Ingegerd Balslev

Apparent diffusion coefficient ratio correlates significantly with prostate cancer gleason score at final pathology

To evaluate the correlation between apparent diffusion coefficient measurements (ADCtumor and ADCratio) and the Gleason score from radical prostatectomy specimens.

Unenhanced MR Imaging in adults with clinically suspected acute appendicitis

PURPOSE The purpose of the study was to evaluate unenhanced Magnetic Resonance Imaging (MRI) for the diagnosis of appendicitis or another surgery-requiring condition in an adult population scheduled for emergency appendectomy based on a clinical diagnosis of suspected acute appendicitis. MATERIALS AND METHODS The prospective study included 48 consecutive patients (29 female, 19 male, 18-70 years old, mean age=37.1 years). MRI examination was designed to be comfortable and fast; no contrast was administered. The sequences were performed during quiet respiration. The MRI findings were reviewed by two radiologists and one surgeon independent of each other and compared with surgical and pathological records. RESULTS According to the surgical and histopathological findings 30 of 48 patients (63%) had acute appendicitis. Of the remaining 18 patients, 4 patients had no reasons for the clinical symptoms and 14 patients had other pathology. For the three reviewers the performance of MRI in the diagnosis of acute appendicitis showed the following sensitivity, specificity and accuracy ranges: 83-93%, 50-83% and 77-83%. Moderate (κ=0.51) and fair (κ=0.31) interobserver agreements in the MR diagnosis of acute appendicitis were found between the reviewers. Sensitivity, specificity and accuracy values for overall performance of MRI in detecting pelvic abnormalities were 100%, 75% (3 of 4 healthy patients were identified by MRI) and 98%, respectively. CONCLUSION Unenhanced fast MRI is feasible as an additional fast screening before the appendectomy. It may prevent unnecessary surgeries. The fast MRI examination can be adequately performed on an MRI unit of broad range of field strengths.

Early experience with multiparametric magnetic resonance imaging-targeted biopsies under visual transrectal ultrasound guidance in patients suspicious for prostate cancer undergoing repeated biopsy

Abstract Objectives. The purpose of this study was to investigate the detection rate of prostate cancer (PCa) by multiparametric magnetic resonance imaging-targeted biopsies (mp-MRI-bx) in patients with prior negative transrectal ultrasound biopsy (TRUS-bx) sessions without previous experience of this. Material and methods. Eighty-three patients with prior negative TRUS-bx scheduled for repeated biopsies due to persistent suspicion of PCa were prospectively enrolled. mp-MRI was performed before biopsy and all lesions were scored according to the Prostate Imaging Reporting and Data System (PI-RADS) and Likert classification. All underwent repeated TRUS-bx (10 cores) and mp-MRI-bx under visual TRUS guidance of any mp-MRI-suspicious lesion not targeted by systematic TRUS-bx. Results.PCa was found in 39 out of 83 patients (47%) and mp-MRI identified at least one lesion with some degree of suspicion in all 39 patients. Both PI-RADS and Likert scoring showed a high correlation between suspicion of malignancy and biopsy results (p < 0.0001). Five patients (13%) had cancer detected only on mp-MRI-bx outside the TRUS-bx areas (p = 0.025) and another seven patients (21%) had an overall Gleason score upgrade of at least one grade based on the mp-MRI-bx. Secondary PCa lesions not visible on mp-MRI were detected by TRUS-bx in six out of 39 PCa patients. The secondary foci were all Gleason 6 (3 + 3) in 5–10% of the biopsy core. According to the Epstein criteria, 37 out of 39 cancer patients were classified as clinically significant. Conclusion. Using mp-MRI, even without previous experience, can improve the detection rate of significant PCa at repeated biopsy and allows more accurate Gleason grading.

