard

PURPOSE To investigate the value of multiparametric magnetic resonance imaging (mpMRI) and to predict extracapsular extension (ECE), seminal vesicle (SV) infiltration, and a negative surgical margin (SM) status at radical prostatectomy (RP) for different prostate cancer (PC) risk groups. PATIENTS AND METHODS In the study, 805 men underwent 3 tesla mpMRI without endorectal coil before MRI/transrectal ultrasonography-fusion guided prostate biopsy. MRIs were analyzed using the prostate imaging reporting and data system. The cohort was classified into risk groups according to National Comprehensive Cancer Network (NCCN) criteria. Of 132 men who subsequently underwent RP, pathologic stage and SM status at RP were used as reference. Retrospectively, we investigated a European Society of Urogenital Radiology (ESUR) score for ECE and SV-infiltration. Statistical analyses included regression analyses, receiver operating characteristics (ROC), and Youden Index to assess an ESUR-score cutoff. RESULTS Area under the curve in ROC curve analyses was 0.82 for ESUR-ECE score to detect pT(3a)-disease and 0.77 for ESUR-SV score for pT(3b). Using a cutoff of 4 for ECE and of 2 for SV, the positive predictive value of the ECE-score for harboring pT(3) was 50.0%, 90.0%, and 88.8% for the low-, intermediate- and high-risk cohort. Retrospectively, the use of the ESUR-ECE score preoperatively would have changed the initial surgical plan, according to NCCN criteria, in 31.1% of patients. In the high-risk subgroup, 9/35 (25.7%) patients were correctly assessed as not harboring pT(3) by imaging (ECE score <4), and would have allowed secure robot-assisted radical prostatectomy and nerve-sparing surgery (NSS). When T3 suspicion on preoperative MRI would be taken into account, intraoperative frozen-sections (IFS) might avoid positive SM in 12/18 high-risk patients and an oncologic secure NSS in 8/20 intermediate-risk patients. CONCLUSION Prediction of pT(3) disease is crucial to plan NSS and to achieve negative SM in RP. Standardized ECE scoring on mpMRI is an independent predictor of pT(3) and may help to plan RP with oncologic security, even in high-risk patients. In addition, it allows more accurate selection of a subgroup of patients for systematic and MRI-guided IFS.

MRI findings before and after prolapse surgery

Background Therapeutical outcome after prolapse surgery is evaluated using a standardized grading system based on maximum prolapse extent, which might not provide the full picture of the patient’s subjective outcome. We therefore applied an evaluation method, which is detached from a grading system. Purpose To evaluate the impact of pelvic organ mobility in dynamic magnetic resonance imaging (MRI) before and after mesh-repair surgery in patients with symptomatic pelvic organ prolapse. Material and Methods To obtain measurements, we performed parasagittal T2-weighted turbo spin echo sequence at rest (TR, 3460 ms; TE, 85 ms; matrix, 512; slice thickness [ST], 5 mm), parasagittal T2-weighted true fast imaging with steady-state precession (TrueFISP) single-shot sequence during straining (TR, 397.4 ms; TE, 1.5 ms; matrix, 256; ST, 8 mm), and parasagittal T2-weighted TrueFISP sequence at maximum strain (TR, 4.3 ms; TE, 2.15 ms; matrix, 256; ST, 5 mm) at 1.5 T MRI. Pelvic organ prolapse (anatomical landmarks: bladder, cervix, pouch, rectum) was measured perpendicularly with reference to the pubococcygeal and the midpubic line. Pelvic organ mobility was defined as the difference between the measured distance at rest and at maximum strain for each anatomical landmark. All patients underwent mesh-repair procedure. Eighty patients could be included in this short-term follow-up study. Due to the physical diagnosis of pelvic organ prolapse, 51 underwent anterior mesh repair, 16 underwent posterior mesh repair, and 13 underwent total mesh repair. Surgery was performed by one surgeon, using mesh implants from several manufacturers. Results Median values of maximum organ prolapse for bladder, cervix, pouch, and rectum preoperatively were 2.54 cm, 0.33 cm, 2.47 cm, and 0.32 cm, respectively, and 12 weeks postoperatively 0.87 cm, −1.79 cm, 1.49 cm, and 0.49 cm, respectively. Highly significant improvement (P < 0.001) of pelvic organ mobility was observed in the treated compartment at 4- and 12-week follow-up. Physical evaluation 12 weeks after mesh-repair showed an asymptomatic POP-Q stage I, if any. Conclusion Dynamic MRI is useful in visualizing the maximum extent of pelvic organ prolapse, as the evaluation of pelvic organ mobility documents the intraindividual therapeutic outcome detached from a grading system based on maximal prolapse values.

