Hedvig Hricak

Evaluation of asymptomatic microscopic hematuria in adults : The American Urological Association Best Practice Policy-Part II : Patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up

P I of this report (preceding article) addressed the definition, detection, prevalence, and etiology of asymptomatic microscopic hematuria. This section of the best practice policy (Part II) is intended to serve as guidance to urologists and primary care physicians with respect to the evaluation of adult patients who may have asymptomatic microscopic hematuria. Recommendations for a nephrology evaluation and for patient follow-up are provided.

Radiomics: Images Are More than Pictures, They Are Data

This report describes the process of radiomics, its challenges, and its potential power to facilitate better clinical decision making, particularly in the care of patients with cancer.

Diffusion-weighted Endorectal MR Imaging at 3 T for Prostate Cancer: Tumor Detection and Assessment of Aggressiveness

PURPOSE To assess the incremental value of diffusion-weighted (DW) magnetic resonance (MR) imaging over T2-weighted MR imaging at 3 T for prostate cancer detection and to investigate the use of the apparent diffusion coefficient (ADC) to characterize tumor aggressiveness, with whole-mount step-section pathologic analysis as the reference standard. MATERIALS AND METHODS The Internal Review Board approved this HIPAA-compliant retrospective study and waived informed consent. Fifty-one patients with prostate cancer (median age, 58 years; range, 46-74 years) underwent T2-weighted MR imaging and DW MR imaging (b values: 0 and 700 sec/mm(2) [n = 20] or 0 and 1000 sec/mm(2) [n = 31]) followed by prostatectomy. The prostate was divided into 12 regions; two readers provided a score for each region according to their level of suspicion for the presence of cancer on a five-point scale, first using T2-weighted MR imaging alone and then using T2-weighted MR imaging and the ADC map in conjunction. Areas under the receiver operating characteristic curve (AUCs) were estimated to evaluate performance. Generalized estimating equations were used to test the ADC difference between benign and malignant prostate regions and the association between ADCs and tumor Gleason scores. RESULTS For tumor detection, the AUCs for readers 1 and 2 were 0.79 and 0.76, respectively, for T2-weighted MR imaging and 0.79 and 0.78, respectively, for T2-weighted MR imaging plus the ADC map. Mean ADCs for both cancerous and healthy prostatic regions were lower when DW MR imaging was performed with a b value of 1000 sec/mm(2) rather than 700 sec/mm(2). Regardless of the b value used, there was a significant difference in the mean ADC between malignant and benign prostate regions. A lower mean ADC was significantly associated with a higher tumor Gleason score (mean ADCs of [1.21, 1.10, 0.87, and 0.69] × 10(-3) mm(2)/sec were associated with Gleason score of 3 + 3, 3 + 4, 4 + 3, and 8 or higher, respectively; P = .017). CONCLUSION Combined DW and T2-weighted MR imaging had similar performance to T2-weighted MR imaging alone for tumor detection; however, DW MR imaging provided additional quantitative information that significantly correlated with prostate cancer aggressiveness.

Advances in Magnetic Resonance Imaging: How They Are Changing the Management of Prostate Cancer

CONTEXT Although magnetic resonance imaging (MRI) is emerging as the most commonly used imaging modality for prostate cancer (PCa) detection, treatment planning, and follow-up, its acceptance has not been uniform. Recently, great interest has been shown in multiparametric MRI, which combines anatomic T2-weighted (T2W) imaging with MR spectroscopic imaging (MRSI), dynamic contrast-enhanced MRI (DCE-MRI), and diffusion-weighted imaging (DWI). OBJECTIVE The aim of this article is to review the current roles of these MR techniques in different aspects of PCa management: initial diagnosis, biopsy strategies, planning of radical prostatectomy (RP) and external radiation therapy (RT), and implementation of alternative focal therapies. EVIDENCE ACQUISITION The authors searched the Medline and Cochrane Library databases (primary fields: prostatic neoplasm, magnetic resonance). The search was performed without language restriction from January 2008 to November 2010. EVIDENCE SYNTHESIS Initial diagnosis: The data suggest that the combination of T2W MRI and DWI or MRSI with DCE-MRI has the potential to guide biopsy to the most aggressive cancer foci in patients with previously negative biopsies, increasing the accuracy of the procedure. Transrectal MR-guided prostate biopsy can improve PCa detection, but its availability is still limited and the examination time is rather long. Planning of RP: It appears that adding MRSI, DWI, and/or DCE-MRI to T2W MRI can facilitate better preoperative characterization of cancer with regard to location, size, and relationship to prostatic and extraprostatic structures, and it may also facilitate early detection of local recurrence. Thus, use of these MR techniques may improve surgical, oncologic, and functional management. Planning of external RT and focal therapies: MR techniques have similar potential in these areas, but the published data remain very limited. CONCLUSIONS MRI technology is continuously evolving, and more extensive use of MRI technology in clinical trials and practice will help to improve PCa diagnosis and treatment planning.