Prostate cancer: 1.5 T endo-coil dynamic contrast-enhanced MRI and MR spectroscopy-correlation with prostate biopsy and prostatectomy histopathological data

PURPOSE To investigate diagnostic accuracy of detection of prostate cancer by magnetic resonance: to evaluate the performance of T2WI, DCEMRI and CSI and to correlate the results with biopsy and radical prostatectomy histopathological data. MATERIALS AND METHODS 43 patients, scheduled for radical prostatectomy, underwent prostate MR examination. Prostate cancer was identified by transrectal ultrasonographically (TRUS) guided sextant biopsy. MR examination was performed at 1.5 T with an endorectal MR coil. Cancer localisation was performed on sextant-basis--for comparison between TRUS biopsy, MR techniques and histopathological findings on prostatectomy specimens. RESULTS Prostate cancer was identified in all 43 patients by combination of the three MR techniques. The detection of prostate cancer on sextant-basis showed sensitivity and specificity: 50% and 91% for TRUS, 72% and 55% for T2WI, 49% and 69% for DCEMRI, and 46% and 78% for CSI. CONCLUSION T2WI, DCEMRI and CSI in combination can identify prostate cancer. Further development of MR technologies for these MR methods is necessary to improve the detection of the prostate cancer.

Upper urinary tract tumors: how does the contrast enhancement measured in a split-bolus CTU correlate to histological staging?

Background Computed tomography urography (CTU) is used widely in the work-up of patients with symptoms of urinary tract lesions. Preoperative knowledge of whether a tumor is invasive or non-invasive is important for the choice of surgery. So far there are no studies about the distinction of invasive and non-invasive tumors in ureter and renal pelvis based on the enhancement measured with Hounsfield Units. Purpose To examine the value of CTU using split-bolus technique to distinguish non-invasive from invasive urothelial carcinomas in the upper urinary tract. Material and Methods Patients who underwent nephroureterectomy between 2006 and 2011 and who had split-bolus CTU prior to surgery were included. The images were available electronically. The attenuation values before and after administration of iodine-based contrast media were measured. The radiology, patient, and pathology records were reviewed. Results Of the 158 patients who underwent unilateral nephroureterectomy 69 fulfilled the inclusion criteria. Histopathological examination revealed 31 patients with non-invasive and 38 with invasive urothelial carcinoma. Neither absolute attenuation nor change in attenuation values obtained at CTU could distinguish between invasive and non-invasive lesions. No patients had a CTU within the last year before the examination that resulted in surgery. Conclusion A split-bolus CTU cannot distinguish between invasive and non-invasive urothelial tumors in the upper urinary tract, but the examination is useful to diagnose a tumor in the renal pelvis and the ureter.

Assessment of the Diagnostic Accuracy of Biparametric Magnetic Resonance Imaging for Prostate Cancer in Biopsy-Naive Men: The Biparametric MRI for Detection of Prostate Cancer (BIDOC) Study

Key Points Question What are the diagnostic accuracy and negative predictive value of novel biparametric magnetic resonance imaging (MRI) in biopsy-naive men in detecting and ruling out significant prostate cancer? Findings In this cohort study of 1020 men who underwent both biparametric targeted and standard transrectal ultrasound-guided biopsies, low-suspicion biparametric MRI had a high negative predictive value (97%) in ruling out significant prostate cancer on confirmatory biopsies. Meaning The biparametric MRI used as a triage test in this study was associated with improved prostate cancer risk stratification and may be used to exclude aggressive disease and avoid unnecessary biopsies in 30% of men with clinical suspicion of prostate cancer, although further studies are needed to fully explore this new diagnostic approach.

