Fabian Steinkohl

High IDO-1 expression in tumor endothelial cells is associated with response to immunotherapy in metastatic renal cell carcinoma

Nivolumab belongs to the standard therapy in the second‐line setting of metastatic renal cell carcinoma (mRCC). Although deep and long‐lasting responses are seen in some patients, the majority of patients will further progress. PD‐L1 is still under critical evaluation as a predictive biomarker. Thus, more accurate biomarkers are clearly warranted. Here, we investigated for the first time the predictive role of IDO‐1, a negative immune‐regulatory molecule, on clear cell RCC tissues of 15 patients undergoing nivolumab therapy. IDO‐1 and other immune inhibitory molecules (PD‐L1, PD‐L2, FOXP3) as well as immune cell subsets (CD3, CD4 and CD8) were measured on formalin‐fixed, paraffin‐embedded sections of RCC specimens by immunohistochemistry. IDO‐1 was predominantly expressed in tumor endothelial cells, and was totally absent from tumor cells itself. IDO‐1 overexpression (>10%) could be detected more frequently in responders (100%, n = 6/6) compared to non‐responders (33.3%, n = 3/9; P = .028), resulting in a better progression‐free survival during immunotherapy (IDO‐1 ≤ 10% vs >10%, median: 3.5 vs not estimated (NE) months, P = .01 by log‐rank test). In addition, IDO‐1 was positively correlated with CD8+ T cell expression (rs = .691, P = .006). PD‐L1 expression on tumor cells was negative in 13 (86.7%) of 15 patients, irrespective of therapeutic response (responders vs non‐responders: 83.3% vs 88.9%). No differences were noticed in the PD‐L1 expression on tumor‐infiltrating immune cells (PD‐L1 < 1% in 66.7% of both responders and non‐responders). In contrast to PD‐L1, these results suggest that IDO‐1 may be a more promising predictive biomarker for response to immune‐based cancer therapy in mRCC.

Retrospective analysis of the development of PIRADS 3 lesions over time: when is a follow-up MRI reasonable?

PurposeOften PIRADS 3 findings are usually followed up with further MRIs of the prostate. Current guidelines do not state an optimal interval between the initial MRI and the follow-up MRI. The aim of this study was to find out if PIRADS 3 lesions evolve over time and to determine how long the optimal interval between initial MRI and follow-ups should be.MethodsIn this retrospective study, 141 consecutive patients were included who underwent at least one follow-up MRI after an initial PIRADS 3 finding. Changes in PIRADS score and the interval between the first and the follow-up MRI were recorded. An optimal duration was calculated.ResultsOf all patients, 76.6% had a change from PIRADS 3 to either 2 or 4 in the first follow-up MRI. Reclassifications to PIRADS 4 happened earlier than reclassifications to PIRADS 2 (after 366.5xa0±xa0217.9xa0days and after 534.2xa0±xa0253.0xa0days, respectively). An optimal point of time for a follow-up to distinguish between changes to PIRADS 2 versus PIRADS 4 turned out to be 379xa0days (12.4xa0months, AUC 0.734, pxa0=xa00.0001). Of all patients with a PIRADS 3 lesion 14.8% harboured a prostate carcinoma.ConclusionPerforming follow-up mpMRI rather than immediate biopsy may be beneficial for patients with PIRADS 3, as most lesions can be reclassified after a manageable period of time. Upgrades to PIRADS 4 seem to happen earlier and within fewer follow-ups than downgrades to PIRADS 2. The optimal interval for follow-up MRIs seems to be 12.4xa0months.

Comparison of multiparametric and biparametric MRI of the prostate: are gadolinium-based contrast agents needed for routine examinations?