IMAGING PROSTATE CANCER

The clinical management of prostate cancer continues to be one of the most controversial areas in medicine, with no consensus on the need for cancer screening, choice of diagnostic tests for pretreatment evaluation, and the need for and appropriateness of treatment for any stage of disease. 66 Controversies in management can be attributed to several unique biologic features of the disease. 77 For example, many prostate cancers do not lead to serious morbidity or death. Autopsy studies have shown that 30% to 46% of men older than age 50 have microscopic prostate cancer, yet less than 20% of men develop clinical prostate cancer in their lifetime. 36,66 Unlike other cancers (e.g., lung, colon, breast, or ovarian cancer), which behave aggressively and are more rapidly and uniformly fatal if untreated, prostate cancer behaves in a less predictable manner. Some cancers are small, well differentiated, and unlikely to cause clinically significant disease, whereas others are large, poorly differentiated, and likely to metastasize, causing death. Despite recent advances in the diagnosis, pretreatment evaluation, and treatment of prostate cancer, significant gaps in knowledge of the underlying pathophysiology of this disease remain. Several major obstacles impede the optimal clinical management of prostate cancer. The first obstacle, related to early detection, is the inability of screening tests to differentiate subclinical disease from clinically significant prostate cancer. Although there is evidence suggesting that most (85% to 90%) cancers detected through prostate cancer screening programs represent clinically significant rather than insignificant disease and are detected at an earlier stage of disease, the feasibility of prostate cancer screening in the general population remains controversial, and the costs of undertaking screening in all men over age 50 years far exceeds presently available health care funds. 40,54,77,85 The second obstacle is related to treatment planning. There are limitations of currently available tumor prognostic factors in differentiating indolent from aggressive disease. Although a number of tumor prognostic factors (e.g., tumor volume, grade, and stage) can generally predict disease at either end of the spectrum, most cancers fall into an intermediate range, where it is difficult to distinguish those cancers likely to progress from those that can be observed. 55,79 There continues to be intense debate about the ability of currently available tumor prognostic factors accurately to assign patients to appropriate risk and treatment categories. 77 Prostate cancer is usually suspected due to an abnormal digital rectal examination (DRE) or elevated serum prostate-specific antigen (PSA) level (Fig. 1). American Cancer Society recommendations for the annual cancer prevention check-up includes DRE and serum PSA testing for men older than 50 years or for younger men at increased risk (black race or family history of prostate cancer) for the disease. 47 Imaging provides additional information in patients with a histologic diagnosis of prostate cancer, but imaging findings alone are not sufficient for the primary diagnosis of prostate cancer. The diagnosis of prostate cancer depends on the histopathologic evaluation of tissue specimens obtained from digitally or transrectal ultrasound (TRUS)–guided prostate biopsies (see Fig. 1). 39 Systematic (sextant) core biopsies of the prostate are recommended to maximize the diagnostic yield of biopsy and to allow estimation of tumor grade and volume. 60

Managing Radiation Use in Medical Imaging: A Multifaceted Challenge

This special report aims to inform the medical community about the many challenges involved in managing radiation exposure in a way that maximizes the benefit-risk ratio. The report discusses the state of current knowledge and key questions in regard to sources of medical imaging radiation exposure, radiation risk estimation, dose reduction strategies, and regulatory options.