A Prospective Comparison of Selective Multiparametric Magnetic Resonance Imaging Fusion-Targeted and Systematic Transrectal Ultrasound-Guided Biopsies for Detecting Prostate Cancer in Men Undergoing Repeated Biopsies

Introduction: The aim of the study was to compare the prostate cancer (PCa) detection rate of systematic transrectal ultrasound-guided biopsies (TRUS-bx) and multiparametric-MRI targeted biopsies (mp-MRI-bx) in a repeat biopsy setting and evaluate the clinical significance following an “MRI-targeted-only” approach. Materials and Methods: Patients with prior negative biopsies underwent prostatic multiparametric-MRI that was scored using the Prostate Imaging Reporting and Data System (PI-RADS) classification. All underwent both repeated TRUS-bx and mp-MRI-bx using image fusion of any PI-RADS ≥3 lesion. Biopsy results from TRUS-bx, mp-MRI-bx, and the combination were compared. Results: PCa was detected in 89 out of 206 (43%) patients. Of these, 64 (31%) and 74 (36%) patients were detected using mp-MRI-bx and TRUS-bx, respectively. Overall, mp-MRI-bx detected fewer patients with low-grade (Gleason score [GS] 3 + 3) cancers (14/64 vs. 41/74) and more patients with intermediate/high-grade cancers (GS ≥3 + 4) (50/64 vs. 33/74) using fewer biopsy cores compared with TRUS-bx (p < 0.001). Using an “MRI-targeted-only” approach in men with PI-RADS ≥3 lesions reduced the number of men requiring repeated biopsies by 50%, decreased low-grade cancer diagnoses by 66%, and increased intermediate/high-grade cancer diagnoses by 52%. Conclusions: MRI-targeted biopsies have a high detection rate for significant PCa in patients with prior negative transrectal ultrasound-guided biopsies and preferentially detect intermediate/high-grade compared with low-grade tumors.

Where Do Transrectal Ultrasound- and Magnetic Resonance Imaging-guided Biopsies Miss Significant Prostate Cancer?

OBJECTIVE To identify the location of missed significant prostate cancer (sPCa) lesions by transrectal ultrasound-guided biopsy (TRUSbx) and multiparametric magnetic resonance imaging-guided biopsy (mpMRIbx) in men undergoing repeat biopsies. MATERIALS AND METHODS A total of 289 men with prior negative TRUSbx underwent multiparametric magnetic resonance imaging. The location of any suspicious lesion was registered and scored using Prostate Imaging Reporting and Data System version 1 classification according to the likelihood of being sPCa. All patients underwent repeat transrectal ultrasound-guided biopsy (reTRUSbx) and targeted mpMRIbx (image fusion) of any suspicious lesion. Biopsy results were compared and the locations of missed sPCa lesions were registered. Cancer significance was defined as (1) any core with a Gleason score of >6, (2) cancer core involvement of ≥50% and for reTRUSbx on patient level, and (3) the presence of ≥3 positive cores. RESULTS Of the 289 patients, prostate cancer was detected in 128 (44%) with 88 (30%) having sPCa. Overall, 165 separate prostate cancer lesions were detected with 100 being sPCa. Of these, mpMRIbx and reTRUSbx detected 90% (90/100) and 68% (68/100), respectively. The majority of sPCa lesions (78%) missed by primary TRUSbx were located either anteriorly or in the apical region. Missed sPCa lesions at repeat biopsy were primarily located anteriorly (84%) for reTRUSbx (n = 27/32) and posterolateral midprostatic (60%) for mpMRIbx (n = 6/10). CONCLUSION Both TRUSbx and mpMRIbx missed sPCa lesions in specific segments of the prostate. Missed sPCa lesions at repeat biopsy were primarily located anteriorly for TRUSbx and posterolateral midprostatic for mpMRIbx. Localization of these segments may improve biopsy techniques in men undergoing repeat biopsies.

Multiparametric MRI in men with clinical suspicion of prostate cancer undergoing repeat biopsy: a prospective comparison with clinical findings and histopathology