PurposeTo investigate, if and how omitting gadolinium-based contrast agents (GBCA) and dynamic contrast-enhanced imaging (DCE) influences diagnostic accuracy and tumor detection rates of prostate MRI.MethodsIn this retrospective study, 236 patients were included. The results of biparametric (bpMRI) and multiparametric magnetic resonance imaging (mpMRI) were compared using the PI-RADS version 2 scoring system. The distribution of lesions to PIRADS score levels, tumor detection rates, diagnostic accuracy and RoC analysis were calculated and compared to the results of histopathological analysis or 5-year follow-up for benign findings.ResultsOmitting DCE changed PI-RADS scores in 9.75% of patients, increasing the number of PI-RADS 3 scores by 8.89% when compared to mpMRI. No change of more than one score level was observed. BpMRI did not show significant differences in diagnostic accuracy or tumor detection rates. (AuC of 0.914 vs 0.917 in ROC analysis). Of 135 prostate carcinomas (PCa), 94.07% were scored identically, and 5.93% were downgraded only from PI-RADS 4 to PI-RADS 3 by bpMRI. All of them were low-grade PCa with Gleason Score 6 or 7a. No changes were observed for PCau2009≥u20097b.ConclusionOmitting DCE did not lead to significant differences in diagnostic accuracy or tumor detection rates when using the PI-RADS 2 scoring system. According to these data, it seems reasonable to use a biparametric approach for initial routine prostate MRI. This could decrease examination time and reduce costs without significantly lowering the diagnostic accuracy.

Ultrasonography for the Diagnosis of Carpal Tunnel Syndrome in Diabetic Patients: Missing the Mark?

PURPOSEnu2002Diabetes mellitus (DM) and carpal tunnel syndrome (CTS) are common pathologies. The diagnosis of CTS can be facilitated by the use of an ultrasound-based wrist-to-forearm ratio (WFR) of the nerve diameter. However, the applicability of WFR in DM-patients is not yet clear.nnnMATERIALS AND METHODSnu2002233 wrists of 153 patients were examined. Cross-sectional areas (CSA) of the median nerve were obtained using a linear array probe. The WFR was calculated.nnnRESULTSnu2002Diabetics with CTS had significantly lower WFR values than non-diabetics with CTS (pu200a=u200a0.002). There was no difference between the WFR of diabetics with and without CTS (pu200a=u200a0.06). The diagnostic accuracy between diabetics with and without CTS was low for measurements of WFR (ROC AUCu200a=u200a0.630, 95u200a% CI 0.541u200a-u200a0.715, pu200a=u200a0.011).nnnCONCLUSIONnu2002Our findings suggest that the WFR has a low diagnostic accuracy in diabetic patients with CTS and should be used with caution in those patients.nnnKEY POINTSnu2002 · The diagnostic accuracy of WFR is low in patients with DM. · WFR should not be used in patients with DM. · The sonographic evaluation of the median nerve in patients with DMu200ashould focus on morphological changes.nnnCITATION FORMATn· Steinkohl F, Loizides A, Gruber L etu200aal. Ultrasonography for the Diagnosis of Carpal Tunnel Syndrome in Diabetic Patients: Missing the Mark?. Fortschr Röntgenstr 2019; 191: 117u200a-u200a121.

Adenomatoid tumor of the testis mimicking malignant testicular cancer on multiparametric ultrasound

BackgroundAdenomatoid tumor is one of the most common histological subtypes of paratesticular cancer arising from the epididymis. In very rare cases, these tumors appear as intratesticular lesions originating in the tunica albuginea, representing a diagnostic challenge.Case presentationWe present a case of a 51-year-old man with a small (0.9xa0cm) hyperechoic lesion of the left testicle mimicking testicular cancer on multiparametric ultrasound. The lesion was localized in the peripheral zone, confirming vascularization and increased stiffness on contrast-enhanced ultrasound and real-time elastography. Preoperative tumor markers and hormone levels were within normal ranges. Staging computed tomography was negative. Organ-sparing surgery with tumor enucleation and frozen section analysis was performed, confirming testicular adenomatoid tumor.ConclusionCurrently, no typical ultrasound features can definitively distinguish intratesticular adenomatoid tumors from malignant testicular masses. Thus, a surgical approach is almost always considered in such a case for both diagnostic and therapeutic purposes.