Prostate Cancer: Identification with Combined Diffusion-weighted MR Imaging and 3D 1H MR Spectroscopic Imaging—Correlation with Pathologic Findings1

PURPOSE To retrospectively measure the mean apparent diffusion coefficient (ADC) with diffusion-weighted magnetic resonance (MR) imaging and the mean metabolic ratio (MET) with three-dimensional (3D) hydrogen 1 ((1)H) MR spectroscopic imaging in regions of interest (ROIs) drawn over benign and malignant peripheral zone (PZ) prostatic tissue and to assess ADC, MET, and combined ADC and MET for identifying malignant ROIs, with whole-mount histopathologic examination as the reference standard. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant retrospective study and issued a waiver of informed consent. From among 61 consecutive patients with prostate cancer, 38 men (median age, 61 years; range, 42-72 years) who underwent 1.5-T endorectal MR imaging before radical prostatectomy and who fulfilled all inclusion criteria of no prior hormonal or radiation treatment and at least one PZ lesion (volume, >0.1 cm(3)) at whole-mount pathologic examination were included. ADC maps were generated from diffusion-weighted MR imaging data, and MET maps of (choline plus polyamine plus creatine)/citrate were calculated from 3D (1)H MR spectroscopic imaging data. ROIs in the PZ identified by matching pathologic slides with T2-weighted images were overlaid on MET and ADC maps. Areas under the receiver operating characteristic curves (AUCs) were used to evaluate accuracy. RESULTS The mean ADC +/- standard deviation, (1.39 +/- 0.23) x 10(-3) mm(2)/sec, and mean MET (0.92 +/- 0.32) for malignant ROIs differed significantly from the mean ADC, (1.69 +/- 0.24) x 10(-3) mm(2)/sec, and mean MET (0.73 +/- 0.18) for benign ROIs (P < .001 for both). In distinguishing malignant ROIs, combined ADC and MET (AUC = 0.85) performed significantly better than MET alone (AUC = 0.74; P = .005) and was also better than ADC alone (AUC = 0.81), although the difference was not statistically significant (P = .09). CONCLUSION The combination of ADC and MET performs significantly better than MET for differentiating between benign and malignant ROIs in the PZ.

Improving Communication of Diagnostic Radiology Findings through Structured Reporting

PURPOSE To compare the content, clarity, and clinical usefulness of conventional (ie, free-form) and structured radiology reports of body computed tomographic (CT) scans, as evaluated by referring physicians, attending radiologists, and radiology fellows at a tertiary care cancer center. MATERIALS AND METHODS The institutional review board approved the study as a quality improvement initiative; no written consent was required. Three radiologists, three radiology fellows, three surgeons, and two medical oncologists evaluated 330 randomly selected conventional and structured radiology reports of body CT scans. For nonradiologists, reports were randomly selected from patients with diagnoses relevant to the physicians area of specialization. Each physician read 15 reports in each format and rated both the content and clarity of each report from 1 (very dissatisfied or very confusing) to 10 (very satisfied or very clear). By using a previously published radiology report grading scale, physicians graded each reports effectiveness in advancing the patients position on the clinical spectrum. Mixed-effects models were used to test differences between report types. RESULTS Mean content satisfaction ratings were 7.61 (95% confidence interval [CI]: 7.12, 8.16) for conventional reports and 8.33 (95% CI: 7.82, 8.86) for structured reports, and the difference was significant (P < .0001). Mean clarity satisfaction ratings were 7.45 (95% CI: 6.89, 8.02) for conventional reports and 8.25 (95% CI: 7.68, 8.82) for structured reports, and the difference was significant (P < .0001). Grade ratings did not differ significantly between conventional and structured reports. CONCLUSION Referring clinicians and radiologists found that structured reports had better content and greater clarity than conventional reports.