Background Multiparametric magnetic resonance imaging (mpMRI) can improve detection of clinically significant prostate cancer (csPCa). Purpose To compare mpMRI score subgroups to systematic transrectal ultrasound-guided biopsies (TRUSbx) and prostate-specific antigen (PSA)-based findings for detection of csPCa in men undergoing repeat biopsies. Material and Methods MpMRI was performed prior to re-biopsy in 289 prospectively enrolled patients. All underwent repeat TRUSbx followed by targeted biopsies (MRITB) of any mpMRI-identified lesion. MpMRI suspicion grade, PSA level, and density (PSAd) were compared with biopsy results and further matched to the radical prostatectomy (RP) specimen if available. Results PCa was detected in 128/289 (44%) patients with median age, PSA, and prior negative TRUSbx of 64 (interquartile range [IQR] = 59–67), 12.0 ng/mL (IQR = 8.3–19.1), and 2 (IQR = 1–3), respectively. TRUSbx detected PCa in 108/289 (37%) patients, of which 49 (45%) had insignificant cancer. MRITB was performed in 271/289 (94%) patients and detected PCa in 96 (35%) with 78 (81%) having csPCa. MpMRI scores showed a high association between suspicion level and biopsy results on both lesion and patient level (P < 0.001). MpMRI was better than PSA and PSAd (P < 0.001) to identify patients with missed csPCa. In total, 64/128 (50%) patients underwent RP; 60/64 had csPCa. MpMRI was significantly better in predicting csPCa on RP compared with TRUSbx (P = 0.019) as MRITB and TRUSbx correctly identified 47/60 (78%) and 35/60 (58%) patients, respectively. Conclusion MpMRI improves detection of missed csPCa and suspicion scores correlate well with biopsy and RP results on both patient and lesion level.

PD43-03 RISK OF PROSTATE CANCER DIAGNOSIS FOLLOWING A LOW-SUSPICIOUS PROSTATE MRI OR BENIGN MRI-TARGETED BIOPSIES: A 3-YEAR FOLLOW-UP STUDY OF MEN WITH PRIOR NEGATIVE TRANSRECTAL ULTRASOUND GUIDED BIOPSIES

INTRODUCTION AND OBJECTIVES: To evaluate the detection rates of targeted and systematic biopsies in magnetic resonance (MRI) and transrectal ultrasound (US) image-fusion transperineal prostate biopsy for patients with previous benign transrectal US guided biopsies in two high-volume centres. METHODS: Two centre, prospective outcome study of 487 patients with previous benign biopsies that underwent transperineal MRI/US fusion-guided target and systematic saturation biopsy from 2012 to 2015. MRI was reported according to PIRADS Version 1. Detection of Gleason score (GS) 7-10 cancer (PCa) on biopsy was the primary outcome. Positive (PPV) and negative (NPV) predictive values including 95% confidence intervals were calculated. Detection rates of targeted and systematic biopsies were compared using McNemar test. AUCs were calculated for PIRADS, PSA-Density and the combination of the both. RESULTS: Median PSA was 9.0 (IQR 6.7-13.4) ng/ml. PIRADS 3-5 MRI lesions were reported in 343 (70%) patients. GS 7-10 PCa was detected in 149 (31%). PPV for detecting GS 7-10 PCa was 0.20 (+/-0.07) for PIRADS 3, 0.32 (+/-0.09) for PIRADS 4, and 0.70 (+/-0.08) for PIRADS 5. NPV of PIRADS 1-2 was 0.92 (+/-0.04) for GS 7-10 and 0.99 (+/-0.02) for GS 4+3 or higher cancer. Systematic biopsies alone found 125/138 (91%) GS 7-10 cancers. In patients with suspicious lesions (PIRADS 4-5) on MRI, systematic biopsies would not have detected 12/113 significant PCa (11%), while targeted biopsies alone would have failed to diagnose 10/113 (9%). In equivocal lesions (PIRADS 3), targeted biopsy alone would not have diagnosed 14/25 (56%) of GS 7-10, whereas systematic biopsies alone would have missed 1/25 (4%). Combination with PSA-density improved the AUC of PIRADS from 0.822 to 0.846. CONCLUSIONS: In patients with high probability MRI lesions, combined targeted and systematic MRI/TRUS image-fusion biopsy is still required, however, systematic biopsy alone may be sufficient in patients with equivocal lesions. Repeated prostate biopsies may not be needed at all for patients with a low PSA-density and a negative MRI read by experienced radiologists.