Quadratic Corotated Finite Elements for Real-Time Soft Tissue Registration

Organ motion due to respiration and contact with surgical instruments can significantly degrade the accuracy of image-guided surgery. In most applications, the ensuing soft tissue deformations have to be compensated in order to register preoperative planning data to the patient. Biomechanical models can be used to perform registration based on sparse intraoperative sensor data. Using elasticity theory, the approach can be formulated as a boundary value problem with displacement boundary conditions. In this paper, we propose to use corotated finite elements (FE) with quadratic shape functions as a robust and accurate model for real-time soft-tissue registration. A detailed numerical analysis reveals that quadratic FE perform significantly better than linear corotated FE for high resolution meshes. We also show that the method achieves nearly the same registration accuracy as a complex nonlinear viscoelastic material model. Furthermore, a phantom experiment demonstrates how the model can be used for intraoperative liver registration.

One-year dynamic MRI follow-up after vaginal mesh repair: evaluation of clinical, radiological, and quality-of-life results

Background Pelvic organ prolapse (POP) is a common disorder in elderly women often surgically repaired with alloplastic meshes; yet knowledge of the pelvic floor behavior and multi-compartment defects postoperatively is scarce. Purpose To evaluate the 1-year outcome after mesh repair in patients with POP using clinical examination (CE), dynamic magnetic resonance imaging (dMRI), and the prolapse quality-of-life (P-QOL) questionnaire. Material and Methods A prospective observational study was conducted of 69 women undergoing pelvic mesh surgery. Clinical examination, dMRI, and the P-QOL questionnaire were applied before and after surgery to evaluate POP. Mean outcome measures were POP outcome as determined on clinical and dMRI examinations and its impact on quality of life. Statistical results were obtained with SPSS version 15.0. ANOVA was used to compare pre-/postsurgical quality of life data. Results Sixty-nine women (mean age, 64.75 years; BMI, 26.75 kg/m2; postmenopausal, 89.2%) were recruited and treated with Seratom® or Perigee™ mesh implants. A significant improvement in the position of bladder neck, vaginal vault/uterus, pouch of Douglas, and rectum was found 12 weeks and 1 year after surgery using POP-Q scale and dMRI. Advanced cystoceles and enteroceles seem underestimated by CE using the POP-Q system compared to dMRI results (P = 0.003 and P < 0.001), vice versa dMRI overestimated POP compared to CE. Sixty-four women completed the P-QOL questionnaire, presenting reduced quality of life before surgery which improves postsurgically. Prolapse impact and physical, social, and role limitations correlated strongest with a low quality of life (P < 0.001). Conclusion The 1-year follow-up after mesh repair showed statistical and clinical improvement for all tools employed. dMRI seems a reliable tool for simultaneous assessment of defects in all three compartments, but tends to overestimate POP compared to clinical examination.

Short-range clinical, dynamic magnetic resonance imaging and P-QOL questionnaire results after mesh repair in female pelvic organ prolapse

OBJECTIVE To evaluate clinical, quality-of-life (QoL) and dynamic magnetic resonance imaging (dMRI) results in patients with pelvic organ prolapse (POP) preoperatively, and 4 and 12 weeks after anterior and/or posterior mesh repair. STUDY DESIGN Thirty-six patients (mean age 65 years) with symptomatic pelvic floor descent underwent mesh repair. The prolapse was quantified using the POP-Q system. Before surgery as well as 4 and 12 weeks after surgery, the pelvic organ positions were measured on dynamic magnetic resonance imaging during Valsalva manoeuvre in relation to the pubococcygeal and mid-pubic lines to assess surgery outcome. Patients also completed the P-QOL questionnaire to evaluate subjective changes at each visit. RESULTS Four and 12 weeks after surgery patients showed improvement of the POP on clinical examination and on dynamic MRI. The latter demonstrated high significance (p<0.001) especially in bladder and vaginal cuff/cervix positions during maximal straining. All quality-of-life domains and some symptom questions of the P-QOL questionnaire significantly improved (p<0.05) 12 weeks after surgery. CONCLUSION Significant anatomical and quality-of-life improvement was demonstrated after anterior and/or posterior mesh repair for POP using dynamic MRI and the P-QOL questionnaire.