Magnetic Resonance Imaging for Predicting Prostate Biopsy Findings in Patients Considered for Active Surveillance of Clinically Low Risk Prostate Cancer

PURPOSE A barrier to the acceptance of active surveillance for men with prostate cancer is the risk of underestimating the cancer burden on initial biopsy. We assessed the value of endorectal magnetic resonance imaging in predicting upgrading on confirmatory biopsy in men with low risk prostate cancer. MATERIALS AND METHODS A total of 388 consecutive men (mean age 60.6 years, range 33 to 89) with clinically low risk prostate cancer (initial biopsy Gleason score 6 or less, prostate specific antigen less than 10 ng/ml, clinical stage T2a or less) underwent endorectal magnetic resonance imaging before confirmatory biopsy. Three radiologists independently and retrospectively scored tumor visibility on endorectal magnetic resonance imaging using a 5-point scale (1-definitely no tumor to 5-definitely tumor). Inter-reader agreement was assessed with weighted kappa statistics. Associations between magnetic resonance imaging scores and confirmatory biopsy findings were evaluated using measures of diagnostic performance and multivariate logistic regression. RESULTS On confirmatory biopsy, Gleason score was upgraded in 79 of 388 (20%) patients. Magnetic resonance imaging scores of 2 or less had a high negative predictive value (0.96-1.0) and specificity (0.95-1.0) for upgrading on confirmatory biopsy. A magnetic resonance imaging score of 5 was highly sensitive for upgrading on confirmatory biopsy (0.87-0.98). At multivariate analysis patients with higher magnetic resonance imaging scores were more likely to have disease upgraded on confirmatory biopsy (odds ratio 2.16-3.97). Inter-reader agreement and diagnostic performance were higher for the more experienced readers (kappa 0.41-0.61, AUC 0.76-0.79) than for the least experienced reader (kappa 0.15-0.39, AUC 0.61-0.69). Magnetic resonance imaging performed similarly in predicting low risk and very low risk (Gleason score 6, less than 3 positive cores, less than 50% involvement in all cores) prostate cancer. CONCLUSIONS Adding endorectal magnetic resonance imaging to the initial clinical evaluation of men with clinically low risk prostate cancer helps predict findings on confirmatory biopsy and assess eligibility for active surveillance.

Renal Masses: Characterization with Diffusion-weighted MR Imaging—A Preliminary Experience

PURPOSE To retrospectively assess the usefulness of apparent diffusion coefficients (ADCs) for characterizing renal masses (ie, viable solid tumors, necrotic or cystic tumor areas, and benign cysts). MATERIALS AND METHODS The institutional review board waived the requirement for informed consent for this retrospective HIPAA-compliant study. The data of 25 consecutive patients (15 men, 10 women; age range, 39-75 years) who underwent renal magnetic resonance (MR) imaging, including diffusion-weighted imaging, before nephrectomy were included. Renal MR examinations were performed by using transverse T1-weighted dual-echo in-phase and out-of-phase sequences and transverse and coronal T2-weighted single-shot fast spin-echo sequences. Three-dimensional fat-saturated T1-weighted dynamic gadopentetate dimeglumine-enhanced sequences also were performed. Precontrast single-shot spin-echo echo-planar diffusion-weighted images were obtained with b values of 0, 500, and 1000 sec/mm(2) at 1.5 T. Regions of interest were placed on renal lesions to measure the ADC of whole lesions, enhancing viable soft tissue, and nonenhancing necrotic or cystic areas. The T1 signal characteristics of the renal lesions and necrotic or cystic areas were recorded. The Wilcoxon rank sum test was used to compare the median ADC values of the various types of lesions and areas. RESULTS Twenty-six renal tumors were found in the 25 patients. Eight patients were found to have 11 benign cysts. Renal tumors had significantly lower ADCs (median, 189.3 x 10(-5) mm(2)/sec; range, [102.0-262.0] x 10(-5) mm(2)/sec) compared with benign cysts (median, 322.8 x 10(-5) mm(2)/sec; range, [217.0-421.0] x 10(-5) mm(2)/sec; P < .001). Solid enhancing tumors had significantly lower ADCs (median, 162.3 x 10(-5) mm(2)/sec; range, [102.0-284.0] x 10(-5) mm(2)/sec) compared with nonenhancing necrotic or cystic regions (median, 247.7 x 10(-5) mm(2)/sec; range, [85.2-310.0] x 10(-5) mm(2)/sec; P = .007) [corrected]. T1 hyperintense lesions had lower ADCs compared with their hypointense counterparts. CONCLUSION The T1 signal characteristics of a renal lesion appear to be related to the ADC of the lesion. ADC may be helpful in characterizing and differentiating renal masses.