Visibility of MRI prostate lesions on B-mode transrectal ultrasound

AIMnProstate biopsies are usually done with transrectal ultrasound (TRUS) in B-mode (B TRUS) but multiparametricxa0MRI (mpMRI) is the gold imaging standard for the visualization of clinically significant prostate cancer (PCa), since a lowPCa detection rate is reported for B TRUS. The aim of this study was to assess the visibility of MRI lesions on B TRUS and toxa0determine which factors may influence the visibility on B TRUS.nnnMATERIAL AND METHODSn142 men with 148 lesions reportedxa0on mpMRI underwent a B TRUS/mpMRI fusion targeted biopsy of the prostate and were included in this retrospective study.xa0During the biopsy, images were obtained and stored in the institutions PACS. These images were reviewed by two radiologistsxa0to determine, whether an mpMRI lesion was or was not visible on B TRUS.nnnRESULTSnOverall 92 from 148 mpMRIxa0lesions (62.2%) were visible on B TRUS. The location of the lesion in the prostate, the PIRADS classification of the lesions and the size of the lesion had no significant influence on the visibility on B TRUS. Only the prostate volume had a significantxa0influence on visibility: in smaller prostates significantly more lesions were visible on B TRUS than in large glands (p+0.041;xa045.1 ml vs 54 ml).nnnCONCLUSIONnThe use of newer high-end ultrasound units as well as experience gained from fusion biopsiesxa0enables us to see 62.2 % of all suspicious mpMRI lesions on B TRUS. B TRUS images merit a thorough examination duringxa0a conventional biopsy setting.

Memory Effect of the Median Nerve: Can Ultrasound Reliably Depict Carpal Tunnel Release Success?

Purposeu2002To evaluate whether ultrasound findings of the median nerve cross-section area (CSA) and wrist-to-forearm ratio (WFR) correlate with neurophysiological and patient-reported outcome after surgery for carpal tunnel syndrome (CTS). Materials and Methodsu2002Subjective pain, CSA, WFR, postoperative scar tissue formation and nerve conduction velocity in 21 hands of 20 patients with clinically confirmed CTS were examined before and after carpal tunnel release surgery. Group differences were compared via a 2-sided ratio paired t-test or one-way ANOVA, and correlations were calculated using a linear regression model. Resultsu2002There were no significant pre- and postoperative changes of the CSA of the median nerve (pu200a=u200a0.293, 95u200a% CI 0.826u200a-u200a1.063) or WFR (pu200a=u200a0.230, 95u200a% CI 0.757u200a-u200a1.074). The nerve conduction velocity (pu200a<u200a0.0001, 95u200a% CI 0.753u200a-u200a0.886) and subjective pain during rest (pu200a=u200a0.001, 95u200a% CI 1.615u200a-u200a5.797) and exercise (pu200a=u200a0.008, 95u200a% CI 0.760u200a-u200a4.888) improved significantly, though. There was no correlation between changes in the median nerve CSA and nerve conduction velocity (pu200a=u200a0.357, ru200a=u200a0.217, R2u200a=u200a0.047) or reported pain intensity (pu200a=u200a0.441, ru200a=u200a0.200, R2u200a=u200a0.040). Conclusionu2002Contrary to common assumptions, there is no significant reduction of the CSA of the median nerve after successful carpal tunnel release. Morphologic median nerve changes may persist for a longer period regardless of successful surgery and clinical improvement. Accordingly, ultrasound appears unsuitable as the primary means of assessing surgical success due to this memory effect. Key Points · CSA of the median nerve does not change significantly after successful carpal tunnel release.. · Morphologic median nerve alterations may persist regardless of functional outcome (memory effect).. · Therefore, ultrasound imaging is not ideally suited to assess the outcome after carpal tunnel release.. Citation Format · Steinkohl Fabian, Gruber Leonhard, Gruber Hannes etu200aal. Memory Effect of the Median Nerve: Can Ultrasound Reliably Depict Carpal Tunnel Release Success?. Fortschr Röntgenstr 2017; 189: 57u200a-u200a62.